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The Rise and Fall of PaxMedica

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Welcome to the new era of brain-based therapy

By John Arden and Lloyd Linford

In the late 1890s, Sigmund Freud, then a highly respected neurologist, abandoned his attempt to create a "scientific psychology" grounded in neuroscience because knowledge about the physical brain was just too primitive. Instead, he had to settle for studying the processes of the mind, which didn't turn out too badly, considering he virtually founded the entire field of modern psychotherapy. Now, a century later, Freud's abandoned dream shows signs of resurrection. An unprecedented outpouring of discoveries in brain science are beginning to affect how therapists think about and practice psychotherapy—possibly bringing the most significant transformation in our field since the invention of psychoanalysis.

We believe we're seeing a dynamic new understanding of how psychotherapy works and how it actually affects the neurophysiology of our clients. We call this new vision of treatment "brain-based therapy," a way of approaching the therapeutic task that draws upon a combination of neuroscience, developmental psychology, psychotherapy research, and complexity theory. While all of this may sound complicated, it carries forward the single most important and powerful aspect of traditional psychotherapy: a healing conversation that transforms mental and emotional suffering. What we're discovering about neuroscience promises to help us understand the question that's beguiled therapists from the beginning: How can a simple conversation—or, as Freud called, it the "talking cure"—change the brain?

This potentially revolutionary new era represents a decided break with therapy as we know it, and particularly with the mainstream therapy of the last 30 years. During the last three decades, a medicalized view of how to think about, classify, and treat mental and emotional problems has become the default therapeutic position for the field. We refer to this institutionalized therapeutic worldview as "Pax Medica," a term adapted from the Pax Romana—the 200-year period of relative peace and conformity that the Roman emperor Augustus initiated among the far-flung lands of the Roman Empire in 27 B.C., thus halting many decades of civil wars, foreign invasions, and other threats to harmony and good order. Like the Pax Romana, the Pax Medica brought a sense of stability, coherence, and legitimacy to the then-fragmented culture of therapy, but it created its own hegemony—heavily influenced by the medical model—which has dominated the therapy field down to the very language we use to describe our work.

The Pax Medica would have seemed an unlikely development during the first 60 years of the 20th century, when psychoanalysis and psychodynamic therapy were just about the only game in town. Indeed, if you had a mental health problem prior to the later 1960s, you generally spent years uncovering subconscious drives, conflicts, repressions, and transference dynamics with a studiously neutral, analytically trained therapist. Those with severe mental illness, not considered "good candidates" for analysis or psychodynamic therapy, received draconian, physical treatments—electroshock, ice baths, insulin treatment, neurosurgery, and lobotomy. In neither category of treatment—soft or hard—did anybody appear to give the least thought to the completely mysterious, indecipherable, and largely irrelevant object located behind your forehead.

By the late '60s, however, the old models were beginning to lose their magisterial dominance. While most of Freud's professional heirs, unlike Freud himself, showed, at best, blithe indifference to empirical inquiry into whether their methods actually accomplished anything, in the early 1950s, one maverick experimental psychologist, Hans Eysenck, actually researched the question, "Does analytically based therapy work?" After reviewing the outcome literature, such as it was, he came out with the scandalous answer, "No!" Psychotherapy, he wrote, showed itself no more effective "than the mere passage of time." Unsurprisingly, the establishment paid no attention to him at all.

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