Neurofeedback in the Treatment of Developmental Trauma - Excerpts from Sebern Fisher's Work of Genius

My discovery of this book was what started me down the path towards becoming a neurofeedback practitioner. It has not appeared to me prudent or worthwhile to purchase this book for every single client and therapist I meet with, although this book is good enough for me to have considered it. It is probably the best book I have ever read, and I have read many books. So instead, I have curated excerpts from the book that seemed to me to be the valuable bits for those whom it might be interested in the topic or to share with clients who may benefit from this treatment to give them some insight into the methods. If anything appears to be outside of your knowledge, don't hesitate to gloss over it and keep going, there are many nuggets within. If you only want to read about stories of her clients, scroll to the bottom to the section titled "Case Examples". I wish you good reading!

A dedication to Sebern Fisher, to all the work she has done to bring profound healing to a very traumatized world. There is no doubt future generations will thank you, but right now, I thank you from the bottom of my heart.

Introduction

"Neurofeedback trains the brain to regulate itself, to inhibit overly slow or

fast wave activity, and to quiet even small, but nonetheless influential paroxysmal

activity, or dysrhythmias, in the brain." pg 56

"What we see in neurofeedback is not just the impact on targeted symptoms of the

patient but on the evolving presence and dimensionality of the person training.

Patients widen their focus, think new thoughts about old problems, and typically even

their vocabulary expands and becomes more nuanced. They are able to escape the

stubborn repetitions of their narrative. In this cosmology, we can think of rigidity as a

core component of mental illness. In developmental trauma, this rigidity arises from

the brain practicing fear; that is, wiring and rewiring fear circuitry. Our job is to help

move the system from rigidity, repetition, and reactivity, to complexity, creativity, and

stability by addressing these circuits." pg 68

"In his editorial on neurofeedback, Frank Duffy, the Director of Clinical

Neurophysiology Laboratory and Developmental Neurophysiology Laboratory at

Children’s Hospital in Boston, came to this conclusion: “The literature, which lacks

any negative study of substance, suggests that EBT [neurofeedback] should play a

major therapeutic role in many different areas. In my opinion, if any medication had

demonstrated such a wide spectrum of efficacy it would be universally accepted and

widely used” (2000, pp. v–vi). Of course, I couldn’t agree more. Our specific focus is

to reduce ambient or acute fear and to enhance self-regulation. This possibility has

profound implications for a person who has lived in fear her entire life." pg 113

[About Barry Sterman's research on SMR training] "This piece of history is important for a neurofeedback clinician to know, particularly one working with patients who have developmental trauma. As we have seen, there is a good deal of speculation about the likelihood, perhaps even the ubiquity, of temporal lobe seizure disorders in this population. This may be a signature brain problem associated with developmental trauma, and we have research evidence that people with epilepsy can learn to control seizures. The chronic

emotional upheaval that characterizes these patients manifests the upheaval in their

brains, and we know from this research on seizures that we can quiet it with

neurofeedback.

This history is also important because, at least in this moment in time, all

clinicians in this field will be told by someone at some point that they are producing

nothing more than placebo effects due to relaxation in the chair, or to the razzmatazz

of the equipment, or to the special attention they receive, etc. Of course, those who

are working with patients with developmental trauma know that these conditions are

hardly sufficient and could never, in and of themselves, predict positive outcomes.

Sitting still rarely feels good, relaxing is unheard of, the equipment itself is, initially,

either a negative or neutral factor for most traumatized people, and for those who felt

“disappeared” as children, there is either never enough attention or threatening

attention. And, to the point, there can be no placebo effect in cats." pg 81-82

"The work of Buzsáki and Llinás (2001), as well as the rapid changes often seen in neurofeedback, suggest that complexity in the brain plays out primarily in its oscillatory and rhythmic domain. Biofeedback to the brainwaves appeals to these rhythms and in this way to the “pattern-making” and “self-organizing” properties of the brain... We see something akin to the butterfly effect routinely in neurofeedback training. We will see the strongest effects locally at the site where we place the sensor, but it seems clear that this perturbation influences all parts of the brain, via its vast neural networks.

What happens to this capacity to develop complexity and stability under the

assault of fear? The brain is affected at all levels. Basic homeostatic rhythms are

disrupted, including those related to sleep and wakefulness, eating and appetite,

reproductive cycles and body temperature —the rhythms of the brainstem and higher order

cognitive and attentional systems are undermined." pg 69-70

"The experiences of neurofeedback clinicians certainly supports the

idea of brain plasticity and suggest, as does the work of Buzsáki (2006), that plasticity

resides primarily in the ability of the brain to change its patterns of oscillation—its

rhythms and self-organization. By providing new information to old, well-rehearsed

rhythms stuck in repetition and reactivity, neurofeedback can encourage the brain’s

plasticity and maximize its latent capacities for self-organization." pg 77

"As I have mentioned along the way, when the history is one of neglect and abuse in

childhood, the patient will be driven by powerful subcortical emotions, most

predominantly fear, even when he may not look afraid or talk about fear. We have

seen that implicit memory of trauma and neglect are held in the dysregulated

amygdala and hippocampus of the RH, as well as in even “older” structures such as

the hypothalamus, brainstem, and cerebellum, and that this memory is sustained as

dysrhythmic, habitual patterns in electrical neural networks that hum with information

and misinformation. With neurofeedback we attempt to intervene in the circuitry that

promotes and sustains states of fear and traits of fearfulness, shame, and rage." pg 78

"Frequency is one measure of a wave form and amplitude is the other. Every wave is

measured by frequency (how fast) and by amplitude (how high) in microvolts (μV), as

mentioned previously. When we are training, we are rewarding the brain to make

more amplitude (bigger amounts) of a desired frequency and lowering the amplitude

of other frequencies that are just causing trouble. The take-home message here is that we are using increases in amplitude to strengthen the frequencies that, in this

population, lead to less fear and reactivity, and we are inhibiting those that contribute

to it." pg 97-98

"Neurofeedback is the working interface between brain and mind. When this

simple fact captures the wider scientific imagination, as it will, there will be many

books written about what arises in the mind when you provide feedback to the brain. I

address how this process unfolds in most people with developmental trauma whom I

have trained. It is a complex picture wrought with every possible individual variation.

We are going to talk about identity as it is tied to arousal, affect, state and trait; how

all of these formulations of self ride on arousal; and what happens when you begin to

dislodge the cornerstone of fear.

Clearly, identity is a multifaceted construction that depends on many important, interlocking variables; family, peers, genetics, epigenetics, class, culture, race,

religion, intelligence, and luck are just some of the contributors that are not addressed

in this chapter. It is the thesis here that the cascade from abuse and neglect to brain

dysregulation is central not only to developmental trauma in childhood but to many

variously named disorders in adults. As we have seen, when you grow up in an

abusive, neglectful, unpredictable, scary environment, there are often few

remembered discrete events, and there is no coherent self to stand back and observe or

report. As Schore (1994, 2003) has taught us, a sense of self requires affect regulation.

In developmental trauma, identity is inseparable from affect. In terms of identity,

these individuals suffer their own Cartesian error—in essence: “I am what I feel.”

This is what I have come to call trauma identity." pg 114-115

"In developmental trauma fear structures and networks are in overdrive, firing too often,

too much, too fast, too repetitively, and too influentially. High arousal correlates with

an overactivation of the amygdala and other brain structures involved in fear and the

underactivation of those structures meant to inhibit them. This brain finds itself, as we

have seen, in a state of disequilibrium characterized by heightened reactivity to stimuli, even apparently benign ones. These inflexible and unstable nervous systems

are routinely overtaken by subcortical neuronal storms that give rise to affect

dysregulation. When arousal becomes emotion, it becomes a quality of the mind and

it is felt: Arousal becomes affect...

Fear, anger, and shame—the emotions of most concern to us like all emotions and the

states they give rise to, have frequencies underpinning them. High levels of

subcortical arousal translate to dysregulated and even wild emotional states. The

people trying to live in these nervous systems will be volatile, agitated, unreasonable,

angry, shame-filled, shaming, and afraid, some even paranoid. They have no mechanisms in their brains to soften the scream of the amygdala. In his book, Waking the Tiger, Peter Levine (1997) quotes one of his traumatized patients:

I don’t know of one thing that I don’t fear. . . . I fear anger . . . my own and everyone else’s, even when anger is not present. I fear rejection and/or abandonment. I fear success and failure. I get pain in my chest, and tingling and numbness in my arms and legs every day. . . I have headaches. I feel nervous all the time. I have shortness of breath, racing heart, disorientation, and panic. I am always cold, and I have dry mouth. I have trouble swallowing. I feel overwhelmed, confused, lost, helpless and hopeless daily. I have uncontrollable outbursts of rage and depression. (pp. 47–48)

This is the narrative of affect in trauma, and it becomes the narrative of state." pg 121

[more on this in section on Chapter 4]

"Helplessness rules state and ultimately becomes a trait in developmental trauma...

The narrative of state begins with “I feel . . . ”; the narrative of trait begins, “I am. . . . ”" pg 124-125

"When states are permanently urgent, managing them will require (or feel as if they require) urgent action. Patients will be riveted to their state and, over time, defined by it. They will do just about anything required to manage it, and all too often they may feel driven to alarming acts, primarily as attempts to influence the impossible, wild firing beneath their awareness. Urgent, fear-driven states cannot be reasoned with, nor can people in them easily learn new tasks. Developmentally traumatized patients get caught in an unreliable but

compelling sense of self and worldview that depends entirely on the state in which

they find themselves. They identify with their state and tend to rely on state-bound

information preferentially over other incoming information. If it doesn’t serve

survival, it won’t be learned. There isn’t time enough. Death or oblivion awaits.

These urgent states, rehearsed over time without interruption or intervention, become

traits. When emotional storms are no longer passing weather, hard enough for the

patient and those in his world to endure, they will become the climate, the prevailing

pattern that underlies any sense of identity. The more practiced a state, the deeper the

“rut” in the brain. This circuitry has fired together and wired together for years, and

each time it happens, the circuitry gets stronger. These states so dominate these

individuals that they become hallmarks of who they are. This identification happens

early in the course of developmental trauma, and it gets folded in to each

developmental stage until, as adults, we see profoundly dysregulated women and men

known to themselves only by what they feel (or don’t feel). What was originally an

unregulated affect and state promoted by the kindling amygdala becomes a prominent

trait. It feels hardwired.

To pursue the weather–climate analogy, after nearly unremitting storms, the

climate of the traumatized person has changed. The storms have reached tornado

proportion and represent not only how they feel or how they behave, but now, who

they are . This chaos that began with erupting neurons is a marker of these patients’

sense of themselves, of their personality, and even of their identity. This unbearable

alignment of affective storm and sense of self is what I am referring to as trauma

identity , fragmented, unregulated, and driven by fear.

The traits common to personality disorders relate directly to the terror arising from

neglect and abuse as a child. Ambient fear is the background condition of being. Fear

narrows focus and attention. Dysregulated arousal leads to dysregulated, volatile

mood. Fear drives cognition. Patients with developmental trauma are angry, ashamed,

and terrified. These are the traits of developmental trauma." pg 125-127

"When we train the brain to change its frequency-based arousal, we change affect,

or felt arousal. When affect changes, state changes. The storms become less intense

and less frequent. There are breaks in the clouds. As the brain becomes less aroused

and states more easily regulated, the narrative begins to change. As the storms recede,

the climate changes. Traits, the hallmark of personality and of personality disorders that seem to be “who we are,” begin to give way." pg 128-129

The Arousal-Regulation Model

"Put simply, this model suggests that there is a vital connection, if not absolute

correlation, between arousal and regulation. This is, of course, the correlation we have

been exploring in developmental trauma, where high arousal of the nervous system

leads inevitably to dysregulation or where fundamental dysregulation has led to high

levels of arousal. Further, the arousal–regulation model attempts to explain how a

brain functions optimally without specific regard to diagnosis. Optimal functioning can be defined as the brain’s ability to shift flexibly between states of arousal, depending on the tasks before it. In broad strokes, we want a brain that wakes up alert and ready for the day, a brain that is influenced but not overtaken by external or internal events, and a brain that turns itself down when it is time for sleep. In people with developmental trauma even this basic level of self-regulation is unavailable because the brain has been driven into states of high arousal and repeating patterns related to survival. People with this level of trauma develop much less state flexibility. They are hypervigilant, hyperfocused, and quick to erupt into states driven by limbic emotions.

As we saw in Chapter 2, all arousal is driven by the frequencies at which the brain

fires. Our goal with patients who have developmental trauma is always to find the

frequencies that help them feel calmer, less afraid, and less reactive. As we consider

this model, it is important to remember that the brain’s two hemispheres normatively

cycle at different speeds. In the arousal model, we expect to lower arousal through

training on the RH (affect regulation), raise arousal by training on the LH (verbal),

and stabilize arousal by training the RH and the LH together." pg 106-107

"In this model, a patient’s arousal is categorized as overarousal , underarousal ,

instability of arousal , and/or a combination of under- and overarousal. Although

developmental trauma almost always falls in the overarousal category, people with

these histories can also have symptoms of underarousal and instability of arousal....

Examples of overarousal include agitated depression, nightmares, restless sleep,

hyper-startle response, and constipation. Examples of underarousal could include

sugar craving, nonrestorative sleep, lethargy, and certain types of depression.

Instability of arousal could include bipolar disorder, migraine, and panic attacks.

(Interestingly, the well-known neurologist Oliver Sacks categorizes migraine as a

disorder closely allied with many other disorders, including epilepsy, narcolepsy,

“angst attacks,” fainting, vagal attacks, acute affective cycles, bipolar cycles,

catatonia, catalepsy, Klein–Levin attacks, protracted vegetative reactions, and even

spasmodic asthma, croup, and angina [1985, p. 195].) If any of these disorders show

up in assessment, the neurofeedback practitioner would primarily think about

instability of arousal as the common thread...

Mixed arousal, the most common pattern, would include significant symptoms of both under- and overarousal. In developmental trauma, I train to lower arousal and see if that takes care of other problems attendant to the disorder, such as difficulty paying attention or sensory overload. It often does.

As we have seen, frequency drives arousal. In this model, as a rule, we continue to

drop the reward frequencies until the patient begins to show signs of a quieting

nervous system." pg 108-109

Neurofeedback with Therapy

[About client] "Until we started to use neurofeedback, we could not develop an interpersonal rhythm. There was no spark, no resonance between us, and this resonance is essential to a therapy that works. As his therapist I was, essentially, trying to talk to his

amygdala, the part of the brain that is shaping these perceptions, memories, actions,

and fears. The nonverbal, subcortical amygdala cannot make sense of words. Talking,

however, is what therapists are expected to do and what patients are expected to

benefit from. (We explore the amygdala and the brain driven by fear in Chapter 2.)" pg 17

"Clearly, addressing the mind helps people. Psychotherapy and meditation are

changing the brain. It would have to be so or else they wouldn’t work, and now fMRIs

can document the actual changes in the brain. It has been my experience, however,

and the central tenet of this book, that we can exercise more influence on the mind by

addressing the brain than we can have on the brain by addressing the mind. This may

in fact be the defining reality in disorders that we find intractable. We just can’t appeal

to this brain’s self-organizing properties solely by engaging, however attuned we are,

with this patient’s mind, a common dilemma in work with those suffering from

developmental trauma." pg 68

"It is important to note that I think of neurofeedback as brain wave training and not

as therapy. It is a learning technology, and in my experience, it is much more effective

when held within the embrace of a good therapy and a good therapist. But it is not

therapy...

