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Ruth Cohn
   
Old Dog New Tricks
Enter Neurofeedback

"Attachment is the fundamental drive in human beings. It is a drive that brings aggression and sexuality to its defense and to its enhancement, and it is the precursor to human love. It is gained through the delicate interplay of vocal tone and facial expression, through body to body communication, through the dyadic system of care that develops when the mother attunes to her baby. When attachment fails through the significant interruption or destruction of this system, the infant suffers not only what appears to be irreparable emotional harm but significant brain damage."
Sebern Fisher1

Just as I began to hope I might soon settle down into the tranquility and wisdom of middle age, I find myself running around the country to trainings, poring over brain twisting books, spending all my money on consultation and scrambling up a wall-steep learning curve.  It all began at the annual Boston trauma conference last June. I've been attending it religiously over twenty years, it is where I have often first learned of what would next inform or revolutionize my practice. It was there that I first heard Bessel van der Kolk talk about the traumatized brain; it was there that I first heard Allan Schore speak about attachment neuroscience; Pat Ogden and Peter Levine talk about trauma and the body; and Francine Shapiro's discovery of EMDR. But over the last few years there has not been much there that was new to me. I figured the trauma field had begun to plateau. This year I thought I was just going to see my friends.

I was surprised to find something new to me being showcased there; neurofeedback. In particular a practitioner named Sebern Fisher presented cases and described work with complex PTSD and Dissociative Disorders, showing video clips of clients saying such things as "What we achieved in a year and a half with neurofeedback, would have taken me a whole lifetime of any other kind of psychotherapy.“ I was intrigued. I had never even heard of this.

Admittedly I have never been able to make peace with how long it takes to heal trauma, or for that matter how long psychotherapy takes. It seems profoundly unjust that people must not only suffer horrors, indignities and injuries in childhood or whenever during their lives, and continue paying for years for what they never asked for. The quest for a methodology to expedite this has always motivated me to learn more and better methods. I listened to Sebern and others. A number of presenters who work with children talked about ADD, ADHD and Autism spectrum disorders, and seeing remarkable results in ten or twenty weeks of twice a week 30-minute sessions. Only because it was this conference, organized by someone as highly esteemed, brilliant and research based as van der Kolk, could I consider believing what I was hearing.

I promptly came home, and after signing up for the training, went out in pursuit of a neurofeedback practitioner. I always insist on experiencing first hand, any methodology I intend to practice. I was surprised to find few neurofeedback therapists in the Bay Area. I ended up with a woman in Palo Alto and began my ritual schlep down to the Peninsula every week.

After about the second session, I was amazed to find myself feeling astonishingly calmer and happier, and things just didn't bother me. I continued the sessions for a total of about 20, over about 6 months. I was repeatedly amazed at the changes I observed in myself. Always right on the edge of being OCD, I observed my character loosening and becoming more flexible. Things I had chronically been anxious or even scared about seemed to spontaneously fall away, my husband with his jaw on the floor observed me rather effortlessly making decisions that would have been unthinkable for me before. Clearly my brain was changing, and so differently from how I had ever before experienced myself changing through psychotherapy. It was not by will, effort or intention, but simply showing up for the sessions and submitting to a truly effortless process. The only effort really was the schlep to Palo Alto. So I have embarked on a journey, attempting to make sense out of this. I took the training, and have begun to practice and observe what happens with clients in this most remarkable process.

Peak Performance for Every Brain

So what then is this neurofeedback? It emerged in the 1960's out of biofeedback. In effect it is operant conditioning, not unlike dog training. As I explain to clients, when the puppy pees outside you give her a cookie. Every time she successfully pees outside you praise her and give her a cookie. After a while, you don't have to give her a cookie anymore. She just knows to pee outside. Neurofeedback works according to the same principle.

The underlying theory is that in effect, all mental disorder (and many physical disorders too), are dysregulations of arousal. In the world of trauma we have known this for some time. The traumatized person, with an overactive amygdala, swings between hyperarousal and hypoarousal, with the gravest of his or her difficulties being the inability to self regulate, or calm down.

We also know from attachment neuroscience that the infant's brain develops in resonance with the brain of the good enough care giver. When the caregiver is dysregulated, dysregulating, or absent, the infant's brain development is destabilized or stalled. And the capacity for self regulating affect and experiencing essential calm and joy, is elusive at best.

