John Arden on Brain-Based Therapy

John B. Arden: I've got to say that the actual title of the book was chosen by Wiley, the publisher. The earlier title had something to do with neuroscience—I forget, actually, what it was. But when this one was chosen, my initial reaction was, "Geez, that sounds so reductionist."

JA: And there's so much out there about neuroscience. A good friend of mine, Lou Cozolino, wrote a book called The Neuroscience of Psychotherapy, so maybe it was too close to his title. But from my point of view, it doesn't have anything to do with reductionism. I still regard Jung's analysis of culture and fairy tales and religion to be fascinating. In fact, I spent a lot of time sitting in yoga ashrams in different parts of the world meditating, and those parts of my development are still with me. I'm still interested in all of that, but I want to integrate it all. And it has to be integrated from a nondualistic perspective. It seems to me that for many years we were in what I call the Cartesian era.

JA: Right. Between 1890 and about 1980, we were in the Cartesian era with no scientific grounding for this view whatsoever because, despite the fact that Freud was a neurologist and wrote a hundred articles in neurophysiology, on such things as the neurophysiology of the crayfish, we didn't really know much about the brain at the time. So the schools of psychotherapy just splintered all over the place—everything from primal scream all the way to radical behaviorism—because there was no common language, no common integrative core.

The picture changed around 1979 to 1981 due to the convergence of a number of different factors. For one thing, the DSM-III—the third Book of Bad Names—developed. And it was a whole lot better than DSM-II and DSM-I, because you didn't have a lot of terms like "neurosis." Even homosexuality, believe it or not, was in the DSM-I. Finally, in 1974, when the DSM-II came out, millions of Americans and Europeans became cured of their disorder. That's why people get really caught up with the diagnostic terms. So DSM-III came about, and there was a whole lot more science to it. People were saying, "Wow, geez, this is so much better. This makes a little bit more sense."

Also, up until about 1980, the efficacy studies for psychotherapy were pathetic. Way back to Hans Eysenck, the mere passage of time was as effective as psychotherapy. Before Timothy Leary went to Harvard, he actually worked for us as a chief psychologist at Kaiser Oakland. He was a pretty bright guy before he started taking acid and flipping out. And he did a study there where he found that people on the waitlist did as well as people in psychotherapy. So imagine all that.

JA:

The Age of Pax Medica

Exactly, until the Smith and Glass studies, which came out in 1979 or 1980. I was at University of New Mexico at the time, and we were pretty excited because this big meta-analysis found that, actually, psychotherapy worked. "Oh, my god. What we're studying and what we're doing really makes sense. We're helping people. Thank God!" Then, too, the development of these SSRIs in the '80s was a major factor in the development of what we call Pax Medica.

JA: Pax Romana was a term used to describe the Roman world roughly 2,000 years ago. You could travel anywhere in the Roman world, and as long as you didn't insult Roman gods and Roman law, everything was cool. Similarly, since 1980, as long as you recognize that that psychiatry is in charge and that the number one factor is psychotropic medication, everything's going to be cool. That's why we call it Pax Medica. We've been operating in Pax Medica roughly since 1980. I think we're ready to leave it.

JA: Because it got us all on the same page. We were all over the place. We were talking about interjected self-objects on one side and behavioral reinforcement paradigms on the other. We didn't have a common language.

But Pax Medica's page is extremely one-dimensional. In fact, the common language that we began to use is rather clunky and presumptuous. So we became a medicalized group, and the psychotherapy world became medicalized psychotherapy. And instead of being called "psychotherapists," we became "clinicians." "Now, you're talking."

JA: Now you're clinically speaking, but what were you speaking before? Is this a new language or something? I've sat around in these big meetings where people say, "So what's the diagnostic picture here?" In other words, they want a name quick, from the Book of Bad Names. And then they say, "What's medically necessary?" Medically necessary, what? The guy just had a divorce. He's really bummed out. "Medically necessary" sounds kind of silly.