Even more than a learning technology, I think neurofeedback is an interpersonal technology. It helps the brain activate its own intrinsic circuits of attachment, of dyadic self–other organization, by reducing the activation of fear, rage and shame, essentially by

inhibiting the amygdala and its circuitry of fear. When you ease the grip of fear, a

person emerges who, by his nature, wants to be in relationship. As we will see in

subsequent chapters, quieting fear is what neurofeedback does. But first let’s take a

look at what it is and how it works." pg 77

"The person who is suffering from developmental trauma lives in a system that has

shut down in response to assault, abuse, and neglect and that is rigid with fear. Our

job as psychotherapists is to help our patients move from repetition and rigidity

toward discovery of innate self-regulating rhythmicity. As their brains learn to

regulate themselves, they will move at all levels—physical, emotional, cognitive, and

behavioral—toward complexity and stability. This is a demanding task for both

patient and therapist when the amygdala is in charge, and difficult to achieve with talk

therapy alone. It is actually not possible to “talk” to an amygdala that devotes itself to

survival and has no sense of time—a subcortical structure deep in the nonverbal RH.

As we have established, this is the epicenter of fear processing and production, and it

is overwhelming and disassembling the very being of the person with developmental

trauma. We have to reach it another way." pg 79-80

"Fundamentally, the journey from dysregulated trauma survivor to well-regulated

peak performer is the journey of brain regulation. Once you begin to use

neurofeedback, you realize that this training is not just about quieting negative

symptoms of trauma but about enhancing the potential of this person in all realms.

When patients are released from the grip of fear, they naturally open to their full

potential. The optimal performance brain is the same brain (physically, not

functionally) as the traumatized brain, just regulated...

Michael Tansey reported a 15-point gain in IQ in children training for learning disabilities (1991, p. 52), and Tanju Surmeli, a psychiatrist and researcher in Istanbul, has reported significant improvement in IQ (from 7 to 40 points) in children with mental retardation (personal communication January 5, 2013)...

These practitioners were working with very different diagnosed disorders and

report changes toward optimal performance. These results bring to mind the card of a

colleague that reads, “Every brain deserves this chance.” I agree completely, and no

brain more so than the brain traumatized in childhood. In my own experience and that

of my patients, neurofeedback enhances many of those aspects of treatment that are

getting a lot of attention these days: affect regulation, trauma resolution, mindfulness,

and the possibility of a life after trauma." pg 83-84

"Narrative arises from state, serves it, and reinforces it. Obviously, psychotherapy

attempts to address this narrative, but LH talk is of little relevance to an erupting RH.

The narrative is the verbal (LH) mind’s best shot at justifying or understanding the

state that arises from subcortical terror driving the non-verbal RH. But the narrative

comes from the mouth of the child, from the imprint of early experience. There had

been no update for him. This man was not the tall, strong, smart adult that he actually

was. Instead he constructed himself from arousal and affect, and he felt that he was a

powerless victim or potential victim, no matter what the circumstances—exactly what

his amygdala dictated." pg 124

"Identity that ascends from the dysregulation of high arousal to intensely felt affect,

to state and to trait, also begins, over time, to change. One of the ways to recognize that this shift is happening is when your patients begin to talk about themselves in the

terms of their brains and in the language of arousal. It is not only that they are picking

up on the idiom of neurofeedback; they are beginning to feel the ebb and flow of

arousal. They begin to feel emotion as emotion, arising and falling away. Typically

they stop using their diagnostic label but instead describe how aroused they feel or

how regulated or dysregulated. The reorganizing CNS produces a new narrative. A

new, tender sense of self begins to organize. These patients will become, in a sense,

less their brain and more their mind. They will have a chance to think and to

experience the nascent ability to reflect. Psychologically, self-reflection requires some

level of affect regulation—in essence, some peace. Neurologically, it requires well regulated

structures doing what they are meant to do. Simply put, the therapeutic

work with neurofeedback involves, first, the regulation of affect through quieting

arousal and then helping the patient to integrate a newly organizing, emerging sense

of self." pg 131-132

"I don’t want to be misunderstood here. I think that therapy can be very helpful.

Feeling understood, cared for, and soothed goes a long way in helping even seriously

disturbed patients, as can teaching them to practice emotion regulation skills. It

cannot, however, quiet the deep, biological pulse of fear that drives their nervous

systems. At best, it teaches them how to better live with it." pg 250

"I have worked with the aftermath of trauma and neglect for my entire professional

career. When I discovered neurofeedback and experienced the dramatic shift in fear, I

began to privately hope that neurofeedback was “the answer” to these childhoods and

that therapy, with its tremendous demand on both the patient and the therapist, would

no longer be required. Some people in the neurofeedback field seem to believe this.

As I am sure you know by now, I don’t. Therapy does become less challenging, but at

least in the treatment of developmental trauma, the regulating, attuned presence of the

therapist is vital.

In a talk she gave describing the rapid changes she had seen in patients with

chronic developmental trauma after introducing neurofeedback, the fMRI trauma

researcher and psychiatrist Ruth Lanius cautioned her audience: “Neurofeedback does

not replace psychotherapy. I think it requires you to be an even better therapist.”

Neurofeedback, as we have seen, can bring about rapid changes, and the therapist

must be prepared for these and agile when they occur. We need to know when to talk

and when to train. One of my metrics for deciding this is how curious the patient can

be about her experience. If she is primarily reactive and not able to be curious, I think

it is more important to train than to talk. When she begins to be curious, then it is time

to pursue the inquiry. When it is the brain that is most in need, then it is time to train.

When it is the mind and identity that need to reorganize in response to CNS changes,

it is time for psychotherapy." pg 276

The Healing Paradox

"I have come to believe that healing developmental trauma requires brain wave training. I see most therapy, as we practice it today, as working around, rather than

with, the amygdala. Our patients learn to manage their primordial fear to a greater or

lesser degree, but they are never free from it. Our record of treatment failure makes it

equally clear that this work-around approach leaves the amygdala in charge. I am not

saying that patients with developmental trauma cannot do well with standard therapy;

clearly, many do and they can even be quite functional. These patients who function

well, atop these volcanic circuits, are those whom Linehan (1993) calls “apparently

competent.” But I think if we don’t go right to the source, the subcortical kindling of

fear, most of these patients are still held hostage by ambient fear. We can help them

quiet their reactivity through insight or through teaching new behaviors, but we

cannot, without neurofeedback, help them quiet the persistent pulse of fear.

Yet, as we have discussed above, the reduction of fear that neurofeedback makes

possible is both welcomed and terrifying. As she began to experience herself as less

afraid, one patient described a separate terror: nothing short of her own annihilation.

This response gives rise to a central healing paradox in the practice of neurofeedback.

How do we address fear in people who define themselves by it? We talk about this

important issue more in Chapters 6 and 8, but here is the short version.

Our goal as neurofeedback clinicians, as well as clinicians, with these patients is

singular: to reduce or ultimately to quiet limbic reactivity. But when we reduce fear,

we challenge fear-based identity, the only known self. Many will cling to fear as if it

were life itself. It is. It is who they are. Fear has also been the primary and often the

only validation of a routinely invalidated traumatic past. It is a memory trace to a

forgotten or overwhelmingly remembered childhood, and we are going to erase it.

Fear is also experienced as a kind of early warning system. These patients will

mistake their affective arousal as evidence that arousal is required. Any hope of a

nurturing relationship has been conceived in need. Confusion and loss can set in as

patients’ need for the mother, and the therapist, diminishes. They can deeply fear that

they will lose not only themselves but the newly emerging other. Depending on where

they are in the process of unfolding fear, they are more or less able to see that these

reactions arise directly from well-learned patterns of reactivity in the fear circuitry,

rehearsed for a lifetime, and are not to be believed.

As we swim in the deep and turbulent waters of affect and identity, it is reassuring

to know that we have no choice. There is no other path; we must reduce fear. We also

must ease fear of no fear. It is especially important for neurofeedback practitioners to

recognize and understand the dilemma that “the cure” creates and to help their

patients recognize and understand it as well. I bring everything I can to bear at this

juncture. We are attempting to disengage the amygdala, and in response it gets

alarmed and reacts. It creates the narrative of its own necessity and its inevitable

dominance. We keep training and talking about changes. We address lack of change with neurofeedback, not with psychotherapy. We ease the brain into this, while

integrating neurofeedback training with whatever therapy we are doing and by

teaching fundamental relaxation techniques such as attention to the breath, body scans

and for those who can do it, meditation. Unfortunately, there will be many rounds in

this shedding of fear as both the brain and the mind gravitate back toward their

familiar and compelling patterns, initially, if left to their own devices. The brain has to

be nudged out of this reactive position, and as it is, the mind comes with it." pg 132-134

What is Possible?

"In this ridiculously linear model, what seems to happen is that neuronal firing and,

most likely, glial activity slowly but surely regulate in response to the training

challenge. Errant provocations such as those that manifest as dissociation are ignored

by the increasingly regulated brain, both subcortically and cortically. Arousal

decreases and patients become more flexible and more tuned to the present than the

past. This emerging nervous system can now participate in a full range of affective

states, but increasingly, calm prevails. These patients find themselves making state

transitions much more flexibly and smoothly and often surprise themselves by

experiencing happy, even peaceful, states that they report are completely new to them.

With lowered arousal they are less claimed by their states and, as a result, are

increasingly less state-dependent. The narrative shifts from the past to the present.

The patient who arrived 5 years ago trying to manage her arousal and dissociation

by clawing at her face, hitting her head, and holding ice packs lives in a very different

narrative today, and a very different sense of self. She no longer has flashbacks, no

longer dissociates, never engages in self-harm, has discontinued her psychiatric

medications, and sleeps free from nightmares. But the change that I am describing as

a change in identity is more profound and less measurable than the absence of

symptoms. She is learning to trust her mind, and she has gained a sense of her own

agency.

Increasingly, these patients are able to see states for what they are: temporary.

When we are no longer state-bound, the traits to which arousal and engrained state

gave rise begin to, well, vanish. A patient told me that she had experienced these

states as living organisms. She felt certain that as she withdrew energy from them

(i.e., reduced her fear), she would experience their deaths. She had been raised by a

terror-stricken and dissociative mother, and she came by her original diagnosis of DID

honestly. It surprised her that nothing bad actually happened. This primary

reorganization of the CNS allows, even demands organization or reorganization in the

sense of self. A video from Melbourne, Australia shows a young adolescent before

and after neurofeedback. He was so out of control, he was about to be sent to juvenile detention. Watching a video of himself battering a door with a pole, he said, “I can’t

believe I was ever like that. Even if I tried, I couldn’t be like that again.” You can

watch this video on YouTube (http://www.youtube.com/watch?v=8uRFRkfBlTs).

Neurofeedback is not a quick fix, but unlike any other approach, at least any other

approach I have tried, it may well be a fix. I don’t think, however, that anyone can

learn and change at this level with brain regulation alone. If that were the nature of

being human, we could just hook people up to neurofeedback systems and let them

train. Neurofeedback enhances affect regulation and attention, and surprising things

happen that we never see with therapy alone. But human beings need other human

beings, and this is probably never truer than for those with histories of developmental

trauma as they begin to coalesce a new, fragile, tentative, but increasingly stable

identity. I can think of no greater privilege than to attend this labor and assist this

birth." pg 134-135

Chapter 1: The Mind in Developmental Trauma

"Childhood trauma makes itself known in physical as well as mental problems,

which is why patients who use neurofeedback may show striking physical as well as

emotional and behavioral improvement. In the course of my work with

neurofeedback, I have seen changes in eyesight, hearing, smell, taste, thyroid

function, stability of blood sugar, constipation, irritable bowel syndrome (IBS), blood

pressure, motion sickness, migraine, neuropathy and other chronic pain problems, and

skin rashes, among other physical complaints, while training the brain to quiet anxiety

or depression. The physical and the mental are inseparable. In Chapter 8 we explore

the resolution of many physical complaints as well as body memory during the course

of neurofeedback." pg 14

"The effects of early abuse and neglect endure. These effects can take many diagnostic trajectories, but it is never the diagnosis we are treating. We are always addressing the individual and her symptoms. I have argued so far that abuse and neglect arise in the absence of the mother and leave the infant afraid for her survival. Not only does

someone with this history feel overwhelmed by terror or, perhaps more subtly,

constantly pressed by fear, she also feels pervasive shame. Shame is the feeling of

being bad, unworthy of being alive (Fisher, 1985). These states —they are more than

transient feelings—give rise to anger, even to rage. Fear, shame, and rage have

chambers in the amygdala, and in this population they drive the sense of self–no self.

People living in the aftermath of these histories find it increasingly difficult to

recognize a self that is other than the feelings they are having. They are fear, shame,

and rage at the same time as they are being torn asunder by them. There is a

compounding effect. Fear gives rise to more fear (we will look at the circuitry of this

in Chapter 2), to anger at being scared, and to humiliation at being incessantly afraid

—and often afraid of nothing.....

All symptoms of developmental trauma relate directly to these negative, primary

emotions that can obliterate, dysregulate, or deform the self. They are either manifestations of these emotions, such as dissociation, nightmares, or hyper-startle

responses, or short-term and ultimately futile attempts to regulate them, such as

cutting or substance abuse." pg 24-25

"Many of these patients engage in frank self-harm, and most often target the skin. They burn and they cut. They report that the pain gives them respite, however temporary, from numbness and derealization or from feelings of fear or shame so intense that they can

no longer bear them, or rage so out of control that they fear they will act on it. As we

will explore more in Chapter 2, numbness, dissociation, and derealization are

symptoms of parasympathic fear, whereas symptoms such as outbursts, aggression,

hyper-startle response, self-harm, and suicidality are signs of sympathetic overarousal.

All too many of these patients suffer all of the above.

Symptom formation is a complex business, and the mind of the trauma survivor as

well as that of the trauma therapist will have tales that justify or explain them. But at

base, they are elaborations of fear. Rage is seeded by fear and shame, too, has fear

embedded in it—in fact one of the worst fears that anyone can have. Shame means

having to live beyond the pale. The expression “beyond the pale” relates to the

custom of exiling the bad one outside the walls of the ghetto, the pale, keeping them

cut off from family or tribe and vulnerable to the attack of barbarians (the other tribe)

and wild animals. This is exactly how my patients feel and exactly what they fear.

When a patient says that she just wants to “feel what normal people feel,” it is a plea

to return to the tribe of which she has never felt herself a member.

Most of us would do almost anything not to feel, even for a moment, the feelings

these patients endure every minute of every day and every night. If cutting

themselves, banging their heads, or drinking or throwing up until their throats burn

quiets or even interrupts these states, they will do it." pg 26

"The core issue is an intense mother hunger, an unbearable

and hopeless longing for a present, loving mother. Some patients have the

combination of courage and desperation it takes to dive deep into these turbulent and

muddy amniotic waters. If the therapist can embrace it, a patient with this history will

attempt to construct their child’s version of being mothered. This can come with

requests to be held, nursed, and taken home. They want and need the experience of

being tucked in and wrapped up. These needs feel deeply humiliating to them and add

to the vicious feedback loop of shame. Asking the patient to analyze these feelings

risks shaming him more, and skills training, when this defining need is acknowledged

at all, can only teach the patient to learn to somehow bear this unbearable, insatiable

hunger.