Where the notion of dysregulated arousal was easy to integrate into my previous thinking. What I had never realized or thought about before, is the specifics of arousal, the actual firing of the brain. Neurons fire at different frequencies. When too many neurons fire at too high of a frequency, we experience hyperarousal, perhaps anxiety or rage. When too many neurons fire at too low a frequency, we might experience depression, numbing or dissociation.  

Of course different brain areas will have optimal ranges of firing frequencies. For example the prefrontal, executive functioning area of the brain optimally fires at a moderately high frequency required to sustain focus, concentration and mental energy. If frequencies are too low in the front of the brain, one might suffer diffuse attention; lack of motivation and follow through; or flat affect.

In the brainstem area, resides the function of calming the nervous system and body. If the back of the brain is firing too high, we are unable to calm down or sleep well. That is when the individual might be prone to substance abuse, overeating, compulsive behavior, or some activity pursued in the service of calming down. So in every brain, in each site of the brain, there are optimal frequencies, optimal levels of neuronal firing, and of course optimal ranges for desired function. We want the front of the brain to slow down in order to relax and sleep, we want it to perk up for driving or taking an exam. What neurofeedback does is train the brain to fire in its optimal range at any given site. It is peak performance training for any brain.

Mirroring and Validating

First attachment theory and later interpersonal neurobiology, have taught us that the brain develops in resonance. Through the experience of being mirrored and validated, through a consistent empathic response that comprehends and attends to her communication, the infant self emerges. The caregiver sees and communicates, “I see you, yes!” As Alan Schore2  and Daniel Siegel3 have taught us, through an interplay of right hemisphere to right hemisphere “contingent communication” the organ of the self, the brain grows, and with it the capacity to self regulate. Our offices are filled with young and old who lack or long for these experiences due to trauma, neglect, or some other loss or disruption. Their worst suffering is in the realm of relationship, which really is the most important thing there is.

That is what brought me to relationship work. The agony and loneliness of dysregulated relationship for many is unbearable. Besides psychotherapy, I learned one way to repair both the missing experience of mirroring and validation, and to heal the injury of relationship, to be in couple’s work that incorporates a communication style that is all about mirroring, validating and empathy.4 It works powerfully, and is probably the most difficult work I know from the client’s perspective. Often it takes time. Many of the injured are not so fortunate as to have a relationship within which to do such work, or are too troubled to tolerate its pain or duration. For some, their partners lack the stamina.

I believe that neurofeedback replicates the dynamic of mirroring and validating. Ironically the computer with its graphics or mechanized beeping reflects the rhythms of the brain waves back to the brain, indicating “Yes! That’s it! That’s good! Do that some more.” Hard wired for positive re-enfocement, the brain complies. Neurofeedback research with other mammals shows the same result. This makes intuitive sense to me. John Gottman the marriage researcher translated it to science 20 years ago, demonstrating that relationship stability requires a 5:1 ratio of positive to negative.5

Timing is Everything

So how does this stuff work? After a painstaking assessment process, the therapist determines which are the brain areas most central to the symptomatology. Of course in the case of trauma and many other attachment injuries, we know the amygdala is the key site. Electrodes are located on the scalp to be in contact with the site in question, and the computer is set to the optimal range of neuronal firing for that site. The complex science of brain wave rhythms is beyond the scope of this article. Suffice it to say, part of why the learning curve has been so steep for me, is that the therapist must become fluent at knowing about both anatomy and the electrical functioning of the brain. Where I was familiar with biochemistry and even a bit about cerebral blood flow as per neuroimaging spect technology, electrical firing was a whole new world to me. I have come to learn that timing is everything and has tremendous impact on neurochemistry and blood flow. The rate per second or per cycle at which neurons fire, as measured in hertz, is in effect they key to mental health, or so believe the practitioners and researchers of neurofeedback. When the timing of the brain’s firing is optimal symptoms disappear, even symptoms of which we were not aware.

The computer is set such as to monitor the rhythm of firing of the various brain waves. When they are firing in the optimal range for that wave, the computer emits a signal communicating “That’s good! That’s good!” It might be a beep or a gong or a picture on the computer screen. The positive feedback, like the puppy’s cookie, trains the brain to keep it up. And the brain does just that. Outside of its owner’s awareness, the brain continues the dance of firing in resonance with the computer and over time comes to prefer the rewarded rhythm. Like the puppy, over time, the reward is no longer required and the brain leaves its training wheels and keeps going that way. The computer does not add anything. It simply measures and reflects, mirrors and validates.

The client does not have to remember heinous scenes, feel painful emotions, does not even have to talk. The process goes on outside of the client’s awareness. For those jaded by years of therapy, sick to death of their own tired horror story, it is a dream come true. They can have healing essentially just by showing up. They can even fall asleep during the session and the brain keeps working and benefitting. Imagine being able to snooze and win!

