Riding the Waves

All brain function–normal and pathological, intellectual and emotional–is bioelectric as well as biochemical. In fact, the brain communicates to itself and organizes its activity through its constant creation of brain waves of differing frequencies. The degree of our mental or emotional arousal largely depends on the frequency of our predominating brain waves. We know that large-amplitude, slow brain waves–known as delta waves–are associated with sleep. Theta waves are associated with a dreamy, sometimes hypnogogic, state. Alpha waves are usually associated with a relaxed meditative state of “open focus.” Narrowly focused states of attention, needed to perform tasks, are characterized by beta-frequency brain waves.

Although the brain’s electrical activity plays a major role in how an individual functions, until recently, surprisingly little attention has been paid to the electrical aspect of the brain. Instead, we’ve tended to view the brain solely as a biochemical organ, devoting billions of dollars to the development and promotion of psychotropic drugs.

At the same time, researchers and therapists have been teaching people to change their brains’ bioelectric activity–and hence their functioning–without chemical intervention. Today, this method, called neurofeedback, is being used by therapists around the world to address an increasing number of disorders, from ADD and AD/HD to bipolar illness, autism, and learning disability.

Neurofeedback is biofeedback to the brain–a form of operant conditioning that rewards the brain for activity at desired frequencies while discouraging activity at other frequencies. As a therapeutic intervention, neurofeedback training can reduce symptoms quickly, allowing the therapist and patient to better focus on broader psychological issues. Their attention need no longer be riveted to disruptions of emotional regulation, like rage, or the attempt to quell them, like excessive drinking. Emotional symptoms are seen and treated as indicators of firing disregulation in the brain.

Since integrating neurofeedback with psychotherapy seven years ago, I’ve used it in the treatment of more than a hundred people, some with diagnoses as severe as dissociative identity disorder, Asperger’s syndrome, borderline personality disorder, and post-traumatic stress disorder. The case that follows highlights its particular effectiveness in treating emotional overarousal.

The Unregulated Brain

Tony, a tall, husky, visibly distressed, 27-year-old man with severe dyslexia came to see me because a friend told him that I could “change his brain.” He paced my office as he described what it felt like to live with dyslexia. Since earliest childhood, classmates had teased him mercilessly. By eighth grade, he felt so humiliated, angry, and filled with self-hatred that his parents thought it best to send him to a boarding school specializing in learning disabilities. “If it hadn’t been for that school,” Tony said, “I’d be either dead or in jail.”

Being with others who were dyslexic, and with teachers who understood and empathized with his condition, made his life bearable. As with most dyslexics, reading was very difficult, and Tony got through school only with the help of tutors and special programs. He was accepted at a community college with a center for learning-disabled students, but he quit after the first semester, discouraged, bitter, and depressed because it was too hard. Since then, he’d worked sporadically as a manual laborer. He told me he dreamed of becoming a filmmaker, because he “thought better in pictures than in words,” but doubted that he ever could succeed in anything.

Tony attributed virtually every problem he had–his chronic depression and seething anger, his excessive drinking, his inability to find a good job, and his history of unstable relationships with women–to dyslexia, either directly or indirectly. He often flew into rages, breaking anything at hand. He couldn’t hold on to relationships or jobs, had panic attacks, couldn’t sleep, and chewed his nails. At the point he came to see me, he was drinking a case of beer a night to manage his agitation and despair.

Although I usually use psychotherapy in conjunction with neurofeedback, all Tony wanted was the neurofeedback. No talk therapy. I thought this would be a good case in which to test the effects of using neurofeedback exclusively.

Before beginning the training, I did a complete assessment of the problematic patterns in Tony’s brainwaves. I began with a symptom-focused questionnaire to systematically evaluate his arousal. Once I’d completed that assessment, I determined that, to control his temper, drink less, and even stop biting his nails–symptoms that indicate a high degree of arousal in the right hemisphere–Tony needed to learn to produce calming alpha waves on the right side of his brain, the hemisphere devoted to affect regulation. So, one treatment goal was to teach Tony to lower arousal in this hemisphere. Additionally, to address the dyslexia, which Tony considered to be the primary symptom, he needed to increase the arousal in the left hemisphere of his brain. Tony’s initial EEG assessment also revealed that he was producing an excess of delta and theta waves in both hemispheres, which interfered with the alertness required for such tasks as driving a car or reading an article. As a result, for Tony, concentrating on reading was like swimming across a lake against huge waves. Another treatment goal, then, was to train Tony’s brain to inhibit the production of excess slow waves and excess fast waves, both of which interfered with his ability to remain focused and relaxed, in addition to encouraging him to produce the frequencies that lowered arousal in the right hemisphere and raised arousal in the left.