JA: Yeah, and I think that the disagreement resulted in a compromised agreement. And the compromised agreement became the clinical role. And the clinical role is, I think, very antiseptic and one-dimensional, and in some ways very subservient to the so-called "principal treatment," which was medication.

Now we know the efficacy studies for antidepressants are rather suspect. The negative studies outnumber the positive studies by 12 times. So the pillars of Pax Medica are actually falling apart in major studies in JAMA and New England Journal of Medicine and other places.

JA: Another part of Pax Medica was evidence-based practice. From roughly the early '80s on, various CBT-oriented therapists were the ones doing a lot of the studies on specific methods. David Barlow and others were showing that specific approaches to panic or OCD were more efficacious, and that dovetailed really nicely with the Pax Medica model, whereby you had a diagnosis and you had a prescribed treatment for the diagnosis. There was a positive part of that, because, come on, now—a person with a panic disorder, you want to sit around and analyze their feelings about their mother endlessly? No, you want to get them doing interoceptive exposure and other approaches that have been found for the last 35 years to be much more efficacious than sitting around analyzing archetypes and other things that, even though I find them intellectually stimulating, are a waste of time with somebody with a panic disorder.

So there's a lot more science in Pax Medica, and that's a good thing. But I think we're ready to integrate many strata of science now, to emerge out of the one-dimensionality. Evidence-based practice is still going to be part of the picture, despite the knowledge that the outcome management people have provided us, which is that there are diffuse boundaries between these psychotherapeutic schools.

I'm arguing that we don't need any more gurus. I certainly don't want to be anybody's guru. We don't need another school. I'm not suggesting brain-based therapy is a school and now everybody's got to be an Ardenian. Oh, what a terrible burden it would be to be one of these gurus—and a hollow experience, at that.

Rather, I think we have the opportunity to integrate evidence-based practice—which still is part of the picture for anxiety disorders and depression—with a better look, for instance, at the building of the alliance. The Adult Attachment Inventory and things like that give us insight into the various types of relationships we have been taught to develop, that are going to be replicated in the therapeutic encounter anyway. So why not include that as part of the overall picture? And we know that certain types of brain dynamics and temperament are associated with relationships—neuroscience is a big part of this new equation, as well.

JA: More than we ever have been. I'm also convinced that in five years, I'll be looking back at what I'm saying to you right now and thinking, "God, John, you had such a limited understanding of what's going on." And I think that's a good thing. So, yes, I think that we can begin to have a dialogue about neuroscience, but are we there yet? No. I don't think we're ever going to be totally there. There is no "there." But we're going to be far more enlightened about what's going on. And certainly, not everybody's brain is exactly the same, but we know that there are psychological syndromes, like anxiety and depression, that have some commonality across people. We ought to be talking about that among ourselves as therapists, and also in therapy with our clients. I'm always talking about the brain with my clients.

JA: I think otherwise. In fact, I think it's an opportunity to focus less on psychopharmacology. Out of the 2,000 of us in the Kaiser system, I'm among the people who refer my clients less for medication evaluations, because I want to work with emotion. That's our province. So how do you work with emotion? Well, if you have people narcotized, you're not going to have access. And certainly with people who have anxiety disorders, anybody on a benzo I'm trying to get off of benzos as quickly as possible.

SSRIs I'm less concerned about, but I only go there when I exhaust all other avenues, including diet, which I'm always talking about at length. Exercise is the most effective biochemical boost that there is—as effective as psychotherapy. Exercise is as good as psychotherapy in alleviating depression. We ought to be doing that and psychotherapy together.

Including all these biophysiological dimensions that don't include the drug cartels is a good thing. Now, the reductionism to a specific neuron—no, I don't go there. Remember, I'm a guy steeped in psychodynamic theory, and I still love all the allure associated with it and all these characters that are battling with one another. It's fun, and it's enlightening in many ways. I think the new psychodynamic perspectives are quite a bit more advanced than the original psychoanalysis.

