The Neuro Files: Innovations in Brain-Based Trauma Treatment

One of the astonishing things about entering my sixth decade, or what I fondly refer to as my “low six figures,” is hearing myself refer to life events from 30 and 40 years ago. Reading Bessel van der Kolk’s recent book, The Body Keeps the Score (2015), I felt I was revisiting my professional journey of over 30 years as it paralleled the evolution of the subfield of psychological trauma. I had the good fortune and challenge of getting in on the ground floor, starting my career shortly after the advent of the PTSD diagnosis in 1980. I also had the privilege of sharing my discoveries, free associations, and assorted wonderings in a decades-long series of Viewpoint articles, where my trajectory is perhaps loosely archived. What a long, strange trip it’s been.

Working directly with the brain’s hyperarousal and hypoarousal systems meant that clients could process trauma without having to remember or relive their agonizing and tired old trauma stories. In my experience, this has been the most successful approach yet.

Looking back, I am proud to recall that the trauma subfield was perhaps the first to become deeply interested in, and intent upon, integrating an understanding of the brain into the work of psychotherapy. Before that time, medications were the domain of psychiatrists, and the realm of the brain and body was essentially divorced from our work. In the words of brain scan pioneer Daniel Amen, “I just don’t get it. Why are we the only medical specialists who never look at the organ we treat?” (Sykes-Wiley, 2005, p. 44).

Early on, trauma researchers and practitioners began to study and comprehend that trauma, which by definition was overwhelming experience, bombarded the nervous system with stimuli greater than it could process in its usual way. Rather than follow the usual sequence of perception by the sense organs, sorting and filing by the hippocampus, and ultimate logging in the appropriate area of the cortex, these researchers found that splintered fragments of sensory, cognitive, and emotional memory were scattered and stored separately and randomly—or not at all—in distinct regions of the brain. Resulting inconsistency and distortion of explicit memory spawned controversy and inspired more research about the function and dysfunction of the traumatized brain.

The intense nightmares and flashbacks of war veterans and long-delayed recall and memory experienced via the body and emotion in victims of rape and many forms of abuse served as the mothers of invention. The late 1980s, following the epoch-making appearance of Prozac and the subsequent family of selective serotonin reuptake inhibitors (SSRIs), brought us quirky and mysterious innovations like EMDR (Eye Movement Desensitization and Reprocessing), which is still not fully understood. EMDR seems to accelerate the processing of traumatic material through a combination of exposure to the available memory material and bilateral stimulation via side-to-side eye movement, alternating sounds, or tapping on alternate sides of the body, from right to left. Although the research was inconclusive and the skepticism and debate in the larger psychotherapy world ran hot, EMDR seemed to work much more successfully and rapidly than other approaches.

In my now fairly lengthy tenure in psychotherapy, I have believed, and I’ve advised anyone who cared to listen to me, that the key to being a good therapist is to get the best consultant (in the field you are trying to learn) that money can buy, tell her everything that is going on in the room, and take direction from her or those few others whose opinion is both credible and preferably evidence-based. During an era in which new and often gimmicky approaches appeared almost weekly (and we did not even have the Internet to disseminate them), my little homily served me well. Following the lead of my trusted counsel, I doggedly studied and practiced EMDR while the research progressed. At that point, it was the best we had, and I enthusiastically embraced it. Although EMDR is still not fully understood, in time even the Veteran’s Administration incorporated it.

The 1990s were declared the “Decade of the Brain.” The advent of neuroimaging technology enabled scientists and medical practitioners to view the living, working brain, resulting in burgeoning research and dramatic advances in the field of neuroscience. As a world community, we have learned more about the brain and nervous system in the last 25 years than in all previous history combined. Researchers and theorists in the field of attachment (Schore, 1993; Siegel, 1999) began to conceptualize not only how the infant brain develops in resonance with that of the primary caregiver but also how the child’s capacity to regulate her/his own nervous system—that is, to manage the natural vicissitudes of emotional and physiological arousal—is learned from attuned interaction with a regulating other. Children who have sustained interpersonal trauma are likely to have missed this key experience. So not only is overwhelming experience fundamentally dysregulating, with its extremes of emotional and physiological arousal, but the ability to manage and recover from dramatic ups and downs is often sorely lacking. These factors in combination give rise to the complex behaviors and defenses we see in traumatized individuals.