Putting on the Brakes, Stepping on the Accelerator

We were ready to begin Tony’s neurofeedback training. As I do with all clients, I explained that the video game he was about to play was linked directly to his EEG, and that its beeps and displays would encourage and reward his brain for the production of the brain waves that would, over time, change his experience. He sat in a comfortable chair in front of a computer screen, and I applied sensors to his head to detect his brain’s electrical activity. The EEG signal was displayed across the top of my computer screen. It showed his brain activity in three bandwidths: the band I wanted to encourage, or the “reward band,” and the two bandwidths I wanted to discourage, or “inhibit bands.”

Tony’s screen had a video game with three spaceships set to respond to his brain waves. The middle space ship represented the frequency that I wanted him to increase. The other two represented the very slow and very fast frequencies that I wanted him to decrease. Whenever Tony’s brain generated the optimal brain-wave pattern, the middle spaceship would pull ahead, and he’d score points in the video game. It was a simple video game, but without a joystick: Tony had to control the game solely with his brain.

Most clients, including Tony, have difficulty believing that “trying” to make the spaceships move doesn’t work. But they don’t know, at first, how not to try. Tony asked several times how to do it, and I couldn’t tell him, any more than I could tell him how to ride a bike. I just assured him that his brain would learn what it had to learn. When he tried to make the space ship move, it stayed in its dock. When he relaxed, the space ship flew out into space. Every time his brain “happened on” the correct frequencies, the center space ship would move ahead, while the other two would fall behind. Tony’s brain gradually began to learn, automatically and without conscious volition, to use this instantaneous feedback as a road map of which way to go. Unlike drug therapies, neurofeedback is a process of learning–the brain learns to regulate itself.

We trained two or three times a week, with 20 minutes of checking in and reassessment and 30 minutes of neurofeedback training each time. I used the quality of his sleep, the amount he was drinking, his appetite, his mood, and the frequency and intensity of his aggressive outbursts for my ongoing assessment of his progress. Changes in these markers indicated shifts in brain function. If the shifts were positive, I’d continue to train left and right hemispheres as I’d been doing. If the shifts were negative and he seemed worse in any of these areas, I’d reassess the training and change the brain-wave frequency of the reward band as needed.

By the fourth session, Tony reported that he was sleeping better, that he felt less angry, and that he’d started taking photographs again. He was also drinking less. But he still felt restless and dissatisfied with himself.

At session seven, he reported that he was bored with TV, that he was no longer sleeping during the day, and that he was feeling calmer and more organized. He could focus better and reported living “a more ordered life.” Tony was, it seemed, beginning to live in a more coherent brain. Neurofeedback training helped him feel increasingly calm and, as that happened, he became less fearful. It was also clear that Tony was beginning to trust me.

As with talk therapy, there are occasionally bumps in the road with neurofeedback. I had to be away for a month, and while I was gone, Tony’s father had a stroke. Tony also quit his new job in a rage and went out drinking several times with friends. The bright spot was that he found that soon after the initial binge, he didn’t want to drink at all. “I just don’t like it anymore.”

The stress of his father’s illness, coupled with the absence of training, accounted for the lapses in his ability to regulate his temper. All brains, particularly early in training, can default to older, familiar patterns of firing. Tony, however, was discouraged by his failures. I asked that he withhold his judgment while we continued to train.

Over the next several sessions, Tony spoke to me with increasing openness about his two most important relationships, his father and his girlfriend. He was still reporting problems with anger and depression, but he began to have more insight into these problems. He talked about his anger at his father, who was now recovering, and his feelings about his deceased mother. Talking like this was new to him, but he hardly seemed to notice. Almost inadvertently, he’d started to engage in talk therapy as well as neurofeedback. This isn’t uncommon with people who come in only for neurofeedback–the training enhances clients’ ability to relate.

At the twelfth session, Tony told me, “You might be interested. I read an entire book, for the first time.”

“What did you read?”

“A book about Vietnam. I’ve always been interested in Vietnam,” he said nonchalantly.

I couldn’t believe that the first book Tony would read, after never voluntarily reading more than a paragraph, was historical nonfiction! The brain’s electrical “short-circuits” had repatterned themselves and the printed page became accessible. The training was working. It was organizing him cognitively and quieting him emotionally.