JA: Absolutely. I'm not suggesting that we don't pay attention to the alliance. In fact, that's one of the principal effective agents. And we know that from psychotherapy research; the outcome management people have shown that to be pretty powerful. But why not pay attention to those parts of the brain that make that possible mirror neurons, the anterior cingulate, the orbital frontal cortex, the insula, the spindle cells? It's interesting for us to know that some people, if they've had a poor attachment history, have underdeveloped areas like the ones I just mentioned.

JA: Let me give a fairly common example. Say you have a client who says to you, "I just don't know why in the first part of the day, when I lie there in bed, I get so overwhelmed and I get paralyzed with this totality of anxiety. I don't know what's going on there. I get anxious and depressed. What am I going to do?"

Well, we know now from all these affective symmetry studies that people who get hyperactive right prefrontal cortex plus underactive left prefrontal cortex get more anxious and more depressed. And what kindles the right prefrontal side are withdrawal and avoidant behaviors. So when she gets into the withdraw-avoidant behavioral response, she's kindling up the right prefrontal cortex.

Now, how to get out of that? You've got to do what are called approach behaviors. The CBT people have known this a long time—it's called behavior activation. What do you do with depressed clients? Do you sit around and analyze things to death? No, you get them doing stuff. And you get them doing it quick. As soon as you start to feel overwhelmed, it's time to do something, because that kindles the left prefrontal cortex, which is about approach behaviors. But you do it incrementally, because it's always very overwhelming to do big, big projects.

We're not talking about the left hemisphere as being the new cool one now and the right hemisphere as passé, where it was the right hemisphere that was the cool one before. No, we're going to be talking about a relative activation of the two hemispheres. In fact, we know, too, that if you get the right prefrontal cortex knocked out, you lose your sense of humor. What's that about? Well, you want to have a sense of humor, right? A sense of humor is about plays on words, metaphors, juxtapositions, and all of that. You want to have that larger picture.

JA: Absolutely. Behavior changes the brain and the brain changes behavior. It's a bidirectional flow of information. It's not one way or the other. Pax Medica had it one way: "Brain changes behavior. All you've got to do is tweak up some neurotransmitter system like serotonin, and everything's going to be fine."

JA: "Chemical imbalance" is so American, isn't it? "Okay, let's just go in there and change that chemical imbalance. I want to fix it quick, will you, Doc?"

JA: I think it's slowly developing. There will always be tidal pools that pull back. For example, you mentioned earlier that some people are saying, "Oh, neuroscience. What's the big deal? Neuroscience isn't going to be part of the picture. Get over it." It's going to be, but how is the bigger picture? I think that there are a lot of people jumping in the bandwagon who aren't paying attention to the science in neuroscience. I'm not going to get into names, but some people make it rather New-Agey, and that kind of turns my stomach.

Science is a good thing. We ought to be paying attention to how the research actually shows this or that instead of, "Well, that's kind of a cool thing. Why don't you just talk about the so-called limbic system?"
How we incorporate neuroscience, I think, is going to be a big part of how we advance toward the future. And it's not going to be reductionistic. It's going to be a part of the picture. We're still going to talk about the relationship and pay very close attention to the alliance. And as I said earlier, it works both ways, because there are parts of the brain and parts of our nervous system that respond to close relationships, and that's something we ought to be paying attention to.

The psychological theories and all the alphabet-soup therapists—EMDR, EFT, CBT—the advances in some of those areas, I think, are going to be part of the picture. But I think the allegiance to the schools is going to be increasingly less of an issue.

JA: It seems to me that the studies that show actual change in the brain resulting from psychotherapy are what will convince everybody that we're moving in the right direction. And there's a wealth of information out there that's developing and will become stronger and stronger, and it'll be undeniable that there's an intersection here. Again, it's all not reductionism: it's integration. And memory is a major part of the picture here.

