point-view

The Rise of Neurofeedback

Technology in the Treatment Room

Magazine Issue
November/December 2017
A headshot of a woman

While technology continues to transform almost every profession, even rendering many of them obsolete, the practice of psychotherapy has remained largely untouched by hi-tech equipment. Sure, most therapists these days have their websites and spend more time than ever communicating with clients via digital devices. But if you were to go into their therapy offices, you’d see little evidence that much has evolved beyond the conversational exchange that’s been our field’s hallmark since the days of Freud—except, of course, if you were to visit a therapist who provides neurofeedback.

Neurofeedback was first developed almost 60 years ago to help people control epileptic seizures by learning to regulate their brainwave activity. Since then it’s developed into a technology that helps clients change their brainwave frequency as a way to reduce symptoms ranging from anxiety, phobias, and depression to personality disorders and PTSD. Prominent among neurofeedback’s advocates has been trauma expert Bessel van der Kolk, author of The Body Keeps the Score, who’s tried to shine a spotlight onto the growing evidence of its therapeutic potency. Commenting on neurofeedback’s effectiveness with a group of traumatized children, he said in a recent workshop, “I was blown away by their development. There’s nothing I know that can do that. When you see something like that, you pay attention.”

Since the 1990s, psychotherapist Sebern Fisher has been a pioneer in bringing neurofeedback into the mainstream of clinical practice. With a background in psychodynamic therapy and attachment theory, she integrates neurofeedback into her practice with clients using a computer that captures their EEG, and with feedback their brains learn to change and control bioelectric activity. As she says in her book Neurofeedback in the Treatment of Developmental Trauma: Calming the Fear-Driven Brain, this training in self-regulation is essential to quieting symptoms enough to free clients to confront their underlying issues. Recently, she took time out from her practice to share her approach and describe its promise for the future.

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RH: How were you introduced to neurofeedback?

FISHER: Back in the mid-1990s, I was the clinical director of a residential treatment center for severely disturbed adolescents. We used conventional approaches, but one day some friends in the field suggested that I might be able to help these kids even more by having them control a video game while electrodes were attached to their skull. I was skeptical but intrigued. So one of these friends, who had a neurofeedback system, asked me if I wanted to try it myself, knowing I was a meditator with a strong interest in exploring my internal states.

I’m not recommending this, but we trained over a long weekend for hours, and it ended up being a truly life-changing event. It was the first period of time that I wasn’t living in ambient fear. Most trauma survivors, like me, live in survival mode, and the affects that go with that are fear, shame, and rage. All those affects diminished with one weekend of neurofeedback, particularly the fear. I immediately went to learn how it worked and how to provide it.

RH: How do you explain that result?

FISHER: Regulation is what the brain does for the body and the mind. Now I recognize that weekend quieted fear circuits. What I experienced was indicative of all the ways that developmental trauma bumps you off that regulation and that neurofeedback can help people establish it.

RH: You were trained in psychodynamic and attachment-based approaches. How does neurofeedback fit with psychodynamic work?

FISHER: Marsha Linehan, the founder of dialectical behavior therapy (DBT), and I have been friends since we were 19. She always tried to convince me with data that DBT was a better approach than dynamic ones. Once I started neurofeedback, she said, “Now you have to admit that you’re a radical behaviorist,” but I still believe in psychodynamic causation. In my world, a client’s history is incredibly important. I’ve never seen people lose their sense of terror with skills training or interpretation alone. I think they manage it better, but managing hell better is still hell. My goal now, as always, is to help my clients ease the fear and the shame—the limbic problems.

RH: Fear and shame are limbic problems?

FISHER: Well, they’re limbically driven. They’re subcortical, usually right-hemisphere-driven affects, and the cortex isn’t developed adequately to quiet them down. Helping a client build cortical structure is what good-enough mothering does. You can’t learn or regulate—you can’t really have good relationships—without the cortical inhibition of the fear circuits in the brain.

RH: You’ve been able to see how neurofeedback can help someone with an anxious attachment style gain a sense of security. What does it look like?

FISHER: I had an experience with a feral little boy who initially wasn’t a therapy candidate at all. In play therapy, he’d knock everything over, and the only words he used were “no, no, no,” along with plenty of swear words. He also couldn’t sleep and had night terrors. At first, the foster parents had to hold him while he did the neurofeedback training, but after the training, he slept an entire night for the first time.

RH: The parents must have been thrilled!

FISHER: He continued with psychotherapy, and the work of parenting could go on. Once these kids begin neurofeedback, very few want to stop. It allows them to tolerate being held instead of always pushing people away. They get quieter and calmer. They discover what containment of their nervous system feels like.

RH: What does a typical neurofeedback session with you look like?

FISHER: For clients of all ages, I first do a lengthy clinical assessment with questions about their physical as well as emotional health. I need to know about bowel function, head injuries, whether there’s a seizure disorder. I’m assessing for the pitch of their nervous system with every question. Most people who end up coming in for neurofeedback have high arousal and emotional reactivity.