The drive toward reconstruction, or initial construction, of a tender and attuned

mother–infant relationship is healthy. Being held in the mind and the arms of the

mother is the way affect regulation begins in the human species. Therapists are,

however, proscribed from holding, primarily due to a history of sexual exploitation in

the field. (Given their histories and the nature of their need, sexual exploitation of

these patients is tantamount to child sexual assault.) But as a result, patients who need

to be held, cannot be. This basic human need will go unmet and all too often

completely unaddressed because of the proscription on the therapist and the shame of

the patient." pg 29-30

"There is hope. It appears that although they have lost the mind’s template for self,

other, and relationship, even those people who have been deeply deprived, neglected,

and injured in childhood, maintain the circuitries in the brain that underwrite their

essential humanness. As we will see, when we activate these underlying circuitries,

we also activate the individual’s innate potential for relationship, and we ease the pain

of history. This is a critically important hypothesis of this book: It suggests that when

we reach this CNS, we will find this person." pg 35

Chapter 2: The Brain in Developmental Trauma

"As we will see, both through emerging neuroscience and through the phenomenology of neurofeedback, the brain regulates itself via the electrical domain of frequency and timing.

Throughout the discussion of specific brain structures, keep this basic fact in mind.

Although these structures are key to our understanding of the problems suffered in

developmental trauma, they are all firing and misfiring in vast neural networks that

connect them rhythmically with all other brain structures. In neurofeedback, we

reward the brain to generate frequencies that allow it to develop new firing patterns at

particular sites related to particular structures that will influence signals throughout

the neural networks." pg 37

"For now suffice it to say that most problems involve vast neural networks and that

within these networks there are identified focal structures. For example, obsessive–

compulsive disorder (OCD) is known to be a problem of overactivation of the anterior

cingulate. This structure misfires and its signals are transmitted over neural networks

that connect the cingulate to other structures. OCD is also one of the common

comorbidities of developmental trauma. It is no surprise to learn that the anterior

cingulate plays a vital role in inhibiting the amygdala. In cases of developmental

trauma it appears that just the opposite has happened: Hyperexcitable and habitual

firing of the amygdala has overtaken and dysregulated the cingulate. Once we know

that the anterior cingulate is overactive in OCD and is responsible for functional

inhibition of the amygdala, we can think about beginning the training at the site

closest to the anterior cingulate....In the case of the anterior cingulate, the site is “FZ.” pg 38

"As we will soon see, the circuitry of fear casts a wide net, but quieting the

amygdala is essential when addressing fear. Further, developmental trauma manifests

with multiple symptoms and disrupts development in many arenas of brain function.

Neurofeedback practitioners need to have a general idea of which structure correlates

with what problem, as they look for ways to reduce toxic fear and all of its ongoing

fallout. Every topic that I touch on deserves at least a chapter, if not its own textbook,

so this chapter can only introduce the reader to the key areas of the traumatized brain

and how unrelenting terror deforms its function." pg 38

"Human beings (and most other mammals) have two interdependent branches of the

nervous system: the autonomic nervous system (ANS) and the central nervous system

(CNS). The ANS is a system of neural pathways responsible for the homeostatic

regulation of organs in the body, including the gut, the lungs, and the heart. The ANS

has two branches: the parasympathetic nervous system (PNS) and the sympathetic

nervous system (SNS). Simply put, the PNS allows the body to rest and digest, and

the SNS primes the body for fight or flight. Optimally, these two systems modulate

each other, which allows for an individual’s ongoing flexibility of arousal in response

to the demands of the environment.

When the environment is chronically overwhelming, however, it can happen that

neither system is able to exercise influence over the other; they are both tapped out.

This is often the case in those with developmental trauma. As babies and small

children, they could not respond to the threat of absence or injury through activation

of the SNS. They could not run and they could not fight. The PNS is often described

as restoring homeostasis after sympathetic activation, but it can also go into overdrive

in an attempt to reduce the futile sympathetic activation that occurs in helpless infants

and young children. Homeostasis is an elusive experience and perhaps even an elusive

concept for those who are systematically injured or mindlessly neglected as children.

The treatment goal is not to return these systems to homeostasis but to establish a new

experience of it.

When both systems go into overdrive, the person trying to manage these now

warring influences is held in an unbearable suspension of his nervous system. When

this occurs, the child has to rely on the most primitive defense that the organism has at

its disposal, one that we have in common with reptiles: the freeze response. Freezing

is seen as a hyperactivation of the PNS. In developmental trauma, this hyperactivation

is dissociation. This child who cannot escape leaves her assaulted, neglected body. In

animals, freezing is called death-feigning ; they are trying to trick the predator into

believing that they are already dead so that they will not be killed. It is probably the

same strategy for the traumatized child." pg 39-40

"As we will see, dissociation shows up in the electrical domain of the brain as

excess slow wave activity, and can look, as it is meant to, like very low arousal. But it

isn’t. As we saw in both cases above, this ANS response has been driven by terror,

which involves hyperactivation of sympathetic arousal, and when you approach this

nervous system with neurofeedback, you will be training the nervous system to lower

its arousal. We’ll be talking a lot about this in subsequent chapters on the practice of

neurofeedback." pg 42

"PNS shutdown is mediated by the vagal nerve. The tenth cranial nerve, the

vagus nerve, extends from the brainstem down the front of the spinal cord to the

colon... The most common somatic complaints in developmental trauma are vagally mediated: stomachaches, constipation and irritable bowel, trouble breathing and a racing and pounding heart or a heart that is pumping much too slowly (van der Kolk, 2009)....Under the sway of this primitive vagus, we are prone to passing out, fainting, and

dizziness. Freezing when speaking in public and fainting at the sight of blood are

vagal events. The vagus nerve is implicated not only in somatic complaints but in one

of the most daunting of traumatic sequelae: dissociation. When there is no escape and

no chance at self- defense, dissociation is the last option—and often a daily reality of

children with developmental trauma histories." pg 42

"In traditional peripheral biofeedback, practitioners enter the brain–body loop through the body and focus on regulating the ANS. They teach people that they can gain control over sympathetic and parasympathetic activation through increasing or decreasing the temperature of their skin, changing skin conductivity (galvanic skin response), releasing tension in their muscles, reducing their heart rates, and slowing the rate at which they breathe. These practices, which are also the practices of most meditation traditions, can help quiet an overly activated nervous system.

However, peripheral biofeedback—deploying the ANS to modulate the CNS—is

as difficult for most patients with developmental trauma as meditation.

Neurofeedback for this population enters the same brain–body loop, but it focuses

instead on the CNS by teaching people to change dysfunctional patterns and rhythms

in their brains." pg 42

"This thesis is important to neurofeedback providers for a number of reasons. First, it

posits the absolute connection between the brain and the self, between the

nonconscious, the unconscious, and the conscious. The second is that it underscores

the central role of the hypothalamus in fear regulation, as is documented in work

investigating the hypothalamic–pituitary–adrenal (HPA) axis. This regulatory system

is highly susceptible to the very stress hormones that it attempts to regulate. It appears

that this entire regulatory feedback loop is disrupted in developmental trauma, making

it ever more difficult to regulate fear, the emotion of most salience to the organism’s

survival.

A third reason is that these primitive brain structures are seen as the least plastic

and therefore should be the least affected by neurofeedback training, which appeals

directly to the mechanisms of plasticity in the brain. I am not at all convinced that this

is true. It seems to be that once the brain finds its pathway to regulation, it may in fact

prioritize the nuclei that give rise to the proto-self. One woman with a history of

neglect and humiliation talked about the effects of neurofeedback training at the back

of her head in ways that strongly suggest this possibility. She said, “I am becoming

the person I would have been if my family had not interfered.” This statement is a

neurofeedback koan and perhaps also a declaration of the proto-self—a manifestation of the regulation of these primitive brain regions. We do expect to see changes in the

ANS when patients with developmental trauma train to reduce fear. We expect to see

improvements in sleep, in heart rate, temperature regulation, breathing, digestion, and

awareness of hunger and thirst, all of which can be significantly dysregulated in

developmental trauma." pg 44

"The cerebral cortex is not, however, solely about thought. It is, first and foremost, about affect regulation— particularly the right prefrontal cortex, which exerts control over the more primitive and often very powerful subcortical brain structures, specifically the amygdala. We

focus mostly on subcortical brain structures and functions in this book because they

house the fear circuitry fundamental to understanding developmental trauma. In

neurofeedback we place sensors on the scalp to pick up EEG readings. When we are

able to affect subcortical functioning, it is likely that we are activating the inhibitory

capacity of the cortex to quiet errant firing deep in the brain." pg 48

"Every one of us makes our rational decisions based on the influence of

nonrational emotions, and in developmental trauma this is the exact process that we

see as the illness. These patients are driven by their emotions. They think what they

feel; they behave what they feel; they are what they feel. There is little apparent LH

influence....

Attachment, empathy, and perhaps even love are capacities

of the right hemisphere. I think of these as very positive emotions” (personal

communication, June 10, 2005). These positive emotions are the ones, of course, that

are most attenuated in this population, crowded out as they are by the survival affects

of fear, shame, and rage. It may be the absence of these compelling affective storms

that researchers such as Davidson are describing as positive affect. For now we don’t

need to enter this debate. In my experience with neurofeedback, when people quiet

their highly aroused nervous systems, primarily through addressing the regulation of

the RH, they experience increasing capacity for love, empathy, and attachment and, as

a direct result, feel happier.

The LH does its best to give language to the felt sense, but in developmental

trauma that narrative itself is overly determined by a malfunctioning, poorly regulated

RH. The capacity to put feelings into words depends on some level of regulation in

the RH. This is, of course, the very real limitation of therapies that depend on

language. As mentioned in Chapter 1, my sense is that language-based therapies that

work may actually be prosody-based therapies. The good-enough therapist’s

communication is a form of motherese. There may also be less possibility for

subcortical disruption in the LH; the survival-oriented amygdala is in the RH. At the

same time, laterality suggests a therapeutic course: regulation of the RH to quiet affect

and regulation of the LH to promote thought, articulation, and the formulation of a

new narrative of self...

We see a high level of learning disabilities in those with histories of developmental trauma, but in this population these are most often nonverbal learning disabilities such as problems with relational cueing, spatial processing, and sense of direction—all RH properties." pg 49-50

"Developmental trauma is primarily encoded as a disorganization and

dysregulation of the RH due to lack of maternal attunement and care during infancy

and early childhood. In better circumstances, the mother’s attunement builds these

structures. I refer the reader to Allan Schore and the work of attachment researchers to

delve more deeply into the relationship between maternal attunement and infant

attachment (Schore, 1994, 2003; Siegel, 1999; Tronick, 2007). Suffice it to say here

that the mother’s self-regulation becomes the baby’s self-regulation because it builds

cortical structures in the young child that inhibit subcortical ones." pg 51-52

"The RH amygdala, however, comes online between 5 and 6 months in utero, the

same time that fetal movement begins. From that time on, at least, the fetus can feel

fear, and this fear is the fear of the mother in her loud, chaotic environment, external

or internal. The fetus can hear her pounding heart and the angry voices, and the fetus

will register the blows the mother takes. All the fetus can do in this gestational period

and in early postnatal times is to react. There is no safety in these wombs.

I worked with a young woman who was pregnant with her third child. The father

of the child didn’t want the baby and during one of their frequent fights, he punched

my patient in the stomach. This kind of assault on the mother predicts attachment

disruption. At about 5 months into her pregnancy, my patient described wild fetal

movement, all elbows and heels. She said, “If I didn’t know better, I would believe

that this baby was aggressive toward me.” Serendipitously, I began to train the mother

prefrontally, using a protocol that seems to directly affect amygdala reactivity. When

she was doing the first session with this protocol, she told me that the baby had rolled over and gone to sleep: “Calm mother; calm baby.” The baby and the mother seemed

to be enjoying the co-arising regulation, and it seems probable that the dramatic

reduction in fear in the mother invited this in her baby. The external environment had

changed very little, but the mother was now much less reactive to it, and so was her

child. This experience in which both the mother and the fetus responded to quieting

the mother’s lifelong ambient fear may suggest that, at least in these cases, this kind

of fetal movement relates to the transmission of the mother’s fearful self quite directly

to her child, brain to brain, body to body. It also suggests that neurofeedback may

have a role to play in interrupting the intergenerational transmission of trauma. I

discuss this case again in Chapter 9.

Our goal in training the brain in patients with developmental trauma is to activate

focal structures, areas, and circuitries that could inhibit high amygdala arousal and the

erratic or habitual firing in response to cues or triggers. The structures that emerge

developmentally to inhibit the amygdala are the insula (F8), the anterior cingulate

(FZ), and the prefrontal cortex (FP1 and FP2). What I have observed in training these

sites—at least as we approximate them on the skull—is that fear does diminish in

most people." pg 52-53

"Most people with a history of developmental trauma experience some level of

difficulty with the integration of sensory information, including hypersensitivity and

reactivity to touch, sound, light, and often to smell." pg 54

"There are of course also two temporal lobes, just as there two occipital and

parietal lobes. Auditory processing, lexical memory, language, logical reasoning,

reading, writing, and arithmetic are lateralized to the left temporal lobe. Prosody,

emotional valance, facial recognition and memory, spatial orientation and memory,

time sense, rhythm, ability to sing on key and remember tunes, as well as the ability to

recognize familiar songs and to enjoy music are all right temporal functions. Schore

(1994, 2003) would argue that the sense of self, and by necessity, the sense of other

organize primarily in the right temporal lobe. Ability to regulate emotions is in great

part a right temporal lobe capacity.

Instability in the temporal lobes, as we have seen, may well be a hallmark of

developmental trauma. Trauma researchers are investigating the overlap between

developmental trauma and temporal lobe epilepsy (TLE), particularly in the right

temporal lobe, and many suspect it is great. Teicher reported that “children with . . .

confirmed diagnosis of depressive signs and symptoms and a history of severe

physical and sexual abuse (without head trauma) have a 72% incidence of abnormal

EEG” (as cited in Lanius et al., 2010, p. 114)." pg 55

"Dysrhythmia simply means “out of rhythm,” which in the brain means errant firing

patterns, poorly differentiated networks, and poorly organized network oscillations.

The focus on seizure-like instability and subclinical seizure in those people with

developmental trauma histories is a fruitful course of research and, as we will see, it

underpins some key points in understanding the efficacy of neurofeedback in treating

developmental trauma and its many comorbidities. Although these authors do not

specifically consider developmental trauma, they do include data on dysrhythmias in

borderline personality disorder, one of the adult sequela. These data include diffuse

EEG slowing; increased slow-wave activity, often bilateral in the frontal lobe, the

temporal lobe, or in a frontotemporal distribution; and a high incidence of paroxysmal

(large bursts) EEG.

As we will see in the next chapter, neurofeedback was originally developed to

control seizure activity in the brain. Seizures amount to a tsunami in the brain, and

research demonstrates (Wyrwicka & Sterman, 1968; Sterman, 2000; Egner &

Sterman, 2006) that a person with epilepsy can learn to control these massive,

disruptive events with neurofeedback. It is likely that it can also help those diagnosed

with developmental trauma who suffer lesser but still profound paroxysmal events.

This likelihood of successful treatment is, of course, one of the central premises of

this book. Neurofeedback trains the brain to regulate itself, to inhibit overly slow or

fast wave activity, and to quiet even small, but nonetheless influential paroxysmal

activity, or dysrhythmias, in the brain. Temporal lobe instability may be close to

ubiquitous in cases of developmental trauma and might even qualify as TLE in many

of these same patients.

Other common sources of TLE include head injuries and middle ear infections.