In 1995 another pioneering neuroscience discovery profoundly affected the direction of trauma therapy (Rauch et al., 1996). Researchers scanning subjects’ brains during induced traumatic flashbacks observed that in trauma, the imperative of survival requires that much or all of the brain’s energy be mobilized to fight or escape the perceived danger. The less survival-based regulating, cognitive, and verbal areas of the left prefrontal cortex partially or even completely shut down, leaving the individual in a state of literally speechless terror. An important consequence for trauma therapy, researchers learned, was that if verbal and cognitive brain areas went offline during the trauma, possibly significant aspects of the trauma material would be inaccessible for processing by traditional cognitive and verbal therapeutic means. In short, there were aspects of experience that the “talking cure” simply could not reach.

Pioneers such as Peter Levine (2010) and Pat Ogden (2006) developed carefully and thoughtfully elaborated somatic approaches utilizing the lessons from neuroscience. Ogden’s Sensorimotor Psychotherapy and, to a lesser extent, Levine’s Somatic Experiencing became my next major undertakings. These methods, though not necessarily rapid, were effective, as they attended to the body experience, tracking sensation and connecting it to emotion and often imagery. Puzzle pieces of fragmented memory slowly became integrated and wholeness was ultimately restored.

I set out to amass an armamentarium of modalities for trauma processing because it so frustrated and angered me that after the profound insult of traumatic experience, recovery was often painfully protracted and arduous. I found myself on a quest to discover ways to speed up recovery and help clients free themselves more quickly from the chronic re-experiencing of past horrors.

In 2010, neurofeedback for trauma treatment arrived on the scene (Fisher, 2014). Used for many years as a treatment for epilepsy, addiction, and ADHD, neurofeedback—essentially biofeedback with the brain’s electrical system—was new to the field of trauma treatment. Biofeedback is a form of operant conditioning, whereby individuals can learn to control seemingly involuntary biological processes from the experience of receiving positive feedback when such process is intentionally achieved. Via the positive reinforcement, the function becomes fluent and habitual. Neurofeedback was my next deep field of study, and it involved the steepest learning curve of my career. Faced with detailed physiology, elaborate technology, and the world of machines, I was way out of my element—but highly motivated. Working directly with the brain’s hyperarousal and hypoarousal systems meant that clients could process trauma without having to remember or relive their agonizing and tired old trauma stories. In my experience, this has been the most successful approach yet, although sometimes I stop and marvel at the plethora of electronic devices that now dominate my psychotherapy office. I ponder my 30-plus years of treating trauma, beginning with the base of psychodynamic and attachment theory, and layering on newer approaches generated by an increasingly sophisticated body of science about trauma and the brain.

I will not say much about neurofeedback here, both because I have written about it previously in Viewpoint (Cohn, 2010) and because I want to tell a new story here. From the very start of my neurofeedback practice, I had the good fortune to work with the person I now believe to be the most brilliant neurofeedback clinician in the country, Sebern Fisher, as my consultant. Again, I was lucky in my timing, because later, when her book Neurofeedback in the Treatment of Developmental Trauma: Calming the Fear-Driven Brain was published and she became a celebrity in high demand, I already had an established and secure spot on her weekly calendar.

In the fall of 2014, Sebern began talking with me about something new she was experimenting with, a device called Nexalin. So far, there is little research on it. Nexalin is another direct, brain-focused modality. But unlike neurofeedback, which does not stimulate or add anything to the brain, only giving feedback on what the brain is already doing, Nexalin emits a low dose of a high-frequency current, presumably targeting deeper brain structures than we can access with neurofeedback. These deeper structures include the brainstem, which houses control of the most primitive bodily functions relating to arousal.

The manufacturers describe Nexalin as a treatment for anxiety, depression, and insomnia. Given that these three are all sequelae of trauma, it would seem a likely treatment for trauma as well. My consultant was finding that Nexalin seemed to be getting results with some of her most challenging “neurofeedback non-responders.” Of course I was intrigued and eager try out this new approach myself.

When I spoke to Nexalin representatives, however, I learned that the device was wildly expensive and that the company only rented rather than sold them. I dithered about whether I wanted to take on something akin to an additional monthly mortgage payment, where to break even, I would have to charge a hefty fee for a methodology that no one had even heard of. Nonetheless, I couldn’t resist what I was hearing about its “amazing” effects, so I decided to go for it.