JA: Understanding memory and the complexities of our various memory systems, including the various types of implicit and explicit memory and how those systems work together to make us who we are, and how we, as therapists, interact with these memory systems—that, to me, is the foundation of therapy. Our job is to help people reconsolidate memory in a much more adaptive and effective way, because there is no such thing as a memory encapsulated in some sealed-off portion of time, where you go back in and you pull it up. That's where the early psychodynamic theorists had it all wrong. Every time we bring up a memory, we change the memory.

That's what we do for a living: we bring up memories in the new context and help people re-adapt in a much more effective way. I regard memory as one of the major foundational aspects to psychotherapy in this unfolding sea change—not a paradigm shift, but actually a sea change—that's occurring in mental health.

JA: Actually, it does incorporate them. If you think in terms of anxiety, for example, it's quite clear that avoidant behaviors make anxiety worse even though, over the short term, they make it feel less severe.

Let's say I'm a socialphobe and I walk into a room. I feel better for the first minute, and then I feel terrible, and my amygdala gets hyperactive as a result. In other words, I'm painting myself into a corner. Exposure is the antidote—the therapeutic direction that we ought to be working in. And that goes back to Joseph Wolpe, who doesn't get enough credit now, even in the CBT community. The whole idea of incremental exposure is critically important in psychotherapy for people with anxiety disorders. So the CBT people are talking about the brain even though they're not using the brain in their dialogue. They're not mentioning the brain because they haven't been really incorporating it into their understanding. But they are changing the brain, because exposure actually changes the brain. It could make the anxiety worse by flooding too quickly, but incremental change could make it much more resilient and adaptive.

JA: We are seeing these changes. And in fact, with psychodynamic theory, the whole concept of working through is the same thing as incremental exposure. A book that I like to recommend that's now 20 years old is Psychodynamics in Cognition, by Mardi Horowitz. I really like that book. It was Horowitz's attempt by to talk about the overlap between psychodynamic theorists and cognitive theorists-maybe they aren't talking about something so different. Let's talk about how defense mechanisms and schemata have an overlap. That's what I'm talking about: finding the overlap between these therapy types. Just because they use different language doesn't necessarily mean that they're not talking about the same thing. Where there is an overlap, I get excited about it.

JA: Neuroscience, and a look at these therapeutic styles. Defensive maneuvers are still relevant, and we can look at them from a cognitive perspective, and from this whole affective symmetry dynamic, as well. In other words, we could look at them from a number of different vantage points, and if all those vantage points have a cohesive quality to them, then I feel much more confident about it.

So we're not just talking neuroscience or just talking psychodynamic or just talking CBT or memory, but rather how these all can overlap and say the same thing to give us a much more robust understanding of what goes on in psychotherapy and what goes on in our own heads.

JA: Absolutely. I've been in the mental health world for 35 years, and when I first started, I was part of this whole the institutionalization movement—we were creating alternatives to hospitals in San Francisco, and then wrote a bill for the New Mexico state legislature in 1980 to do the same thing. What I thought was going on back then is quite a bit different from what I think about what's going on now.

Even in 1976, when I was working with autistic kids—God, we had a stupid understanding of what was going on with those kids back then, because we didn't understand what was happening in their brains. We thought it had to do with these really cold mothers. Bettelheim was our popular hero. My God, what a dumb, dumb way of understanding.

It didn't mean, though, that what we were trying to do, in terms of developing a good relationship with the kids, wasn't a good thing to do. We called it reparenting, but nowadays we'd think about it as being helpful to the kids so they could acquire better social skills and develop a better ability to have human relationships.

JA: And that has helped us to understand the role of the striatum very well, because that's the area of the brain that gets attacked viciously in these kids during the infection. And we know that the front part of the striatum is kind of like a spam filter. In people with OCD, unfortunately, that striatum doesn't work like a spam filter, and the orbital frontal cortex gets flooded with all this nuisance information: "This is wrong, this is wrong, we've got to do something, wash your hands, wash your hands," or whatever it is. Baxter's group down at UCLA showed very clearly the orbital frontal cortex being flooded with all this nuisance information, and that what can help alleviate the OCD is to "rescue" the orbital frontal cortex with the dorsal lateral prefrontal cortex (which has a lot to do with working memory) via CBT with a mindfulness approach. In these imaging studies, you could see OCD patients before and after the treatment. And the strep infection material was supports the idea that OCD involves this "gate" that is left open in the striatum.