Blows to the head and ear infections are, of course, sadly common in the histories of

abused and neglected children. It is important that the neurofeedback clinician assess

for history or indicators of TLE, subclinical or clinical, and generally assess the

functioning of the right temporal lobe. It is also important to know that injury to the

right temporal lobe, whether developmental or acquired, can lead to hyperreligiosity

or spirituality and hyper- or hyposexuality. As we will see, the right temporal lobe is a

common focus in neurofeedback training for developmental trauma (T4, T6)." pg 56-57

"The frontal lobe and the prefrontal lobe are considered a single lobe with each

area having specialized functions. The frontal lobe is engaged with planning, and the

prefrontal lobe, or orbital area, with execution. The left prefrontal cortex is heavily

involved with agency, with going out into the world. The right prefrontal cortex

exercises control over the impulses of the amygdala. When the amygdala is out of

control—or perhaps more to the point, too much in control, as is so often the case in

this population—we may consider training this area of the brain to activate and

strengthen its inhibitory prerogative...

As pertaining to emotional arousal, it has also been postulated that the orbital area exerts a major influence on the experience of anxiety” (Gray, 1987). This part of the brain, which is responsible for executive function, is often impaired in these patients due most likely to excess fear or lack of inhibition of the right amygdala...

The orbitofrontal cortex (OFC) lies directly behind the bridge of the nose and

exercises judgment, particularly over the needs of the body. It is also the terminus for

the signals from the amygdala to the prefrontal cortex. For survival purposes there are

many more pathways from the amygdala to the OFC than from the OFC back to the

amygdala. When a predator or truck is bearing down on us, it is vital to react

immediately, not take time to think. As we have seen, the person suffering from

developmental trauma anticipates predators, and as a result, tends to react before

thinking, particularly in situations that the amygdala has deemed dangerous." pg 57

"The dorsomedial prefrontal cortex (DMPFC), along with many distant regions,

becomes activated when people reflect on themselves. (The fact that this function is

not localized to the DMPFC reminds us that although one area may be focal for an

activity or function, it is always embedded in neural networks that connect to other

areas of the brain.) This area is critical to the capacity for conceptual self-awareness

(Fogel, 2009) and to our sense of personal biography. “The DMPFC, then, is related

to thinking and making decisions specifically about one’s own thoughts and to

thoughts about one’s own feelings” (Fogel, 2009, p. 96). Developmental injury to the

DMPFC results in impairment of the conceptual self, the self as known to us

cognitively: the self that produces coherent autobiographical narrative." pg 58

"The dorsolateral prefrontal cortex (DLPFC) relates to working memory and “the

ability to keep an emotion in mind so that it can be evaluated by higher cognitive

centers in the prefrontal cortex responsible for decision-making and affect regulation”

(Fogel, 2009, p. 69). Anyone who has survived early childhood neglect and abuse, or

who has worked closely with someone who has, will recognize the breakdown of this

structure and its malfunctioning neural networks. Impulse overtakes reflection,

impulse that is riding the pulse of fear. These patients distinguish themselves for being

unable to learn from experience and for their routinely poor judgment. (F5, F6, and

FPO2).

The ventromedial prefrontal cortex (VMPFC), which sits just below the

DMPFC, relates primarily to awareness of being in the body—to, as Fogel puts it,

“the embodied sense of self” (2009, p. 53). It has significant connections to the

amygdala. Many patients with developmental trauma report the lack of a reliable, felt

sense of their bodies or of themselves inhabiting their bodies." pg 59

"Interestingly, when the DMPFC is activated (reflecting on the self or conceptual

self- awareness), the VMPFC (body awareness and embodied self-awareness) shuts

off, and vice versa. According to Fogel (2009), and as many meditators will attest, it

is impossible to inhabit both kinds of awareness at the same time. People with

developmental trauma who are often, at best, holding together a diffuse and

fragmented sense of self, will experience impairment in both types of self-awareness.

They find it challenging to conceive of themselves at all, and when they pull together

some sort of self-concept, it is usually infused with perseverative self-hatred

(originally the hatred or perceived hatred of the mother). And perhaps needless to say,

patients with developmental trauma have learned not to inhabit their neglected,

defiled, and blamed bodies. This truncated embodiment can be seen as the primary

dissociation of trauma survivors, and it seems to be the failure of this prefrontal

structure, under the onslaught of abuse and neglect, that is responsible. If the brain

structures that represent self in the mind fail to develop, there can be no self (FZ and

FPO2)." pg 60

"The posterior cingulate, at the back of the head, mediates the person’s recognition

of her existence in space. The precuneus is located here, and it may hold a good deal

of a person’s autobiographical memory, and in that, her sense of identity." pg 61

"The default mode, also called the resting state networks, is dysregulated in people with developmental trauma. They do not rest; they go blank." pg 62

"This small almond-size nuclei that lies deep in the temporal lobe is involved primarily

in rage, shame, and fear reactions, but also more generally in establishing the

emotional valance of incoming stimuli. The RH amygdala is devoted to survival and

reacts to threats, both real and perceived. As is true of the hippocampus, the amygdala

is highly prone to kindling, the term given to repetitive neuronal firing that gains

amplitude with each repetition until it collapses. This pattern of activation makes each

experience a prime for the next episode; that is, each kindling event lowers the

threshold to future ones, making them more likely. This vulnerability may help us

understand why developmental trauma usually gets worse over time and why the

amygdala may react to increasingly tangential stimuli in its efforts to keep its owner

alive." pg 63

"People living in the throes of high amygdala arousal have no sense of time passing

or of a past at all. It is as if the abandonment, abuse, and neglect suffered as children

were ongoing, even though they know cognitively that this is not true. It is impossible

to know how these events are actually held in the brain, but these early threats to life

are likely distributed in subcortical patterns of activation throughout the fear circuitry." pg 64

"Individuals with developmental trauma have grown up with the limbic CNS informing their feelings, beliefs, and actions. They are captured by an overactivated amygdala that has no effective regulators. The insula, the anterior cingulate, the prefrontal cortex, and perhaps the cerebellum are meant to exercise inhibitory influence. In developmental trauma, these inhibitory structures are either not available or are functioning poorly, leading to dysregulated behavior and cognition heavily determined by shame, rage, and fear—each of which has a “chamber” in the amygdala...

In common parlance the amygdala has become synonymous with fear and

although we have seen that fear, like memory, is a widely distributed survival

function, the focal point of fear reactivity is the amygdala. Fear is, of course, central

to our developing thesis. I agree with LeDoux when he says that “fear is a core

emotion in psychopathology” (1998, p. 132). It seems, in fact, that fear may well be

the core emotion in psychopathology, and there is no group for whom this is truer than

for those who have suffered from developmental trauma. These individuals are also

prone to intense shame reactions and to disorganizing rage. Fear and rage are

activated to save the life of the organism.

At first look, shame, also an amygdala affect, may not seem so clearly protective,

but it is. “It appears that shame, at least through evolution, has served to keep the

individual’s behavior in line with cultural norms that further ‘survival of the tribe.’ It

may, in fact, be the emotion that underlies formation of a conscience” (Rothschild,

2000, p. 63)." pg 65

"Izard (1971) argues that “shame comes to play an adaptive central active

role in the regulation of (impulsive) emotional expression, and therefore for more

effective social interaction” (as cited in Schore, 1994, p. 210). Shame socializes and

protects our connections to other human beings.

Those who are described as borderline or narcissistic are characteristically swamped by shame and organize themselves to avoid it. Fear, anger, and shame all have adaptive, survival functions. In developmental trauma, however, these affects, rather than informing the sense of self, overcome it. And there is evidence that in their toxic forms, they contribute to illness both psychological and physical and in many cases to early death." pg 66

Chapter 3: Neurofeedback

"Mindfulness means calming the reactivity of the mind and acting from that state of

mental quietude and attention. One of my patients with developmental trauma, an

accomplished martial artist who had done sitting meditation for years, told me that she

really learned to meditate only after neurofeedback and that it was for her like being

on a fast track. She is much more able to practice both meditation and mindfulness on

a daily basis, because the pulse of fear she’s lived with since childhood is much less

likely to arise, and if it does, to kindle and overtake her. A regulated brain gives rise to

mindfulness; mindfulness in turn encourages a regulated brain." pg 83

"Neurofeedback is a computer–brain interface that uses sensors placed on specific

areas of the scalp (corresponding to specific parts of the brain) to provide the brain

with almost instantaneous feedback on frequencies in the EEG. It represents a new paradigm in brain science, and as is always true on the frontier, there are battles being

waged over it. Unfortunately, the most common association people make between

electricity and the brain is electric shock treatment, which induces the very activity in

the brain that neurofeedback seeks to mitigate: a seizure. It is important to note here

that in most systems, no electricity enters the brain in neurofeedback training. Instead,

frequency information is picked up through sensors on the scalp and displayed on a

computer screen as a scrolling EEG. Frequencies are selected to be rewarded or

inhibited, based first on assessment and then on response and ongoing assessment,

session to session. Neurofeedback is only information, but information to the part of

us that can use it best, the brain. The power of neurofeedback suggests that we are

talking in the brain’s language. We will look at this process in more detail in Chapter

6.

As we explored in Chapter 2, therapists who use neurofeedback address

dysrhythmias in the brain, and as we have seen, these dysrhythmias are profound in

those who have been neglected and maliciously injured as children. Mental health, on

the other hand, correlates highly with a well-regulated brain and may, in fact, be

dependent on it. “One of the interesting findings . . . was that relatively good

personality structure relates to a normal EEG” (Shelley et al., 2008, p. 11). Although

this may indeed be more true than untrue, I have seen EEGs of many struggling

people that looked pretty good. I am presently working with a man who was

traumatized in adulthood and who is anxious and prone to temper outbursts and road

rage. When he settles down to train his brain waves, at least on the metrics available

to me using neurofeedback alone, he shows no apparent trace of these problems. I

joke with him that he has the brain of a Buddha. Of course, beneath his reactivity this

man does in fact have a “good personality structure.” The point here is that a person

can be symptomatic and still have a normal EEG, and we can still have a positive

effect on her symptoms through training the EEG. The obverse can also be true. Not

all abnormal EEGs show up as symptoms. That being said, I have yet to see a normal

EEG in someone with developmental trauma." pg 85-86

"David Kaiser (2013), a cognitive neuroscientist and neurofeedback researcher,

reviewed the charts of over 100 children with ADHD who had had successful

neurofeedback outcomes. Fifty percent of these children showed significant EEG

changes, and 50% showed little change in their EEGs. In part in an attempt to

conform to what we already know about learning, many neurofeedback researchers

default to operant conditioning of the EEG as the explanation for how it works.

(Operant conditioning is a type of learning in which a behavior is strengthened—

meaning, it will occur more frequently—when it is followed by reinforcement/reward,

and the behavior is weakened—it will happen less frequently—when followed by

punishment.) As we will see, there are rewards (no punishments!), such as they are,

for changing your EEG, but it is clear that we are quickly tapping into intrinsic

rewards that sustain and propel the training process. We could see these intrinsic

rewards as a proliferation of complexity and a move toward the self-regulation that is

so prized by the brain. It feels good. These intrinsic reward systems in the brain may

play by more complex rules." pg 86-87

"Whenever we talk about circuitry, we are talking about frequency and amplitude. The frequencies at which the brain fires underwrite every feeling, thought, and deed, so frequency is important. Frequency , in our context, is the number of times a brain wave rises and falls in the period of 1 second. It is measured in Hertz (Hz), also called cycles per second (CPS). The brain operates in frequencies from 0 to 100 Hz and perhaps even higher. There are names attached to these frequencies, noted below, that are useful to know because they are so widely used, but in keeping records and talking to colleagues, you will

always want to specify the actual numerical frequency range and not the name given

to it. With that caveat, here are the names. (See Figure 3.3 for the wave formations of

these frequencies.)

0–3 Hz Delta

4–7 Hz Theta

8–11 Hz Alpha

12–15 Hz SMR, also low beta

15–18 Hz Beta

18–36 Hz High beta

36–45 Hz Gamma

These frequencies, as we will see, relate directly to arousal and to state." pg 89

"Seeing delta frequencies in patients with developmental trauma suggests to me the likely presence of developmental brain injury. At the very least this frequency in a patient is an indicator that this brain at this sensor location is not appropriately interactive with the external environment and perhaps lost in its own repetitive internal brain dialogue. A system meant to be “open” to its environment is closed and necessarily self-referential. In most cases, we want our patients with developmental trauma to reduce the prominence of delta overtime, which is the purpose of inhibits. As we will see, we train the brain not only to produce more of certain frequencies (i.e., what we reward), we also ask it to make less of other frequencies, such as delta or theta (i.e., what we inhibit)." pg 91

"We pass through theta as we fall asleep, when we are drowsy and filled with

hypnogogic images. Theta is considered a highly creative state, unlinked from the

constraints of logic and daily demand. With practice its images are retrievable by the

more conscious mind. It is reported that when Einstein felt stumped—when he had

been wracking his brain without a breakthrough—he would take a nap, most likely to

induce this theta state. He could then solve the problem that had perplexed his fully

awake mind. Theta is the state induced by most hypnosis, and it also relates to some

of the deepest states of meditation...

There is an approach to training called alpha–theta that rewards the brain to visit

these deeper theta reaches while maintaining intermittent access to alpha, ideally

allowing the trainee to remember what she experienced and bring it into conscious

awareness. Alpha–theta training is done in a reclining position with eyes closed. Body

position affects brain wave production. We naturally make more slow waves as we

recline, which is why most of us need to lie down to go to sleep. As we will see in

Chapters 7 and 8, alpha–theta training can be very helpful in working with

developmental trauma as well as with addiction, a sadly common comorbidity in

adolescents and adults. Clinical experience has demonstrated that alpha–theta training

facilitates access to traumatic memories otherwise unknown to the patient." pg 92

"In normative terms, by the time a child reaches age 6, the dominant frequency in

the brain is closest to alpha and by age 10 it will be around 10 Hz. Alpha is

resplendent in the relaxation literature and associated with calm, perhaps even being

“laid back” (note the postural reference). It may be difficult to put these two images

together: that of a 6-year-old and that of relaxation—the very last thing that most 6-

year-olds have in mind. Clearly the predominance of alpha frequencies (and for that

matter, any frequency) can be experienced differently by different people, and there

are very different environmental imperatives for children and adults. In children the

frequency of alpha establishes what will become the dominant frequency for the adult.

The dominant frequency is the background rhythm of the brain, or the sampling rate

the brain uses in its interface with the outside world. It is also used to modulate activation. It is typically measured at PZ. In adults, a reading lower than 9 Hz or

above 12 Hz usually signals problems. Ideally the adult dominant frequency is

between 9 and 11 Hz.

Interestingly, alpha frequencies are not necessarily relaxing for adults either. For

some, training to produce alpha can lead to heaviness and lethargy, and in others, to

increased levels of reactivity and anxiety. The latter pattern is the most common in

those with developmental trauma. Even alpha reinforcement (reward) can be too

arousing for their overly aroused nervous systems." pg 93-94

"When the field was young, there were three placements: C3,

C4, and CZ (you’ll understand more about placement in the next section, “Applying

the Sensors”) and two frequencies to train, 12–15 (SMR) to lower arousal, usually on

the right (C4), and 15–18 Hz (beta) to raise arousal, usually on the left (C3). I

mentioned that alpha is not always calming and the same can be said of SMR, even

more so, particularly with people who are dealing with trauma. It is rarely quieting for

people who have endured this primary insult. In fact, this is a pretty safe beginning

assumption until an individual’s brain teaches you otherwise.

My chronically suicidal “borderline” patient reported feeling a sense of dread after

training at 12–15 Hz. By then the neurofeedback system had evolved, and we had a

full range of frequency filters—which meant that we could train at any frequency

from 1 to 45 Hz. At 13–16 Hz the dread dissolved and she reported, “My whole brain

is smiling.” SMR was too low for her, but this is not a typical reaction. In cases of

developmental trauma, 12–15 Hz is usually too high.