The recommended Nexalin protocol is 10 to 15 consecutive daily sessions (with weekends off), which amounts to two to three weeks of daily sessions. During sessions, clients can sleep, read, watch a movie, or engage in a full-on psychotherapy session (even Sensorimotor Psychotherapy) while hooked up, as long as they do not move their heads and dislodge the electrodes. I later discovered that for an attachment theory-oriented, non-analyst like me, the opportunity to do daily psychotherapy for two weeks was a tremendous boon to the work, even apart from the Nexalin factor; the combination of daily sessions and Nexalin was a powerful elixir.

As with all the other methodologies I practice (and like many of us, I’m sure), my first practice client and research subject was myself. I administered the initial 10 daily, 40-minute sessions to myself, and although during the sessions I enjoyed a delicious, deep, and restorative sleep, at the end of 10 days I found myself sheepishly disappointed. I did not notice anything notably different in myself. Had I been duped? Or was I a Nexalin non-responder? Either way, I did not want to tell anyone. So I kept sadly quiet. But some three or four weeks later, after I had stopped the intense self-scrutiny for any change, I began to notice some dramatic—even transformative—changes in myself. There were several big ones, but I will describe just one of them here.

For almost 46 years (wow, there it is again!), I have been a serious bicyclist. From the start, I was always a strong climber and could beat even the most tenacious and competitive male riders up the mountain. On the downhill, however, I was, from the start, a brakeclutching, scared old lady. I desperately feared and dreaded the descent, and this fear and dread had plagued my bicycling life for all the subsequent decades. My husband and I had long worked out a rhythm where I waited for him at the top of the mountain and he waited for me at the bottom.

On a bike ride subsequent to my Nexalin sequence, I was stunned to discover that I was suddenly, miraculously fearless. With brand-new chutzpah, I found myself cresting a high mountain and flying down the hill, leaning through the hairpin turns, accelerating on the straight stretches, and passing everyone. I was still mindful and careful, but not excessively so. I barely recognized myself.

Most of all, far from terror and dread, and even beyond the awe at the change, I loved the experience! Suddenly, I was exhilarated and thrilled by the experience of speed. To my amazement, this change has continued now for over six months. I have begun looking forward to both the swift ascent and the euphoric flight down. It was true what my consultant had said: “Fear is fear.” When we process the arousal of fear, it will transform any and all of them, even those we may never have imagined or targeted. Meanwhile, I have morphed into the Little Old Lady from Pasadena.

So Nexalin is the latest of the trauma-processing tools I use with clients. I have seen some dramatic shifts out of debilitating depression and anxiety, integration of dissociated parts, and some more subtle changes in the deepening of affect, which tends to improve outcomes for anhedonic and depressed individuals. Some clients have responded at lightening speed, while others, like myself, improve with a time delay. Still others have responded

little. I am experimenting with taking some new clients through the 10-session sequence prior to beginning neurofeedback, sex therapy, or couple’s work to see if it might serve as a jump-start. It is informal but fascinating research. For me, the trail remains uncharted and unpredictable, just as it has been over the last 30 years. The journey continues. As I am fond of saying to myself: “Go Granny, Go!”

References

Cohn, R. (2010). Old dog, new tricks: Enter neurofeedback. Viewpoint, 3. 1-9.

Fisher, S. (2014). Neurofeedback in the treatment of developmental trauma: Calming the fear-driven brain. New York: Norton.

Levine, P. (2010). In an unspoken voice: How the body releases trauma and restores goodness. Berkeley: North Atlantic Books.

Ogden, P., Minton, K. & Pain, C. (2006). Trauma and the body: A sensorimotor approach to psychotherapy. New York: Norton.

Rausch, S. L., van der Kolk, B. A., Fisher, R. E., Alpert, N. M., Orr, S. P., Savage, C. R.,…Pitman, R. K. (1996). A symptom provocation study of posttraumatic stress disorder using positron emission tomography and script driven imagery. Archives of General Psychiatry, 53, 380-387.

Schore, A. (1994). Affect regulation and the origin of the self: The neurobiology of emotional development. New Jersey: Erlbaum.

Siegel, D. (1999). The developing mind: Toward a neurobiology of interpersonal experience. New York: Guilford.

Sykes-Wylie, M. (2005). Visionary or voodoo: Daniel Amen’s crusade has some neuroscientists up in arms. Psychotherapy Networker, Sept/Oct. 1 (Abstract).

van der Kolk, B. (2015). The body keeps the score: Brain, mind and body in the healing of trauma. New York: Viking.

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Old Dog New Tricks: Enter Neurofeedback

Old Dog New Tricks: Enter Neurofeedback

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.

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