JA: It's interesting that you say depressed and anxious, because under Pax Medica, if you were depressed and anxious together we would have two diagnoses on Axis I—a comorbid problem. Well, you're one person. Are these two genetic disorders you have? What a silly idea. And the prescribed pharmacological agents actually work against one another. These stupid benzos, which are really a nuisance in the mental health world, would actually contribute not only to addiction, tolerance, and withdrawal problems, but also to depression. And then you'd toss in an SSRI or something like that, so you'd have this weird cocktail.

There is an interesting neurochemistry that occurs with anxiety and depression. For example, for 90 minutes after you experience a severe stressful incident, your levels of dopamine, norepinephrine, and serotonin will be down. Let's say that you've just found out that you can't get into school. All the PhD programs have turned you down. That's a pretty big blow, right?

So you're going to get a downregulation of all those neurotransmitter systems, and you're going to withdraw a little bit. But it's what you do with that neurochemistry and those neurodynamics that can tumble you into more anxiety and more depression, or get you out of it. If you do things that kindle up the same systems that would get you more anxious and depressed, you'll get more anxious and depressed.

Now, we're going to have bumps in the road. It's what you do in response—it's that resiliency. Some of the positive psychology spinoffs are paying attention to that, and of course the counseling psychologists have long done that.

JA: I often do that, just to get an idea of how people react to certain events in their lives—to get a characteristic description. I'm also paying attention to the way they describe them to me, because that interaction between us is so important. It replicates other relationships they're having that might have great continuity with the earlier attachment-based relationships. It tells me a lot about how I can intervene, because I don't want to create more resistance. I do like Milton Erickson a lot—that indirect approach. I'm not going to want to shut you down and have you screen me off, but rather do some motivational interviewing to some degree—which is very Rogerian, in fact. Bill Miller was a Rogerian from the school that I came from.

JA: No, I didn't. In fact, I didn't know about him until after I left. I don't know if he was there then—that was 30 years ago. But had he been there and I missed him, I would have been disappointed, because I really like his contribution to the substance abuse community.

JA: There is some literature to suggest that if you have two alcoholic parents, your vulnerability to become an alcoholic is heightened. But let's say the concordance rate is 50 percent. Well, what about the other 50 percent? It isn't a one-and-one factor.

In a discussion I had with Fred Blume, one of the pushers of the alcohol gene concept, I asked, "How about an acquired disease? You guys are really into this disease concept." AA's really into it. AA and NA are the most powerful self-help groups in the world, in my opinion. My sister-in-law's life was saved as a result. Fantastic groups. I love their little jingles and all that. But they're too into this disease concept. It's useful in early recovery, but you could create a disease. It's bidirectional. The more I drink alcohol, the more I feel like I need alcohol, because my biology changes. I downregulate various neurotransmitter systems, so now I feel like I need to mellow out because now I'm downregulating the synthesis of GABA. That means I need more GABA-like effect because I'm always dampening down glutamate.

What I think therapists ought to be paying attention to is how these various substance abuse habits, if you want to call it that, create psychological symptomatology. [quote:I see all sorts of people here in the North Bay who are suffering from anxiety and/or depression, and I find out they're just drinking a glass or two of wine at night.

JA: I think it's a lot of wine. I drink a glass every week or two. It would be nice if you could have two glasses of wine a night, but my sleep gets all messed up. You get the mid-sleep-cycle awakening and all that. And that's a small snapshot. What about the next week? These are subtle effects, but when I used to do neuropsychological testing and psychological testing, and then later teach it, we used to say, "Don't test a wet brain for up to three months after your last drink." There are all sorts of artifacts to subtle alcohol consumption.