I met with a colleague, a trauma survivor in a country of trauma survivors. He was

chain-smoking, speaking rapidly, jumpy and anxious. When I asked him if he was

training himself, he said he that he’d given up, that it didn’t work for him. He had

done over 100 sessions at 12–15 Hz. The frequency was much too high for him and

actually drove his nervous system into higher arousal and more dysfunction, rather

than less of both. He had been a believer in SMR, and he’d made a classic mistake by

pinning his training on theory rather than on observation of his own experience. When

he trained at a much lower frequency, he was able to relax deeply. His assistants told

me they had never seen him so at ease. This is just a cautionary tale. Although the RH

normatively cycles at 12–15 Hz, or there about, it does not mean that it will

necessarily benefit from training at that frequency. We find that out from an

individual’s response. We’ll look into this issue more in Chapter 7 when we discuss

protocols." pg 94-95

"Beta is the presumed cycling speed of the LH; it cycles faster than the RH

primarily to support speech. Our brains are making primarily beta waves while we are

reading, writing, or doing math. If you are not cycling in beta, you will have trouble

with demanding cognitive tasks, and if you produce too much beta, it will be difficult

to access the lower frequencies implicated in creative problem solving. In working

with developmental trauma the problem generally is one of very high arousal. It is

very easy to tip these nervous systems into overarousal with an outpouring of reactive

shame, anger, and terror—the last thing you want to do. So when working with these

patients it is the general rule to tread lightly on the LH and when LH training is

indicated, a frequency band lower than 15–18 may feel better. In neurofeedback

training what feels good is good." pg 95-96

"We have seen that as we raise frequencies, we raise arousal, all with mental state

correlations. High beta has less of a mental signature. It is usually regarded as

reflecting muscle tension and is almost always inhibited in standard neurofeedback

setups. The goal for the trainee is to lower the amplitude of these wave forms both by

relaxing their muscles and by watching the screen. A young Russian adoptee showed

me her prowess during my visit to her residential center. She was able to reduce her

amplitudes of fast wave, in the 30s, to 6 in the course of a few minutes without my

being able to discern any effort on her part to relax her body. After the training she looked more relaxed and reported feeling so. She was on her way to becoming one of

their success stories, and she was delighted with her ability to control frequencies in

her brain.

This is not a trivial ability when you have lived believing that you had no control

over anything—yourself or anyone else." pg 96

"Frequency is one measure of a wave form and amplitude is the other. Every wave is

measured by frequency (how fast) and by amplitude (how high) in microvolts (μV), as

mentioned previously. When we are training, we are rewarding the brain to make

more amplitude (bigger amounts) of a desired frequency and lowering the amplitude

of other frequencies that are just causing trouble. The take-home message here is that we are using increases in amplitude to strengthen the frequencies that, in this

population, lead to less fear and reactivity, and we are inhibiting those that contribute

to it." pg 97-98

"In this population if the training is accurate in relation to the

needs of the person’s nervous system, he might feel noticeably calmer and less

reactive. It could also be said that it is the brain’s job to bring the patient for training. I

say this now only to suggest to the new practitioner what seems to be a neurofeedback

law: If the protocol is right, the patient will want to come for training; if not, he won’t." pg 100

Chapter 4: Trauma Identity

"Neurofeedback is the working interface between brain and mind. When this

simple fact captures the wider scientific imagination, as it will, there will be many

books written about what arises in the mind when you provide feedback to the brain. I

address how this process unfolds in most people with developmental trauma whom I

have trained. It is a complex picture wrought with every possible individual variation.

We are going to talk about identity as it is tied to arousal, affect, state and trait; how

all of these formulations of self ride on arousal; and what happens when you begin to

dislodge the cornerstone of fear.

Clearly, identity is a multifaceted construction that depends on many important, interlocking variables; family, peers, genetics, epigenetics, class, culture, race,

religion, intelligence, and luck are just some of the contributors that are not addressed

in this chapter. It is the thesis here that the cascade from abuse and neglect to brain

dysregulation is central not only to developmental trauma in childhood but to many

variously named disorders in adults. As we have seen, when you grow up in an

abusive, neglectful, unpredictable, scary environment, there are often few

remembered discrete events, and there is no coherent self to stand back and observe or

report. As Schore (1994, 2003) has taught us, a sense of self requires affect regulation.

In developmental trauma, identity is inseparable from affect. In terms of identity,

these individuals suffer their own Cartesian error—in essence: “I am what I feel.”

This is what I have come to call trauma identity." pg 114-115

"Fear is the death before death. Patients with developmental trauma survive, but they

don’t live. They cannot trust their minds or even their sensations. Just stop for a

moment and imagine that right now, you cannot trust what you are perceiving: You

don’t quite know if you recognize this room, or the meaning you should take from the

voices across the street. It isn’t a conceptual error but a perceptual warp. Most people

with developmental trauma know what is real; they just don’t know what is safe." pg 115

"Fear sets the tone of trauma identity in the body and in the mind. I explore a way to

think about what happens to the self that is engulfed in fear when the brain learns to

interrupt incessant, reactive fear circuits. Neurofeedback offers us a new template for

understanding how identity can form and re-form in the seemingly impersonal realm

of brain wave frequencies." pg 118

"In developmental trauma fear structures and networks are in overdrive, firing too often,

too much, too fast, too repetitively, and too influentially. High arousal correlates with

an overactivation of the amygdala and other brain structures involved in fear and the

underactivation of those structures meant to inhibit them. This brain finds itself, as we

have seen, in a state of disequilibrium characterized by heightened reactivity to stimuli, even apparently benign ones. These inflexible and unstable nervous systems

are routinely overtaken by subcortical neuronal storms that give rise to affect

dysregulation. When arousal becomes emotion, it becomes a quality of the mind and

it is felt: Arousal becomes affect...

Fear, anger, and shame—the emotions of most concern to us like all emotions and the

states they give rise to, have frequencies underpinning them. High levels of

subcortical arousal translate to dysregulated and even wild emotional states. The

people trying to live in these nervous systems will be volatile, agitated, unreasonable,

angry, shame-filled, shaming, and afraid, some even paranoid. They have no mechanisms in their brains to soften the scream of the amygdala. In his book, Waking the Tiger, Peter Levine (1997) quotes one of his traumatized patients:

I don’t know of one thing that I don’t fear. . . . I fear anger . . . my own and everyone else’s, even when anger is not present. I fear rejection and/or abandonment. I fear success and failure. I get pain in my chest, and tingling and numbness in my arms and legs every day. . . I have headaches. I feel nervous all the time. I have shortness of breath, racing heart, disorientation, and panic. I am always cold, and I have dry mouth. I have trouble swallowing. I feel overwhelmed, confused, lost, helpless and hopeless daily. I have uncontrollable outbursts of rage and depression. (pp. 47–48)

This is the narrative of affect in trauma, and it becomes the narrative of state." pg 121

"Levine’s patient speaks for most people with developmental trauma. They are afraid

most if not all of the time and usually ashamed and angry as well. The amygdala driven

affects determine their states and their experience of themselves and of the

world. State can be understood metaphorically as weather, ever-changing, and trait ,

which we will discuss soon, can be seen as climate, prevailing, fixed. Patients with

developmental trauma endure recurrent storms in the repetitious assaults of fear. State

subsumes the discrete experience of emotion. Acute fear folds into the background

ambient state of fear. Emotions are not experienced as arising and falling away, the

reality of all emotion, but as phenomena that are more enduring and more self defining.

The person is no longer just capable of anger or of getting angry; he is increasingly defined, by self and others, as angry." pg 122

"These resources and respites [refractory periods] are not available to those with histories of developmental trauma. They have few, if any, refractory periods. They are driven by intense sympathetic and parasympathetic arousal, which leaves them immobilized,

frozen, and helpless. These patients either feel afraid all the time or never—the

difference perhaps between BPD and APD—and sometimes the difference between

women and men who have survived these childhoods. Women are more often overrun

by feelings; men are more often overtaken by no feeling; but, of course both men and

women could experience either. Whatever the manifestation, adults with

developmental trauma, being bereft of self and of discrete emotions, are not just

dependent on their state, they are defined by it." pg 123

"In all of us, arousal gives rise to affect, affect to state, and state

to reinforcing narrative—and all that, in this population, coalesces into trait and then

identity. We believe our states, particularly urgent ones. It would be very difficult not

to, when the state is determined by the felt threat to survival." pg 124

"Narrative arises from state, serves it, and reinforces it. Obviously, psychotherapy

attempts to address this narrative, but LH talk is of little relevance to an erupting RH.

The narrative is the verbal (LH) mind’s best shot at justifying or understanding the

state that arises from subcortical terror driving the non-verbal RH. But the narrative

comes from the mouth of the child, from the imprint of early experience. There had

been no update for him. This man was not the tall, strong, smart adult that he actually

was. Instead he constructed himself from arousal and affect, and he felt that he was a

powerless victim or potential victim, no matter what the circumstances—exactly what

his amygdala dictated." pg 124

"Helplessness rules state and ultimately becomes a trait in developmental trauma...

The narrative of state begins with “I feel . . . ”; the narrative of trait begins, “I am. . . . ”" pg 124-125

"When states are permanently urgent, managing them will require (or feel as if they require) urgent action. Patients will be riveted to their state and, over time, defined by it. They will do just about anything required to manage it, and all too often they may feel driven to alarming acts, primarily as attempts to influence the impossible, wild firing beneath their awareness. Urgent, fear-driven states cannot be reasoned with, nor can people in them easily learn new tasks. Developmentally traumatized patients get caught in an unreliable but

compelling sense of self and worldview that depends entirely on the state in which

they find themselves. They identify with their state and tend to rely on state-bound

information preferentially over other incoming information. If it doesn’t serve

survival, it won’t be learned. There isn’t time enough. Death or oblivion awaits.

These urgent states, rehearsed over time without interruption or intervention, become

traits. When emotional storms are no longer passing weather, hard enough for the

patient and those in his world to endure, they will become the climate, the prevailing

pattern that underlies any sense of identity. The more practiced a state, the deeper the

“rut” in the brain. This circuitry has fired together and wired together for years, and

each time it happens, the circuitry gets stronger. These states so dominate these

individuals that they become hallmarks of who they are. This identification happens

early in the course of developmental trauma, and it gets folded in to each

developmental stage until, as adults, we see profoundly dysregulated women and men

known to themselves only by what they feel (or don’t feel). What was originally an

unregulated affect and state promoted by the kindling amygdala becomes a prominent

trait. It feels hardwired.

To pursue the weather–climate analogy, after nearly unremitting storms, the

climate of the traumatized person has changed. The storms have reached tornado

proportion and represent not only how they feel or how they behave, but now, who

they are . This chaos that began with erupting neurons is a marker of these patients’

sense of themselves, of their personality, and even of their identity. This unbearable

alignment of affective storm and sense of self is what I am referring to as trauma

identity , fragmented, unregulated, and driven by fear.

The traits common to personality disorders relate directly to the terror arising from

neglect and abuse as a child. Ambient fear is the background condition of being. Fear

narrows focus and attention. Dysregulated arousal leads to dysregulated, volatile

mood. Fear drives cognition. Patients with developmental trauma are angry, ashamed,

and terrified. These are the traits of developmental trauma." pg 125-127

"As discussed earlier, identity is a complex affair and may not be distinguishable from

personality. I don’t want to get caught up in semantics, but it seems to me that identity

is deeper and more ineffable than personality. It doesn’t really matter here, the

important message is that identity, or the way we experience and know ourselves,

rests on firing patterns deep in the brain. When we change these patterns, everything

we know as ourselves is up for grabs. Many of my patients have struggled to describe

this experience. Most often they say something like, “Who is this person?”, referring

to something they said or did that they could not have conceived themselves saying or

doing. One woman, who was timid in her job as a manager, found herself being

assertive in a meeting with those she supervised. She watched this unknown self in

disbelief while she also observing her known fear of what her supervisees would

think. At a neurological level she expected terrible blowback to her asserting herself,

even to taking up space at all, and she was quite surprised by the feedback she got.

Many told her that it was a relief to them; they’d been waiting for someone to step up.

No one reacted badly. This kind of assertion is a common development with these

patients in the process of neurofeedback training. This is assertion not freighted with

aggression. It has no charge in it, no threat. Another patient with developmental

trauma told me about looking at a building and seeing that it was “safe.” She

described it as the first time in her life that she had a feeling that the world was safe.

One of the most rewarding aspects of doing neurofeedback is witnessing this level

of change in how people know themselves. When these changes do happen—a

potentiality of any nervous system—these patients feel simultaneously familiar and

entirely unknown to themselves" pg 127-128

"When we train the brain to change its frequency-based arousal, we change affect,

or felt arousal. When affect changes, state changes. The storms become less intense

and less frequent. There are breaks in the clouds. As the brain becomes less aroused

and states more easily regulated, the narrative begins to change. As the storms recede,

the climate changes. Traits, the hallmark of personality and of personality disorders that seem to be “who we are,” begin to give way." pg 128-129

"Identity that ascends from the dysregulation of high arousal to intensely felt affect,

to state and to trait, also begins, over time, to change. One of the ways to recognize that this shift is happening is when your patients begin to talk about themselves in the

terms of their brains and in the language of arousal. It is not only that they are picking

up on the idiom of neurofeedback; they are beginning to feel the ebb and flow of

arousal. They begin to feel emotion as emotion, arising and falling away. Typically

they stop using their diagnostic label but instead describe how aroused they feel or

how regulated or dysregulated. The reorganizing CNS produces a new narrative. A

new, tender sense of self begins to organize. These patients will become, in a sense,

less their brain and more their mind. They will have a chance to think and to

experience the nascent ability to reflect. Psychologically, self-reflection requires some

level of affect regulation—in essence, some peace. Neurologically, it requires well regulated

structures doing what they are meant to do. Simply put, the therapeutic

work with neurofeedback involves, first, the regulation of affect through quieting

arousal and then helping the patient to integrate a newly organizing, emerging sense

of self." pg 131-132

Chapter 7: Neurofeedback Protocols for Developmental Trauma

"I no longer see these as distinct disorders or comorbidities but as different

manifestations of the same overwrought, dysregulated nervous system. With

neurofeedback, we are attempting to tweak the dysrhythmias into rhythmic flow. Our

protocols are designed first to quiet fear in this person, as it manifests in her, not to

treat a disorder. In the process we would expect the patient to develop more regulated

eating habits because she feels hunger and satiation, to quiet obsessive thoughts and

compulsive behaviors, and to become uninterested in substances, whether prescribed,

legal, or illegal. When the brain learns its own regulation, these symptoms and

behaviors drop away because they no longer serve their primary purpose. When the

neurofeedback protocols are on track, training will establish rhythmic flow,

movement, even dance. It is about emergence. The process is best felt as a verb.

Diagnoses are coffin-nail nouns." pg 211-212

"Although I recommend other protocols, C4 is often a good place to begin to get a

feeling for the frequency reward that this brain appreciates. Unless there has been an

injury near this site, it tends to be less reactive than either temporal or frontal lobe

placement. You are likely to train both temporally and frontally over time—as we

have seen, Schore (1994, 2003) has found considerable data indicating that these

locations are important in developmental trauma—but C4–A2 usually offers us safe

harbor as we explore reward frequencies.