Tony trained for 10 additional sessions. By the end, he was reading every day and we were talking at every session. He was holding down a steady job on a road crew and making plans for his future. He no longer suffered panic attacks, had stopped drinking, and had ended the relationship with his girlfriend, which he realized was destructive. He was sleeping well and rarely had explosive outbursts. He felt that neurofeedback had been more helpful to him than anything else he’d done, and that he’d accomplished most of what he’d sought to achieve. Most important perhaps, he felt good about himself.

I ran into Tony a year and a half later. He’d opened his own retail business. He was working at another job part time to support his fledgling endeavor, but would soon be making enough money to devote himself entirely to his new enterprise. I asked him, with equal parts curiosity and trepidation, if he was still reading. “Oh yeah.” he said, “that stuff you do must work.” He was reading a book on management, and he read fiction for pleasure. An inveterate channel surfer before neurofeedback, he no longer watched TV. The brain regulation that he’d learned in less than 12 hours of actual training time had held for 18 months without any further intervention, without any further training, with little psychotherapy, and with no medication.

Tony’s case demonstrates that biofeedback directly to the brain can help organize brain function, both cognitively and emotionally. It can do so predictably and efficiently, and it can do so even for the large part of the population in need of help who, like Tony, have no interest in psychotherapy. Through reducing overarousal, boosting underarousal, and organizing the brain to function closer to its optimal capacity, neurofeedback enhances clients’ ability to relate and, in many cases, makes therapy with them not only possible, but more deeply rewarding.

Case Commentary

By Margaret Wehrenberg

In this case, neurofeedback made change possible, where mentoring, tutoring, and talking had been unable to solve Tony’s presenting problem. Sebern Fisher shows the importance of both respecting a client’s initial request (“fix my brain”) and, when necessary, being willing to go beyond traditional treatment methods.

Neurofeedback is one in a growing number of bioelectrical and neurophysical methods that psychotherapists are bringing into their work, especially in cases involving conditions like attention deficit disorder, trauma, learning disorders, impulsivity, and anger control. These methods include techniques that use metronome pacing, neurophysical movement, and colored light to change brain function. They represent a new clinical armamentarium designed to correct underlying problems in brain function, rather than just provide strategies to manage the underlying condition. Methods like neurofeedback hold tremendous promise in cases where standard treatments have proven ineffective, but therapists must be sure to balance the hope of a new way to help against possible risks, as Fisher appears to have done in this case.

My biggest concern isn’t with what takes place in this case, but with what’s left out. After forging a highly effective therapeutic bond with Tony, I was disappointed that Fisher didn’t use that relationship to more emphatically argue the case for further treatment to Tony. While it’s tempting to see a change in brain function as sufficient, with a client like Tony, who has so many developmental gaps and relationship issues, the necessary therapeutic learning can’t occur as fast as his brain function can change, nor until it changes.

It’s up to the therapist to provide clients with a broader vision of what therapy can provide, along with encouragement to continue on a fuller course of treatment. Even if brain-pattern change can be made quickly, it’s important to emphasize that short-term shifts aren’t enough to change lifelong relationship patterns. For example, once a client shows progress in controlling his impulsivity, I’d then highlight the need to learn to read the emotions of others–something his poor impulse control previously blocked from developing properly. I’d directly state that developing empathy requires time and practice, and use therapy as a place to learn and evaluate new skills for self-control and interpersonal relationships.

While in this case, neurofeedback dramatically opened up possibilities for Tony to move on in his life, I’d be much more convinced of a long-term positive outcome if treatment had altered more than the brain-wave pattern and given more attention to the relationship, career, and self-management skills he’d missed.

Author’s Response

I couldn’t agree with Margaret Wehrenberg more. My preferred practice is to interweave neurofeedback and psychotherapy. I find that neurofeedback enhances the capacity for relatedness, and the relationship, in turn, helps the client better recognize and incorporate their brain-wave changes. I typically introduce neurofeedback to clients who come to me for therapy and psychotherapy to those who come for neurofeedback. Even clients who seek brain-wave training because of disappointing results with therapy often change their attitude as the neurofeedback training proceeds.

While Tony only wanted to “fix his brain” when he first came to see me, the neurofeedback training fostered a strong relationship between us. As our work together continued, we moved more and more into what I considered a therapy relationship. Although Tony never thought of our sessions in this way, we not only talked about his dyslexia but also the relationship and life skills Wehrenberg mentions. For him, the issue of ending treatment was pragmatic: while he could finally read and felt better, he was out of money. I agree that he’d have benefited from more therapy.

When we ran into each other recently, Tony said he wanted to come back to see me. My hunch is he will, and when he does, I think he’ll want both therapy and neurofeedback.