And red wine isn't that cool, you know. It's the resveratrol in the skin of the red grape. You can drink Welch's grape juice and still get the same effect. You don't need the alcohol.

JA: Everybody here does. And pot is one that I really pay close attention to in the North Bay, because of all these people on medical marijuana cards. They have a sore back. Well, give me a break. So do I, but I don't smoke marijuana now. I did 40 some years ago as a young hipster, but I'm glad I stopped 40 years ago, because otherwise I'd be muddled and kind of down. THC is chemically structured like a neuromodulator called anandamide, which is Sanskrit for "bliss." It orchestrates the activity of a number of neurotransmitters, so when you're stoned you get what we call virtual novelty. "Look at this cup! God, that is so incredible. Look at the way it's shaped, and the colors! This is amazing." Then the next day you get what we would call in the '60s "jelly brain," because everything's downregulated now. And you never get the same high.

So now what we see are all these people smoking medical marijuana who have low-grade depression. They can't remember much, because they downregulate the acetylcholine release in their hippocampus and have symptoms very much like ADD. God, I get people with ADD evals all the time who are smoking marijuana.

So with regard to substance abuse, psychotherapists should perform a full analysis of everything the clients are doing, instead of saying such things as, "Do you abuse alcohol?" I want to know what they're consuming rather than ask blanket questions.

JA: Exactly. But if somebody's drinking two, I'm concerned about that, especially if she's anxious or depressed. Or if somebody's taking a toke of marijuana a night, and he's coming in with this low-grade depression, muddled thinking, and attentional problems, I'm concerned about that.

JA: We're always a little too symptom focused. I still think we ought to be paying attention to symptoms—that's an important part of the picture—but we also ought to pay attention to what clients are telling us about their overall improvement and their perspective in life: "I'm feeling so much more hopeful and so much more resilient and I'm not as easily stressed." And we're getting more of that from the outcome management process, instead of, "You originally came in with these panic symptoms. How's the panic doing?" "Oh, I don't have those panic symptoms anymore." Well, that's good. That's only part of the picture, though. There's got to be a larger look at things: is the relationship improved, for instance?

JA: What got me intensely concerned and preceded the development of Brain-Based Therapy was typified by an answer to the question, "What do you want to do in the next year?" In the Kaiser Northern California, we have 60 postdocs in 20 medical centers, and another 50 interns. When I interview a postdoc and ask, "What do you want to do over the next year?" they say, "I really want to find my theoretical home." You want to what? We're certainly not going to be helping you find your theoretical home. In fact, I want to dissolve those theoretical homes into a grand unified area. So that's a concern.

And a lot of young therapists come out of these schools too young and inexperienced—they haven't had to go out in the world and learn business and all this, to augment their academic understanding. Between undergraduate and graduate, I spent a year in Asia and the Middle East, and I just kept circling the globe. I was gone for a year, and I don't know how many countries I visited. What an incredible education. I matured so much during that period.

Life experience is critically important. Having to deal with some stressful events can really help a therapist. Just being pumped out of all these professional schools with all these fancy degrees and all that, boy, that's such a limited area. I get a little concerned about too-young therapists being plopped out and wanting to be Dr. Somebody-or-other.

JA: That's a pretty interesting question. I remember when I was being interviewed for my PhD program, that was a question in the interview. I was in the Counseling Psych department, even though I later got involved in both departments. I was really into talking about Dostoevsky and D. H. Lawrence, and that perked up the interest of the interviewers. Contrast this with the clinical program applicants—I call them the GREs. All they got was a high GRE score and a good GPA. Big deal!

JA: If you immediately go from a bachelor's to a master's and, usually, especially the professional schools, straight to a PhD program, I see a lot of that. And physicians, unfortunately, hardly read at all. It's just shocking that the educational system kills the quest for reading in diverse areas. It's amazing.