I always choose C4 or C4–P4 (right parietal) to begin with people who express

their dysregulation primarily in the soma. For many with severe childhood histories,

the psychosomatic becomes the somatopsychic. These patients look less mentally ill

and more physically eroded. .... The digestive system may be the most sensitive system to unrelenting stress. I use C4–P4 when there are issues with the digestive tract such as reflux, hiccups, or constipation, and look for the frequency that will increase parasympathetic tone and calm the nervous system." pg 213-214

"It is common for patients with developmental trauma to show signs of CNS

instability, such as panic attacks, IBS, or migraine (interhemispheric symptoms), and

when I see these symptoms, my initial training is at T3–T4...T3–T4 can also be useful when the patient is highly reactive generally; when there are many symptoms endorsed, right and left; or when you get a clinical sense (sometimes your own low-level dread) that this nervous system is not only highly aroused, it is highly unstable." pg 214

"Most of the literature on affect regulation and a good deal of what’s written on

interoception focus on the RH. The subcortical drivers are nestled along the midline,

deep in the temporal lobes. Even when my patients have somatic markers, which most

do, I most often begin training at T4–P4. I still, of course, keep track of the body, but

my focus is on emotion regulation, and the fear structures are, for the most part, in the

temporal lobe. But as a reminder of how important it is to follow the brain and not the

theory, let me tell you about one patient’s response to temporal lobe training...I trained another patient at C4–P4, but it wasn’t helpful to her, regardless of frequency. I changed her to T4–P4 at the same frequency and she told me at the next session that I had changed her life, “literally.”

In the initial stages of training, we are looking for the right frequency at the right

placement, hoping to find a default protocol." pg 215

"Unfortunately, there is no rule for a beginning frequency except that dictated by

developmental trauma itself. These are among the most overaroused nervous systems

you are likely to encounter. Because I know this, I tend to begin at 10.5–13.5 Hz to 9–

12 Hz. Most adult patients will tolerate somewhere in this frequency range, at least at

the beginning, and most will train comfortably lower than this, even much lower.

There are also patients who will need to train higher, as we saw in the case of my

suicidal “borderline” patient. When she reported feeling dread after training, I hooked

her back up and raised the frequency. Her report: “My whole brain is smiling.” In

people who calibrate in fear tones, dread usually means that the frequency is too low." pg 216

"If the patient has done well with anticonvulsants (mood stabilizers), this is an indication for stability training at either T3–T4 or C5–C6. My colleague, Ed Hamlin, has worked with many people with severe bipolar disorder, usually genetic and not traumatic in origin. With this group, he found that C3–C4 was not enough to stabilize them, but that they were usually too reactive at T3–T4. His experience was that interhemispheric training was the right course, so he tried C5–C6, which was more predictable and less dramatic." pg 217

"We have the entire frequency spectrum from 0 to 45 Hz to consider in protocol

decisions. With developmental trauma, we are training with one goal—to reduce

arousal—and to do this we take the reward frequency as low as it needs to go. For

some, this can mean training as low as 0–3 Hz, a bandwidth that targets 1.5 Hz (the

midpoint), and, as we will see, practitioners are exploring frequencies below 1 Hz. In

this case, we are using this bandwidth to leverage arousal, not to “up-train” slow wave

frequencies. And we see no increases in slow wave—which are also inhibiting (see

the next section, on inhibits)—even when we seem to be training the brain to make it,

but we do expect to see a reduction of fear. We are always exercising some

homeostatic mechanism in the brain no matter where we train or what we ask it to do.

When we make the right request, the brain will propagate new patterns manifesting in

new but apparently inherent capacities—emotional, physical, and cognitive. However,

I don’t begin training at very low frequencies. We get there only at the brain’s request." pg 217

"I begin with a 0–6 Hz inhibit. I use a standard 22–36 Hz inhibit for excess fast wave, which is less characteristic of this population. The fear of these patients seems to be coded in the slow waves. That’s where we’ll see amplitude increases if the patient begins to dissociate or has a run of fearful thoughts or memories. As we’ll discuss shortly, alpha–theta training is predicated on the notion that the demons live down deep—as do, with fear quieted, the angels." pg 218

"Our decisions will prove out, or not, over the next 2 hours to 3 days. If the

frequency was too high, you will see increases in arousal symptoms (right column in

the tables in Chapter 6); if it is too low, an increase in symptoms of underarousal (left

column); if destabilizing, more symptoms of instability (middle column); and if it is

just right—you’ll know. Overshooting is not uncommon and generally not to be

feared. We are in the conversation and the brain will respond with plasticity. There are

moments, however, such as those with my rage-filled client, when training effects

take on emergency proportions, almost always because arousal is too high. This is a

state that can give rise to a dangerous narrative that can be acted upon, and you will

want to address it immediately. Once you find the protocol that quiets fear and also

allows cognitive clarity, this will be your default protocol for that particular patient,

and you will train here as long as the effects continue and remain positive. As

mentioned above, once you have established this protocol, in most cases, you’ll have

your footing and can begin to explore other protocols that could benefit function.

Most training for high arousal is on the RH, but there is usually a need for LH training

as well. As a general rule, if you have trained below 10–13 Hz on the right, you’ll

want to train below 14–17 Hz on the left." pg 221

"A colleague reported an overwhelming sense of smell. She could smell everything

at twice its normal intensity, and she was on vacation in the Caribbean where every

flower and vine competed for her olfactory attention. I had a similar experience.

Shortly after FPO2 training, I was driving down a highway when I suddenly smelled

hamburger. It kept getting stronger until I came to a Burger King about 2 miles from

where I first caught wind of it. The smell went away shortly after I passed it. My

sense of smell was more like that of a wolf in the wild than a woman on her way to

Cape Cod. The olfactory bulb lies directly behind FPO2 and we can activate it at this

site." pg 225

"As you may remember from Chapter 2, the frontal areas of the brain are devoted to

planning and execution (executive function). Emotion serves motion, and motion that

is not in response to habit, instinct, or emergency requires planning. RH frontal sites

are also very much involved in regulation of the amygdala. Without this capacity,

events are processed as emergencies, even when they’re not, which makes planning subjectively irrelevant. Under threat, we don’t make plans, we take action. Training at

these sites, either unipolar or in a bipolar montage with T4, can be helpful in quieting

reactivity. FZ may be the most useful frontal site. It sits atop the dorsomedial

prefrontal cortex (DMPFC)—the center of conceptual self-awareness—and beneath

that, the ventromedial prefrontal cortex (VMPFC)—embodied self-awareness—and

seems to speak to them. As the fMRI literature in OCD (Fitzgerald et al., 2005) and

clinical neurofeedback experience would suggest, training at FZ can address

obsessive and compulsive symptoms. Studies of peak performers (Baumeister,

Reinecke, Leisen, & Weiss, 2008; Doppelmayr, Finkenzeller, & Sauseng, 2008) as

well as EEG studies related to anxiety (Inanaga, 1998; Suetsugi et al., 2000) reveal

interesting, somewhat counterintuitive findings on frequency at FZ. These studies

show that peak performers make higher than average theta amplitudes at FZ. As a

result of these findings, I begin training at 5–8 Hz, ready to move the reward band up

or down, more often down, depending on the individual response. Practitioners have

also used F3–F4 to quiet reactivity in this region. F4 has been colloquially referred to

as “the valium spot.”" pg 227

"Alpha–theta, or deep state training, is probably the most celebrated protocol in the

fields of PTSD, addiction, and, interestingly, peak performance. This is a protocol

with many authors, the most influential among them being Elmer and Alyce Green

and Eugene Peniston. The Greens, then at the Menninger Clinic in Topeka, Kansas

(Green & Green, 1989), were exploring theta training as a portal to expanded

consciousness. One of the Greens’ workshop students, Eugene Peniston, took their

work with “normals” and designed what was to become the Peniston–Kulkosky or

alpha–theta protocol. His goal was to provide his patients with access to the often

unremembered trauma (coded in theta) while holding the nervous system in a state of

calm (alpha).

Peniston worked at the VA Medical Center in Fort Lyon, Colorado, with men

suffering from severe PTSD and crippling addiction to alcohol. Their first study

(Peniston & Kulkosky, 1989) was with alcoholics who had been hospitalized four or

more times due to relapse. All participants were given an EEG, the Beck Depression

Inventory (BDI), the Minnesota Multiphasic Personality Inventory (MMPI), and the

Millon Clinical Multiaxial Inventory (MCMI). They all had blood taken to measure

levels of stress hormones. Ten of the 30 study participants were not alcoholic and

were only given these measurements; 20 were relapsed alcoholics. Ten alcoholic

controls were provided with standard therapies (i.e., talk sessions and a 12-step

programs) and 10 of the 20 relapsed alcoholics were trained with alpha–theta every

day for a month in addition to standard therapy.

All of those given standard treatment were rehospitalized within 18 months. In the

alpha–theta group, eight stopped drinking completely, one drank once but got sick

(dubbed the Peniston flu ) and didn’t drink again, and one continued to drink but the

alcohol didn’t make him drunk. These patients showed increased power in both alpha

and theta frequencies, stabilization of beta-endorphin levels, clear and positive

changes on both personality inventories, and a marked reduction in depression as

measured by the BDI. These results were maintained, without further hospitalization,

on 3-year follow-up. Experts in addiction have told me that they expect a 75–80%

relapse rate.

Of course, most of these vets had a comorbidity: the Vietnam war. These were the

men (there were only men in these initial studies) whose condition had called for a

new diagnosis: PTSD. In 1991, Peniston and Kulkosky published the results of a

second study on the use of alpha–theta to resolve symptoms of PTSD. By the end of

the month-long study, again the alpha–theta group showed marked improvement in

clinical scales and in symptoms. They too normalized their MMPI and MCMI scores

(see Figure 7.4). Nightmares, flashbacks, and manifestations of hypervigilance were

significantly reduced, and they used less psychotropic medication after training. In a

follow-up 2½ years later, 12 of the 15 alpha–theta veterans were living normal lives,

whereas all 14 in the control group were still suffering from PTSD." pg 234

"Before we venture further into theory, let’s get a picture of how this process

proceeds. In my practice, I work with my patients, using eyes-open training and

psychotherapy, to stabilize fear and reactivity and to acquaint their nervous systems

with a state of calm before we do any deep state exploration. I introduce deep state

training only when my patients are no longer reactive—that is, when they inhabit a

nervous system in control of itself. As you’ll soon see, I learned this the hard way.

This preparation will help patients assume and maintain a “witness position,” rather

than becoming, yet again, an unwilling participant in horror, should training in theta

exhume early disturbing events. They can look at events that arise as if they were

passively watching a film. Bill Scott describes it this way: “Because they are in a

quiet state, people don’t have flashbacks or re-experience the trauma. They become

emotional, and they’ll cry, but they won’t re-experience. They process it cortically”

(as cited in Robbins, 2000, p. 170). This has been the case most of the time in my

practice too, but, as we will see shortly, not always." pg 237

Chapter 8: The Integration of Neurofeedback and Psychotherapy

"This is a quote from a patient who suffered from dissociative identity as a result of

severe maternal abuse and neglect, routine physical and sexual assaults, paternal

abandonment, domestic violence, and poverty and food insecurity—the total

catastrophe of developmental trauma. She is describing the core change I have come

to expect with the integration of neurofeedback and psychotherapy: the emergence of

a self and an other.

As we have seen, this emergence comes about through affect regulation, just as

Schore, Siegel, van der Kolk, and others have said—most specifically, through

regulating the circuitries of fear, rage, and shame that have been firing and wiring

together since birth, or even earlier, since the birth of the amygdala at 5 to 6 months in

utero. I have just not found this level of healing possible with psychotherapy alone. I

have been able to help my patients understand both why and how these histories have

affected them. I have worked with them dynamically and behaviorally to learn to ride

these storm surges as best they can, but before neurofeedback I had no way to help

them stop the surges where they begin: in the brain. It bears repeating that it is much

easier to reach the mind through the brain than it is to reach the brain through the mind." pg 246-247

"Lack of self-regulation usually translates to behaving badly, erratically, and often

dangerously. More often than not it leads to conflictual, need-based relationships,

including those with therapists, and these conflicts routinely create even more

amygdala-driven reactions. These patients are ashamed of being ashamed and afraid

of being afraid. This is true for most of us, of course, but thankfully most of us do not

feel these feelings with the same level of unremitting intensity. Rage often seems

more syntonic, particularly for men and boys. It can pass as a narrative of power and

fearlessness. It is always self-justifying, and it can mask shame." pg 247

"Trying to ride these primary negative emotions is like riding a tall, wild horse. The

reactions to them, the emotions over having emotions, make the ride even harder. It is

akin to putting a second wild horse on top of the first and trying to ride them both.

This geometric propagation of negative affect is always at the ready because these

patients live in kindling, reactive nervous systems. They live in reaction; it is their

default mode. As we have discussed, our first task in life and in psychotherapy is

affect regulation. Neurofeedback will help accomplish this. But as is true for young

children, affect regulation is a necessary but not sufficient condition for self." pg 248

"Transference in developmental trauma begins in the felt experience of “no mother.”

Motherlessness is the lowest ring of hell for a baby and small child, creating a

background fear of death or obliteration. If this weren’t enough, it leaves these

children feeling either insatiably hungry for this primary connection or so damaged

that they can no longer feel the longing. They are truly orphans in the storm and they

need a mother. More precisely and importantly, they need to feel the way they would

have felt, had they had a mother who could comfort their fears, understand and

regulate their anger, soothe shame, and repair breaches. Many patients with

developmental trauma dismiss or demean this need, but it is inevitable." pg 248-249

"I don’t want to be misunderstood here. I think that therapy can be very helpful.

Feeling understood, cared for, and soothed goes a long way in helping even seriously

disturbed patients, as can teaching them to practice emotion regulation skills. It

cannot, however, quiet the deep, biological pulse of fear that drives their nervous

systems. At best, it teaches them how to better live with it." pg 250

"Everything I do now in psychotherapy and in neurofeedback I do to address fear,

to try to establish that the survivors do not need to live forever ruled by the fierce

whims of this circuitry. I don’t know ultimately how successful this approach will be

for any individual, but it is the goal. Or perhaps it is more accurate to say that I don’t

know how long this will take for any given person, but it is what I expect to happen.