It does sound too good to be true, I know. And yet my experience continues to be astonishing. One woman, Rhonda, was referred to me recently by her psychodynamic therapist. After many years of good therapy she had a traumatic athletic accident, not only terrifying but disfiguring. Even a year out from the trauma her symptoms would not abate. Both she and her therapist were frantic as her flashbacks and emotional activations began to jeopardize her employment. She was desperate enough to try anything.

Assessment revealed that Rhonda had a whole childhood of chronic abuse that exacerbated the adult trauma. After her first session of amygdala training she began to calm down. She felt hopeful, although she considered the possibility that it might be placebo, or the prospect of something different. But by the fourth session when both she and her therapist were amazed at her resilience and rapidly growing stability, in addition to the increasing calm and confidence, she already began referring her friends to me for neurofeedback. Even the physical pain of her injury was abating. This is only one of many examples of the wonders I have seen even in the short time I have been practicing. Of course it sounds like snake oil. It would have to me too if I had heard about it from anyone but van der Kolk. Seeing is believing.

So I am studying neuroanatomy and physiology (and a fair amount of arithmetic!) like a madwoman so inspired to learn this. It seems to be what I have long been searching for: a way to move people quickly through trauma, and really most any other affliction.  I am increasingly coming to believe, it is dysregulation of arousal, most often rooted in disordered attachment that underlies most if not all symptomatology and pathology. To me it makes sense.

Of course there are transference issues. I now touch my clients, pasting the electrodes on their head and ears. I am actively messing up my clients’ hair! And as Fisher points out6 the attachment disordered might relate to the computer like a rivalrous sibling, apparently compelling the therapist’s attention and interest.  I too have had these experiences. Yet as the brain gets trained, either the stability becomes available to work with the transference issue, or the symptom just simply vanishes.

Neurofeedback is not a substitute for relationship work or the depth work of psychotherapy.  Rather, like medication it may provide the stability requisite to making progress possible at all. Speaking of medication, many clients find that as the brain finds its peak performance zone, their medication dosage initially begin to feel like an overdose, and even eventually become superfluous. Another perk. The intrigued, curious or skeptical who wish to read more might have a look at www.eegspectrum.com which recommends readings and has archives of articles on many subjects. Or give me a call. Maybe I’ll hook you up!   

The perennial question is, why doesn’t anyone know about this? First I would say is the old koan about research money: it takes large scale research to gain validity in today’s world. In order to get research grants a certain amount of validity is required, to warrant the investment; and of course the way to the validity is the large scale research... The deep pockets for research money are with the government and the pharmaceutical companies. So people like van der Kolk fight for grant money from the National Institute of Health. Fortunately he is intrepid and tireless. As for the pharmaceutical companies, why would they consider funding research for a methodology that promptly gets large numbers of people off their meds?  

Additionally touchy feely and/or deeply feeling therapists, not unlike myself, might balk at a methodology with a beeping computer as its medium, likening it to the monkey baby’s wire mother. My 20 year old niece, now an undergraduate studying for a career in psychology recently said to me, “This works so quickly, aren’t you worried that everyone will get better so fast that you won’t have any clients?”

References

1. Fisher, Sebern F. Neurofeedback: A Treatment for Reactive Attachment Disorder  From the web site of EEG Spectrum International
2. Schore, Allan, Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Development. New York. Lawrence Erlbaum Associates Inc. 1994
3. Siegel, Daniel, The Developing Mind: Toward a Neurobiology of Interpersonal Experience. Guilford Press. New York. 1999
4. Hendrix, Harville, Getting the Love You Want, A Guide for Couples. Henry Holt and Company. New York. 1988
5. Gottman, John, Why Marriages Succeed or Fail: And How You Can Make Yours Last. Simon and Schuster. New York. 1995
6. Fisher, Sebern F., On Becoming a Neurofeedback Therapist: Thoughts on the Integration of Psychotherapy and Neurofeedback. From the web site of EEG
   Spectrum International.

Ruth Cohn, MFT and AASECT Certified Sex Therapist, is in private practice in Oakland, CA. Also certified in EMDR and Sensorimotor Psychotherapy, she specializes in work wih adults with histories of childhood trauma and neglect and their intimate partners and families. She is currently preparing for certification in EEG Neurofeedback. She can be reached at cohnruth@aol.com or www.cominghometopassion.com.

© 2010