Therapists don't read enough. And when they do read, unfortunately, they read in their own little clubhouse. Where you get more cognitive reserve, if you will, is where you step out of your own zone of comfort. I particularly like to step out of all these mental health areas completely and pay attention to what other scientists are doing.

Particularly, I love complexity theory. When I'm back in Santa Fe, I like to go to the Santa Fe Institute. This place is incredible—founded by three Nobel laureates, two physicists, and an economist. And then there are biologists and computer scientists and archaeologists, all talking about the change in complex systems. Well, aren't we a complex system?

So I think we don't read enough, and not only of another psychotherapeutic school, but, also another area of science. It would be really good for us to do that on a regular basis. I'm perpetually advocating for that.

JA: Yeah. In fact, in the Sonoma State University, there's the Hutchins School, which is very much like St. John's College in Santa Fe, whereby you have more of an interdisciplinary approach. At St. John's it's more of a classics approach, but at Hutchins, you have a department with anthropologists and biologists and other people all there. It's that interdisciplinary approach that I think is so valuable.

JA: I don't necessarily see Kaiser as being a CBT mental-health dispensary. I'd look around at all my colleagues, and one person might be into EMDR, another person CBT, another person steeped in psychodynamic or narrative. But we do pay attention to evidence-based practice. In fact, we have a whole administrative structure just for that. But we also have an administrative structure just for outcome management. The convergence of the two is pretty important.

JA: That's kind of old news—20 years old. All departments are graded for access right now. I was hired during the Model of Care, which was 20 years ago, where we tripled or quadrupled the size of many departments because it was all about access. Every department now is graded on how quickly a client can come to see someone. If you call in right now, we've got to give you an appointment within two weeks. That's called initial access for the new, and there's a seen-to-seen that we're being graded in, too. We've improved dramatically in the last 20 years.

JA: Kaiser's in a difficult position because it's swimming in this vast sea of other medical providers, and it's trying to survive at the same time as thrive—to use that term. So I know what those folks are saying, and we're not immune from any criticism. There are always these concerns about improving, and that's a good thing.

JA: Absolutely. Access is critically important. I know that we're trying to do whatever we can. I'm in meeting after meeting about improving access. We're always talking about improving access, while at the same time we're talking about hiring new people. But where are you going to get the money to hire the new people unless the membership rates go up? It's a complex situation.

JA: That there is this exciting sea change occurring in mental health, if you pay close attention to it and if you read voraciously. Just because you're out of graduate school, we don't want you to stop reading. We don't want you to get rigor mortis. In fact, we want you to now read more than you read before, and go to more workshops in areas that you don't even have any interest in initially. That's where you get the best change, really, is if you go, "I have no idea what that person is going to be presenting over there." Those are the ones you want to go to, rather than, "Yeah, I'm really into that kind of therapy." How many more times are you going to hear that particular frame with a little bit of a twist to it here and there? In fact, you get more neuroplasticity if you get into an area you have no knowledge about at all. What we want to do for this next generation of therapists is to be integrators and to be active consumers of diverse areas of science.

JA: I'm concerned about the economy affecting mental healthcare and, again, as somebody who in the '70s and '80s was helping people who were chronically mentally ill and homeless, I'm really concerned about mental healthcare for the poor. Here I'm in Kaiser right now, and who are the Kaiser members? Well, they're people with jobs. So I'm really concerned about the disadvantaged groups, and that has a political component, too, because if we go Tea Party zone, you're talking about massive cuts in the safety net, and it's pretty primitive.

Into the more advantaged stratum, I'm concerned that, even though I think there's a sea change going on, it could go the other way—the continued focus on these clubhouses. But I'm heartened that things are going to change eventually. I'm totally convinced that they will, because of these converging fields. When it will happen is another thing. It might be more in your generation and in my son's generation who, like you, is applying for graduate schools right now, than my generation. I think for quite a while, we're still going to have the gurus out there. But hopefully they will be talking in more integrative ways and less about themselves, so to speak.