Constant fear just cannot be their inheritance. Fear reduction should be quite

straightforward and received wholeheartedly by patients as the gift it is, but as we will

see, it doesn’t always go like that. It is the attuned relationship within the therapy that

holds these patients as their nervous systems shed layer upon layer of fear." pg 250

"As the anticipation of assault wanes, that fear yields to the deeper and even more

pervasive terror of abandonment and loss. Abandonment is the ground of being for

those with developmental trauma. Addressing fear at this level takes time, patience,

and dedication. The therapy has provided a first home for many and, the therapist

regardless of gender, the first mother. Absent their biological mothers, these patients

have no relational trace of growing up, no internal track or gauge. Many were asked

by parents or circumstances or both to be grown-up as very young children. One of

my patients was cooking for her older siblings and parents when she was 7. These

patients don’t know what it means to grow up within a nurturing relationship and then

to leave a parent at a developmentally appropriate time. These profoundly motherless adults, independent or dependent, functional or dysfunctional, have never grown up

and left home. There was no brain pattern or psychic structure for this." pg 254

"When the terror begins to ebb, patients may experience periods of confusion over who

the therapist is and has been to them and shame about who they have been in this

process. Growing up has been telescoped; patients have described themselves as Alice

falling down the rabbit hole. Many have told me that they are experiencing all ages at

once, as well as a speeded up developmental course. With neurofeedback we can

address the earliest developmental needs at the same time as the patient begins to feel

a sense of mastery, of adulthood and of a real self." pg 255

"For all too many people suffering from developmental trauma, the therapy flounders

in the patterns of negative expectation that we call negative transference . Longing for

the mother, now the therapist, brings fear and anger and shame with it, and as we have

discussed, these states create a powerful narrative that doesn’t yield readily to rational

inquiry, insight, skills, or even patience. For some, everything the therapist does or

says is suspect. At least initially, neurofeedback is not exempt from suspicion, even

when this person has sought out the training. When fear is so intense that it can easily

edge over to paranoia, change in state, no matter how deeply desired, will not be

trusted. It will be feared and so will you. Most of these patients have highly reactive

brains underlying these highly reactive states, and we can, unfortunately, expect

negative effects, particularly as we are getting to know this brain. Harder still, we

might make a mistake that leaves a patient feeling terrible. I have spoken about a

young woman who came to me for uncontrollable rage. When I trained to raise her

arousal slightly, she had the “worst night of my life; worse than the worst ever cocaine

trip.” Had she also been distrustful of me, this would have created a significant breach

in our relationship." pg 256

"As therapists, it is considerably easier to inhabit the positive transference than it is

the negative, but both represent a distortion of the core reality that we are discussing

here: We can change our brains and the minds they give rise to. On the therapist’s end,

with neurofeedback, we can feel overly identified with making this patient feel better

and when we do, we can make the mistake of owning this or assigning it to the

training and not to the patient’s inherent capacity for change. It is therapeutically

important, particularly with these uniquely disempowered patients, to remind them

that they are the ones who are changing their brains. That being said, most of my

patients still credit me more than they credit the training for their feeling better, and

this too is OK. I know that I am central to the changes in state and in sense of self that

they are feeling—just not as central as their newly self-regulating brains." pg 257

"At some point the patient will look for the transference surround and it

won’t be there. When patients no longer live in an insistent past, it means they don’t

need it. Regulation is the mother. The hunger is deeply met. Reactivity ceases. Slowly,

in awkward developmental steps, they can come to experience that we are in this

healing venture together, as equal adults, without fearing loss." pg 258

"A neglected and poorly regulated nervous system will give rise to both the diagnosed

“illness” and the often insatiable hunger for attention. When the early deficit is a

deficit of maternal attention, getting attention means survival. Most of my patients

who have spent any time in institutions talk about the stigma they felt when one of the

staff would inevitably say they were just “trying to get attention.” They had all heard

this as an accusation, and it induced shame in each of them. It happens so frequently,

that you have to wonder if it serves any other purpose. The parasympathetic tone of

shame can crash arousal and can get people to stop what they are doing. It can also set

the brain on fire and send someone into rage. Invoking shame makes people who are

already shame-based critically and desperately shamed, and they will react to that in

whatever way they have habitually reacted—either withdrawal or explosion. It can

feel cataclysmic to be caught in behavior over which you have little, if any, real

control, and particularly in the behavior that reveals infant hunger and the need for the

life-giving attention of the mother." pg 259

"Patients with developmental trauma, no matter how well they have managed their

lives, even those surrounded by family and friends, live in isolation. They often don’t

recognize this isolation until they begin to make newly deep and real attachments... No patient with developmental trauma that I have known expects kindness, and they all have

some difficulty in engendering this in others. In the course of their training, they are

met more often with kindness and with the challenges of kindness, in part because

they become kinder themselves. They have to learn how to settle into a new relational

matrix of self, other, and possible kindness, a matrix unknown to them but, it appears,

always known to their brains, and in their time they do, so much so that they no

longer comment on an act of kindness as a unique experience.

When the fugue clears, the experience they have had of themselves becomes poignantly clear. They have lived cut off from the world and have looked into it, much as a poor child might look into the window of a locked candy store.

It is, sadly, not uncommon for these patients to feel as if they have been expelled

from the universe by their creator. Those children abandoned by their mothers feel

abandoned by God. Many have expressed astonishment as they came to see that the

world is a suffering place and when they recognize that most people are worse off

than they. One patient had a sudden recognition that at that same moment millions of

people were suffering as terribly as she was. She had not been pathologically

delusional. She had known cognitively that this was a fact, but it was suddenly real to

her. It was for her a flash of enlightenment, and it opened the door for her to the world

as it is. From the position of isolation, patients with developmental trauma don’t

expect this. They have expected that recovering from their childhoods would mean

admission to Disneyworld, not to the real world. Some have initially felt betrayed or

resentful. It’s not difficult to empathize with them; their intense lifelong struggle for

emotional regulation has now spit them out onto the street (or at least, that’s how it

can feel), eyes open and feet under them, and they must begin, with the help of brain

regulation and psychotherapy, to learn acceptance.

Ultimately, acceptance of what is grants us freedom, and learning to accept is an

important part of the therapeutic process—not only for people suffering from

developmental trauma, but for all of us." pg 260-261

"If there are, at a given moment in time, just one too many attractors (triggers), a patient with developmental trauma can fall back into the vortex of terror. The brain may default to the patterns it has practiced since early in life to deal with trauma. This can be deeply disheartening and disappointing. “I thought I was done with this!” is a common lament. It is interesting to note that, with protest, there is a new sense of separation of self from symptoms. Such experiences look and feel like a relapse, and at these moments patients are likely to feel that they will never be free of their childhoods. Hold steady. There is a great deal of density in this history, and it takes the time it takes. Keep track of the

field trauma has produced and how it is changing. Your accident-prone patient should

begin to have fewer mishaps. Those who attract unsavory people will find fewer of

them in their lives and will come to want nothing to do with them. When we see this,

we are watching the trauma field shrinking. The density of early experience lessens,

as does its ability to attract trouble. The responses that arise are evidence to me not of

setback but of the power of the early terror. And this is exactly what we are

addressing.

I think we are seeing a contest between newfound regulation, new oscillatory

patterns, and the foundational patterns of dysregulation...

For many, these replays serve as revelations that they have, in fact, survived these

dreadful childhoods. These episodes used to disquiet me considerably, but now they

feel inevitable. These are the rounds of releasing fear to which I referred earlier. But

they do lose their power. Even when these moments are fully felt, they are not fully

believed. These patients are learning to put distance between themselves and their

amygdala-driven reactions. They are no longer fearing fear." pg 264

"Many patients have described an increasing capacity to discern falseness and appreciate the genuine. Several have described themselves as having an enhanced “BS detector.” People report being better tuned into others, and many describe becoming more intuitive.

These changers can either stabilize or destabilize. This patient is having a unique,

private experience within her brain as well as within her constructed sense of self, and

this is an experience that can be difficult to share with others. As they gain regulation,

these patients are often losing the company they have kept. In these ways,

neurofeedback training can be lonely. A woman in her late 50s described feeling alone

but also strangely OK with this. It felt accurate now, when before training, it had felt

singular and even tragic. She described walking in her town and feeling separate from

all of those around her. She felt herself as the quiet in the storm. She told me that

“there was no species barrier,” but she did not recognize herself in any other way in

the swirl of street life. In her newly arising self-regulation, she could not identify with

the level of ordinary tumult in which others seem to reside. She wasn’t drawn in or

toward. This feeling of separation, like all feelings, gave way pretty quickly toward

one of inclusion, but she reports that she still never feels drawn toward drama, the life

bread of her relationships prior to training. Her feelings of loneliness ebb and flow.

When they are flowing, they seem to be just what they are. She doesn’t react. There is

no wild horse. When there is no reactivity, the feeling just “is.

As we discussed, these changes can be quite disconcerting, but if the patient feels

better as a result, they are not refused. As you proceed, it is important to talk with

your patients about their internal sense of change (often not so easy to render

verbally), the changes that you see in them, any fears of change that arise, and to help

them validate and incorporate the newness as it arises in them. There will be a strong

correlation between lowering arousal, symptom reduction, and an increasingly

nonreactive and fluid sense of self. The organizing CNS allows for a new level of

choice. These patients are no longer captive to impulse. I ask my patients to make

every decision, from when they go to bed, to what they take into their bodies, to those

they choose as friends, thinking about how it will impact their regulation. The rule is

straightforward if not always observed: Choose regulation.” pg 265-266

"Throughout this book, we have focused mostly on fear, but shame is ubiquitous in this

group and, like the fear of abandonment, seems to outlast overt expressions of fear. I

talked earlier about watching for the leading indicators of arousal, and these are often

in the realm of shame. The leading indicator of shame is blame. One of my patients

admitted to looking for someone to blame when she stubbed her toe! But it would not

have to be another person. I want to hear a reduction in reflexive judgments not only

of the other but of the self. Appraisal is fine; assertiveness is welcomed; judgment is

overarousal. I work with my patients to observe this in themselves and when they do,

to begin to practice mindfulness." pg 266-267

"I have discussed the growing consensus that memory is state-dependent and that it

seems to be coded in the brain wave frequencies available to the person at the time the

remembered or unremembered events took place (van der Kolk et al., 2007, pp. 292–

293). As we have seen, the frequencies of early childhood are not routinely available

to adults. I think this phenomenon explains, better than repression does, the absence

of memory or the fragmentation of memory that is ubiquitous in those suffering from

developmental trauma. Repression suggests a psychological intentionality. We deploy

repression to keep the awfulness away. I had always accepted this elegant formulation

until I began to engage with the brain. Shock alters brain waves. Shock in childhood

disorganizes brain rhythms, and enduring shock reinforces this disorganization." pg 267

"Neurofeedback can make trauma memory available but ideally in a way that does

not further traumatize. Alpha–theta training takes us into the rhythms of early

childhood. Before we take this particular path, however, patients need to feel on their

feet and neurologically and psychologically stable—which, for these patients, could

often mean several hundred sessions of eyes-open training. We don’t want to evoke

the destabilizing brain event of trauma memory before the patient’s system can

manage it, but we don’t always have the last word. As we are stabilizing the brain

against this buildup–discharge cycle, the brain will have episodes of buildup and

discharge, until it takes control of itself, often for the first time. When trauma memory

no longer erupts, it is no longer trauma memory. It becomes like any other memory,

something faultily known and in the past." pg 269

"Patients with developmental trauma do not live in their bodies. They are, for the most

part, unbearably disembodied. One patient described sitting at a playground watching

her children and feeling the wind go through her. To me, this represents the original

sensory registration of no mother . We discussed the common and terrible feeling that

some of these patients have described, that their nervous systems extend out forever

into space. They have no felt sense of physical boundary or of the physicality of self

and other. There is no shape to being. Human beings need to inhabit a body to develop

a self. The physical and psychological co-arise and both depend on the mother’s

holding, on her touch, on her presence.

Disembodiment gives rise to distinct symptomatic expressions related most

commonly to self-harm and to eating. As the CNS quiets fear, shame, and rage, there

is less and less call for self-harm. The impulse moves from acts that typically stop

pretty quickly, to impulses without action, to thinking about self-harm when under

stress, to no thoughts or impulses arising.

Chewing and swallowing normally induce a parasympathetic response. That’s

what we mean when we talk about emotional eating . In the midst of sympathetic

arousal, we can use eating to nudge our CNS toward “rest and digest.” Eating is

primarily about affect regulation, not about nutrition, clearly, or even appetite. Eating

disorders can be seen through this lens. Bingeing quiets arousal, and purging

addresses the fear of gaining weight and gaining shame...

Although eating disorders may not always be generated by trauma, disordered eating,

body distortion, and hatred of the body are ubiquitous in developmental trauma and

relate, I think, directly to disembodiment...

Memory is stored in the disenfranchised body. The body does in fact keep the

score (van der Kolk, 1994). In my experience, although very helpful, it is not

sufficient to notice and address trauma indicators in the body, without touch. We are

bound by professional practices to leave these un-nurtured bodies untouched, but

these patients need therapeutic touch to begin to know the reality of their bodies. For

those who are open to it, I make referrals for trauma-informed body work. I have

come to believe that patients with developmental trauma need access to three avenues

for their recovery:

1.Through the brain, obviously with neurofeedback

2.Through the mind and its behaviors with psychotherapy

3.Through the body with hands-on trauma informed body work. Memory is not

only in the hippocampus or even in the distributed networks of the brain; it is

distributed in the body." pg 270-272

"As fear quiets with neurofeedback training, the body begins to manifest. More

than one adult patient has described suddenly discovering his own hand, much as a

baby would. It has dimension, shape, and sensation there in front of his eyes. Patients

begin to feel their bodies as part of themselves, as a place to be for the first time. They

begin to take care of themselves, brushing their teeth, eating vegetables, taking walks.

Self-care has little meaning when there is no self.

The regulating brain is helping the body to regulate, and the regulated body in turn

provides ongoing feedback to the brain to stay regulated. We can expect somatic

complaints, particularly those that are vagally mediated, to ease...

Digestive distress, constipation, and IBS are common in this population and commonly decrease in severity and, optimally, go away as the nervous system organizes itself. Sometimes chronic pain will lift, but at the very least reactivity to it will. These reductions in symptoms make the newly emerging body a more inviting place to live." pg 274

"I have worked with the aftermath of trauma and neglect for my entire professional

career. When I discovered neurofeedback and experienced the dramatic shift in fear, I

began to privately hope that neurofeedback was “the answer” to these childhoods and

that therapy, with its tremendous demand on both the patient and the therapist, would

no longer be required. Some people in the neurofeedback field seem to believe this.

As I am sure you know by now, I don’t. Therapy does become less challenging, but at

least in the treatment of developmental trauma, the regulating, attuned presence of the

therapist is vital.

In a talk she gave describing the rapid changes she had seen in patients with

chronic developmental trauma after introducing neurofeedback, the fMRI trauma

researcher and psychiatrist Ruth Lanius cautioned her audience: “Neurofeedback does

not replace psychotherapy. I think it requires you to be an even better therapist.”

Neurofeedback, as we have seen, can bring about rapid changes, and the therapist

must be prepared for these and agile when they occur. We need to know when to talk

and when to train. One of my metrics for deciding this is how curious the patient can

be about her experience. If she is primarily reactive and not able to be curious, I think

it is more important to train than to talk. When she begins to be curious, then it is time

to pursue the inquiry. When it is the brain that is most in need, then it is time to train.

When it is the mind and identity that need to reorganize in response to CNS changes,

it is time for psychotherapy." pg 276

Chapter 9: Three Women

In this chapter Sebern Fisher goes into the lives, treatment, and outcomes of three women she provided therapy and neurofeedback training to. You want to read about them, then buy the book!

Afterword

"It felt to me analogous to the unfolding we have been discussing throughout this book: the movement from repetition and rigidity in the brain—at its most painful in mental

illness—to complexity, flow, organization, and newness culminating in optimal brain

functioning, in optimal mental health.

Neurofeedback allows the brain to explore and establish potentially unprecedented

and even beautiful new patterns. We could describe what happened for the three

women we met in the last chapter and others in this book in these terms. With

training, their brains jumped the ruts of their individual manifestations of the second

condition—which we know as their symptoms—and moved them into the third

condition. Developmental trauma exerts a persistent drag on this capacity for

newness, but I think, given enough time and therapeutic help, most patients with

developmental trauma will make the leap and some will even find themselves

inhabiting the fourth condition, usually to their great surprise.

Many of my patients have reported just this phenomenon in language more

familiar to them: “My fresh new brain”; “I don’t know who said that”; “Who is this

person?” These are the breakthrough moments in Wolfram’s frame: the fourth

condition. When we are working with developmental trauma we see patterns of

change, the new, arising simultaneously with the old, repetitive and familiar ones...

We have seen that we can learn to quiet and organize traumatized brains and that

neurofeedback makes this possible by direct appeal to the brain’s organizing

properties: its rhythmic oscillations. Neurofeedback provides the brain with

information on itself, on how it is firing and how it can change how it fires, in the

language it understands: in the declensions of frequencies. When the brain’s

dysregulation is primed by the wild firing of the RH or survival amygdala, it can take

as many as 100–500 sessions, at least presently, to strengthen cortical control over

these powerful subcortical pulses. All through the training process we will see

changes that signal lowered arousal and enhanced regulation. Many of these changes

will be in the realm of symptoms, but there are also subtler, more pervasive, and

ultimately more important changes in the person beneath the symptoms. These are the

changes in the sense of self.