RH: So you’re helping them manage brain arousal.

FISHER: Yes. They can also have instability of arousal. Bipolar illness and panic attacks are examples of this. Through assessment I figure out what treatment protocols to begin with from the information I’m getting, and then I’ll do brain training based on a hypothesis of what this brain is trying to tell me from this assessment. Typically, a brain-training session lasts between 9 and 12 minutes.

The client, or trainee, sits in a chair, and the assessment tells me where to put the electrodes and what frequency to ask the brain to make. Neurofeedback teaches people how to change the frequency at which their brains fire. By looking at a video game that corresponds directly with the frequencies on the screen, clients learn through the game if they’re making too much slow wave, or too much fast wave, and if they’re making the frequency they’ve been asked to make.

They have to learn to accomplish three separate tasks: make less slow wave, make less fast wave, and make more of the frequency we’ve chosen to reward. The goal is to find the place that feels good to their nervous system; it’s entirely personalized. I can usually get close from a clinical assessment, but from then on, the brain is telling me they liked it or they didn’t like it. So if somebody has always had nightmares and starts not to have any, or if they describe themselves as having a fun encounter at a coffee shop instead of withering into a corner, I say we’re on the right track.

Some people get sleepy after sessions, so I remind them to be aware of their driving. Typically, they come back twice a week at the beginning of training. This gives me an idea of what the training has done and time to do it again in close succession. If you wait too long before you repeat a session, the brain goes back to what it’s known before. What we’re trying to do is get the brain to practice new patterns.

RH: Do the neurofeedback sessions involve exposure? Is it like EMDR, where clients are encouraged to recall the traumatic event while training?

FISHER: Trauma response at the level of the brain is repetitive firing of fear circuits in response to certain stimuli. The stimuli could be external, like the loud pop of a firecracker for the traumatized vet, or the smell of a certain cologne for a rape victim. Or it could be internal, like the thought of the mother’s boyfriend coming through the door. Every time these circuits fire together, they strengthen their connectivity, and they’ll fire together more readily the next time.

Our goal with neurofeedback is to help the brain learn not to fire like this. It’s best if there’s no exposure, to give the traumatized brain a chance to quiet the fear response. Of course, with developmental trauma, people are usually exposed to plenty of moments in vivo, so I don’t need to add any more challenges.

RH: Do the neurofeedback results inform the dynamic attachment work that you’re doing?

FISHER: Yes, very much so. Ultimately, it’s not neurofeedback that’s healing. It’s the ability to have good relationships and sustain them over time. I expect my clients to warm up and find these relationships. It can take a while. You don’t always see that right away.

RH: But do some people experience profound changes quickly through neurofeedback?

FISHER: A woman who’d been in therapy for 20 years, had done DBT work, and had been hospitalized many times came in and said, “Therapy isn’t working. I want to train my brain.” She could barely work, and was on six psychotropic medicines. Now, she’s working full-time as a certified nursing assistant. She’s no longer on medication, loves her career, and is part of a Buddhist sangha. She often says, “I’m just not the same person I was.” And this is someone who started neurofeedback at age 50. Of course, a period of grieving can follow this much improvement: people may feel that they’ve spent their entire lives living in so much torment when help might’ve been available.

RH: Is there ever a time when neurofeedback isn’t helpful?

FISHER: There are individuals whose brains don’t train. We don’t know why. I’d say between 80 and 90 percent of clients do benefit, but some will fall into that 10 to 20 percent.

RH: What about someone who doesn’t have a trauma history?

FISHER: This is becoming a less well-kept secret, but Olympic athletes all over the world are now using neurofeedback. After all, being the fastest person down the hill in the giant slalom race requires the best possible timing in the brain. Additionally, sometimes when I’m training for other issues, people naturally stop drinking, or their putting game gets better, or they start to sing, or they dance. Rhythmic activities and the things that take a certain amount of precision and quietude all improve.

RH: So it’s a peak-performance tool as well?

FISHER: I don’t see those people very much, but I’ve worked with a couple of top athletes and a singer who performs at the Met; he gained an octave after brain training. He didn’t believe it’d be possible, but that’s the plasticity of the brain.

RH: Is the field of neurofeedback growing?

FISHER: Yes, one example is that monastics at Plum Village, Thich Nhat Hanh’s retreat center in southern France, have begun to explore neurofeedback as part of their practice. They’re calling it “Brainfulness.” Clinicians with Cambridge Behavioral Health (the public mental health arm of Harvard) were just trained in neurofeedback. It’s coming along fast.

 

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Ryan Howes

Ryan Howes, Ph.D., ABPP is a Pasadena, California-based psychologist, musician, and author of the “Mental Health Journal for Men.” Learn more at ryanhowes.net.