Although we focus our attention on reduction of symptomatic behavior, in those

who have suffered the ravages of developmental trauma we should be looking for and

encouraging the emergence of a regulated self, a sense of the reality of the other, and

the capacity for meaningful, empathic relationships....When the brain learns to release itself from repetitive, self-reinforcing patterns, it discovers not only its own capacity for

regulation, but its own unique trajectory of unending emergence...

A good deal of what we see as mental illness or as behavioral disorder has its roots

in the density of developmental trauma, and thankfully, our field is moving toward

“trauma-informed” therapy. Experience with neurofeedback suggests that traumainformed

treatment should also be brain-informed treatment—and not just to know

that the brain is at issue, but to work with it directly. As we have been exploring, even

those patients with developmental trauma who have access to psychotherapy (and

most don’t) are being treated without specific regard to their brains and even more

specifically without regard to their wordless RHs and, even more specifically yet, to

the subcortical storms that overtake them. It has become clear to me, and hopefully to

you as well, that we need to address the fear circuitries directly. As therapists we’ve

had only indirect access to the brain before the advent of neurofeedback. Now, with

brain wave training we can reach what so deeply afflicts people who have suffered

these childhoods: primal terror, shame, and rage. It is hard to imagine what mental

illness would look like were everyone able to quiet fear, shame, and rage...

The practice of neurofeedback suggests, of course, that one primary and critical

common factor is the failure of cortical brain structures to regulate subcortical ones,

with significant behavioral, emotional, and cognitive consequences. Neuroscientists

have known this for over a century. Neurofeedback reveals that with accurate

feedback, the brain can learn to strengthen cortical control and quiet subcortical

eruptions.

Brain dysregulation is the core factor in all mental illness, and as we have seen,

even severely dysregulated brains can progress toward regulation, and typically, if

given enough time, a supportive environment, and therapeutic guidance, can achieve

it.

Heckman’s work, like Sroufe’s, emphasizes the devastating effects of poverty on

family cohesion. I think it would also be safe to say that the majority of dropouts are

dealing with developmental trauma histories that affect impulse control, cause-andeffect

thinking, and their ability to learn the lesson, social or academic. Dropouts

typically make little if any contribution to the economy and all too many will require

system support for most of their lives. Heckman makes a compelling case for

programs tailored for these at-risk kids to keep them in school and learning. Although

he doesn’t use this language, Heckman’s primary goal for these interventions is to

help disadvantaged children learn to self-regulate. He is an economist and he has done

the math. Even intensive one-on-one support programs throughout the school years

are less expensive than letting these kids flounder and fail.

Neurofeedback may well offer an alternative. Although it is clear to me that

neurofeedback is best provided within the context of a psychotherapy relationship, it

is a learning technology, and those teachers trained in special education, as well as

school counselors, would be well equipped to provide it, once trained in

neurofeedback and with appropriate mentoring. The experience of neurofeedback

practitioners across clinical populations indicates that people cooperate with training

their brains. They show up, because it feels good to them to have access and control

over their own brains, over themselves. And, I have to admit, I do like the acronym

for brain wave education in school: BE.

One young patient who had suffered most of the assaults and degradations of

developmental trauma was able to complete her dissertation, interestingly in the field

of education, in record time. She arrived one afternoon after a testy student faculty

meeting and dropped into the training chair. She looked up at me and said, “I can’t

wait until we have a neurofeedback nation!” One day, we might realize her vision, but

in the meantime it is important for us as therapists to understand that none of our

patients (none of us) can be better than their brain and that we now have the

opportunity to converse with it directly as it seeks its birthright: regulation and human

connection." pg 326-330

Case Examples

"People suffering from developmental trauma can either ignore self-care altogether

or attempt to hold themselves together with an unholy devotion to it. One woman

went weeks without brushing her teeth or taking a shower. Her hygiene obviously

became an important focus of behavioral intervention, but this behavior was

symptomatic of something more than inadequate self-care. It was for her yet another

manifestation of no internalized mother. When she did shower, she felt torrents of

shame about her body, which then spiraled into a vicious feedback loop, making the

next shower even more difficult." pg 25

"I work almost exclusively with adolescents and adults, not with babies, but the

same arousal and attachment dynamics seem to be at play. We are quieting arousal by

training the RH to inhibit subcortical excesses, and when we do so, the brain

recognizes its bias toward attachment. One of my patients, a very bright, extremely

overaroused young executive, noticed the changes in herself but even more in her 20-

month-old daughter. She had always turned away from her mother and toward her father. When this mother quieted her nervous system, she reported that her daughter

started coming to her spontaneously. Her parenting behaviors had become less rigid,

but it was more than this. She was becoming approachable and inviting and more

rhythmically attuned to her child. It was natural and easy for them to be together." pg 112-113

"The brain and the body are not separable. The regulated brain begins to regulate

the body and seems to quiet vagally mediated distress. One woman in her mid-60s,

steeped in an early history of neglect and possible sexual trauma, reported that for the

first time in her life she was not constipated. Her body temperature was newly

regulated and she was able to sleep. Fluctuations in body temperature are common in

developmental trauma and the fact that these fluctuations are normalized by brain

wave training suggests again that we may be reaching primary regulators of arousal in

the brainstem and the hypothalamus." pg 117-118

"I witnessed a dramatic example of the interface between arousal, affect, and state

just weeks after my initial workshop in neurofeedback. I was seeing a professor who

suffered from unipolar depression and whose sister had committed suicide in the

midst of a bipolar episode. We had been pursuing this issue in the only way I knew

how: through talk therapy. She was uninterested in medications. She arrived that day

sobbing, and said, “I am falling into this depression so fast that it terrifies me.” She

couldn’t teach her classes, she couldn’t sleep, she couldn’t think. She was a popular,

high-functioning professional, suddenly profoundly disabled.

She asked to try neurofeedback, which I was quite reluctant to do. I felt too

inexperienced—a vital caution for anyone new to this approach. We both knew,

however, that we’d done what talking could do. It wasn’t what she needed. This was a

brain that had toppled over its own edge. I trained her in the way I’d been taught.

Unlike almost everyone with developmental trauma, she needed to raise her arousal.

Over the next 30 minutes, I watched her state change. By the end of the first 30-

minute neurofeedback session, she was no longer depressed and had experienced a

complete change in her worldview. She was no longer hopeless. She knew she could

teach, and the terror was over. By addressing underarousal in the firing of her brain, we dissolved her urgent and compelling affect, thereby changing her state. She had an

auditory dream that night about neurofeedback. She heard a voice saying, “The path

to the enigma is now clear.” She had 23 sessions of neurofeedback, about 11 hours in

all, and never had another episode of depression. I did a 12-year follow-up with her,

and she said, “Sometimes, not often, I can wake up a little blue, but it’s nothing that a

cup of coffee or meditation can’t take care of.

It is important to stress that most depressions will take longer to resolve, and some

may not resolve, even with neurofeedback, at least as we know it today.

Developmental trauma can take even longer. But this vignette illustrates the direct

connection between arousal, affect, and state. This woman never identified with her

states, probably because they were so clearly episodic. There was an “I” who was

falling into depression; she wasn’t self-defined by depression. The state did not reify

into trait because she had long refractory periods in which she had a self that was not

depressed, she had loving parents, and she was not under unrelenting assault by her

amygdala.” pg 122-123

"One of my patients was seen, and saw herself, as a very angry person. In one instance, a car stopped too close to her in a crosswalk, and she slammed her fist down and dented the hood. When she talked about it, she felt entitled to her reaction: “Anyone would react this way.” It was very difficult for her to see this incident in a different perspective until her brain could process threat differently. Like the man above, and most patients with developmental trauma, she believed that she was the victim of malignant intent. She lived in this pattern of reactivity. In the frenzy of overwhelming shame, another of my patients, a

woman who had grown up profoundly deprived and abused, would have to fight with

herself not to key an expensive car that blocked easy access to hers. She knew better,

but it was, of course, neither a cognitive nor a moral appraisal that drove her. It was

the paroxysmal force of unregulated shame and rage. As her training organized her

brain waves, such impulses (e.g., keying cars), which had been state-syntonic, became

not only dystonic but unimaginable. Both of these women were able to regulate the

neuronal firing pattern that gave rise to sudden, violent outbursts that had, in turn,

defined their very sense of being.

Not only do these patients suffer the original insults, they suffer them again each

time they lose control. They are retraumatized by their own reactivity. It is almost as

if they can feel the circuitry wiring itself more tightly. Those who can still feel may

then feel deeply humiliated, angry, and terrified at being out of control. They are

caught in a terrible affective feedback loop. The woman who dented the car described

her nervous system “unfolding” as she trained. At the beginning of training, when

outbursts would occur, she described them as more intense but of shorter duration.

She reported feeling surprised at this; it didn’t feel like her. She experienced more of

herself outside of her affective state, so she was able to ride the rocket propulsion of

rage, and although a bit helpless to its intensity, she was able to observe it. She was

even more taken aback by how quickly and completely it resolved. Before training

she would have felt the tsunami continue to flood her with multiple affective

aftershocks. Now the event just ended. It was over when it was over, an experience

she had never had before. She was probably reporting the absence of kindling in

response to strong emotion. Len Ochs, one of the pioneers of neurofeedback,

described this pattern in his patients as well. He also saw it as a sign that this pattern

was on its way out (personal communication, February 4, 1999).

Over the course of training, the woman who felt so angry so often that she

identified herself as an angry person felt less and less easily provoked. After

beginning neurofeedback, she no longer experienced herself as angry, nor did others.

Early on she noticed that she could drive on the highway in the rain without bracing,

formerly a signature to her of her baseline high arousal. Her shoulders dropped below

her ears. She could make small talk. As is true for most patients with developmental

trauma who train, her CNS became noticeably less reactive.

In a similar way, the woman who could barely control her urges to key offending

cars noted that the impulse was suddenly “just gone.” She didn’t need to control it

because it was no longer arising. In her case, she became aware of her “shadow side,”

to use her term, her history-based antisocial bent, as she emerged from the burning

carapace of overwhelming affect. Her temper quieted, as did shame and fear, and in

the process, she found herself developing an observing ego, increased empathy—

informed partly by her dawning awareness that others also experienced much of what

she had experienced—she was gaining a theory of mind—and a relational, prosocial,

and moral self. She described a deepening sense of internal coherence that she’d never

felt before. She stopped dissociating and was able to describe the way it felt: “It’s like

I feel the impulse [to react] begin [often literally felt at the temporal lobe], but my

brain just can’t go there.” The healthy, regulated neurons stemmed the tide and instead

of following that well-worn fear circuitry, settled into rest. The temporal lobes did not

ignite into what Daniel Amen (2001) calls the ring of fire ." pg 129-131

"Another adult with developmental trauma arrived at my office after almost two

decades of both psychodynamic and DBT therapies. She was dissociative and

working mightily, but unsuccessfully, to manage daily flashbacks. She was organized

solely around her traumatic experiences. What little identity she had was a trauma

identity. As she started to feel the grip loosen, she expressed a core fear that, in my

experience, arises uniquely in brain wave training: “Who will I be when I am no

longer afraid? Fear is what I am.” This profound question predicts the crisis of

identity that you will encounter when you work with these patients using

neurofeedback." pg 131

"A man in his mid-60s came to me to see if we could calm his “states of terror.”

Steeped in understanding and treating developmental trauma, I heard these descriptors

and trained him to lower arousal. He noticed something, but he was not calmed. He

does not have a history of developmental trauma, but that, in itself, would not rule out

RH training. Overarousal is overarousal. Except in him it wasn’t. Patients with

developmental trauma have trouble functioning because they are terrified. This man

felt terrified because he couldn’t function. He did much better when we raised his

arousal on the LH, which allowed him to rise to the occasion, not to be cowed by it." pg 218

"We have spoken about the young woman, diagnosed with borderline personality

disorder, who came to me because she was afraid she would kill someone. Her rage

diminished greatly with several sessions at C4, and she felt it vanish after training at

FPO2. She endorsed this site in her own idiom: “This is better than the best drug I’ve

ever had. Everyone should have this training.”" pg 225

"Although not diagnosed with developmental trauma, this next patient, a 36-yearold

woman, came to me feeling overrun with fear and saying that she felt she was at

the end of a fraying rope. She had been in therapy for 30 years to address her history

of being mercilessly bullied almost daily in school. Her parents acknowledged her

struggles and tried to help with practical steps and advice, but it never stopped and she

felt pretty much left alone to manage it, day after day. By her 18th neurofeedback

session, she told me that she was definitely calmer. She gave me the following

example. She had gone out on a blind date with a man who liked to tease. The first

thing she noticed was that she didn’t warn him about her sensitivity. In the past, she

had always warned people that she could not bear being teased. She reported that

when he teased her, she felt the same terror that always arose, “but only for a

millisecond and then it was gone.” She went on to say: “I didn’t know what to do

then. There was a kind of emptiness where the terror used to be. I felt disconcerted,

even disoriented, and kept expecting the response that didn’t come.” She summed up

this experience by saying, “I feel disoriented but not disorganized.” This woman, even

with the disorientation, welcomed the absence of fear without ambivalence." pg 252

"Another woman became enraged and dissociative when she thought I was asking

her to forgive her neglectful mother. If I was asking this of her, then I clearly had no

idea what she had suffered. She felt terribly misunderstood. She had talked about her

mother for 20 years without resolution, but after training for 2, she spontaneously

called her mother, just to talk. She never had to engage in what was for her a tour de

force: an act of forgiveness. Acceptance and forgiveness arose not because we had

talked about them—we couldn’t—but because they are prosocial emotions that are

inherent and in wait. The world as it is came into focus. In her own time, my patient

arrived at a new and genuinely felt understanding: “My mother did the best she could.

She was a trauma survivor herself. No wonder she acted the way she did.” These were

all proposals that therapists had undoubtedly made to her over her long therapeutic

course, but now they were arising spontaneously from within her." pg 262

"In my experience, reunions with family members are quite common after the

nervous system quiets down. One woman who had had what she called an obligatory

relationship with her mother, wanted genuinely to be with her. Although her mother

had never engaged in therapy or training, she seemed to change as her daughter

trained. Both mother and daughter became softer and more accepting. My sense is

that the changes in the daughter required a realignment in the field between them and

allowed new patterns to emerge. Their relationship, at least to the daughter, felt

unprecedented." pg 265

"We began this chapter with my young patient’s reflections on her changing sense of

self and other. She credits brain wave training for her own emergent self and with it

the capacity to recognize my existence as well. She came to consult with me after her

discharge from a residential program at age 18, as an outpatient. We’d first met when

she was my patient in a residential treatment program. Although she was living in a

town only a few miles away, she was late for her first appointment because she could

not figure out how to catch the buses that went by her. “I just couldn’t organize

myself.” After training twice a week for 18 months, she flew alone to join a peace

march in Japan. “I found my way through Nerita Airport,” she told me, “without too

much trouble—and that’s saying something.” Her account reminds me of the

drawings of the boy’s family in Chapter 4 (see Figure 4.1, p. 120). It is almost as if I

could see her nervous system organizing in these reports during this year and a half.

She and I had begun our work together sitting on the linoleum floor in a seclusion

room when she was 16 years old. She spent all of her adolescence in treatment

centers. She is now 30, has gotten her bachelor’s degree in a strenuous program, and

she is praised for her work with her patients. She is weighing the possibility of

beginning a family and starting graduate work in her field." pg 274-275