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Articles    H3'ed 4/24/11

Neurofeedback: A Treatment for Reactive Attachment Disorder

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Holding therapy, however, gives us a way to think about the neurological substrata of the attachment dilemma. Barry Sterman had successfully used neurofeedback to control seizures in cats. When he sought to replicate this work with monkeys, he ran into a predictable problem. His new subjects would pull the electrodes off their heads. This meant that they had to be restrained. After an initial struggle, at the point when they succumbed to the restraints, they produced a predominance of 12-15 Hertz, the very brain waves Sterman wanted them to make. Like the cats, they too learned to become seizure-resistant, and when they did, they also became calmer, more sociable and less aggressive. One has to wonder if this is also the mechanism, neurologically, that accounts for the successes of holding therapy. In the process of release into the hold, the child's brain begins to shift into a dominant 12-15 Hertz pattern, a pattern that is often described as the relaxation response. In this state shift, the child can begin to recognize the holding for what it is, rather than as a threat to her survival. She can begin to see her mother's face and may even begin to feel the yearning and grief that are the frozen feelings in RAD. It suggests that the key in successful holding is the induction of a change in brain wave activity that may mimic the brain activity of a relaxed infant, bonded to and held by her mother. It follows then that we can significantly impact people who suffer the ravages of brain disorganization that we call RAD if we can teach them how to produce these brain wave patterns. This is the potential of neurofeedback.

Neurofeedback is increasingly available as a clinical tool. It is a system through which people can learn to alter the timing and communication patterns in their brains through operant conditioning. Sensors are placed on the patient's scalp to record the real time EEG and then, as determined by assessment and protocol, they are provided feedback when they produce the desired brainwaves. People meeting criteria for RAD are often rewarded for increasing the amplitude of lower frequency brain waves from SMR (12-15 Hertz) to alpha (8-12 Hertz) in the right hemisphere of their brains. In this process, the RAD patient learns to change the timing of the right hemisphere and to reduce the arousal of the entire system. With the lowering of arousal come decreases in aggression and impulsivity. The individual not only begins to behave more pro-socially but to feel more pro-social. As the threshold of terror is reduced, he warms up, and he begins to feel a greater array of affective states. Over time this resetting of the brain's rhythms can translate into significant changes in state, and the state change translates into the person's perception of himself and others.

Several case histories will help to illustrate the effects of neurofeedback. T. is a thirty-two year-old man who was abandoned at birth and raised in orphanages and residential treatment centers. At age ten, he was adopted by a family ill-prepared to parent an attachment disordered boy. The adoption was terminated after a series of assaults on the adoptive mother, the last of which was a blow across her head with a two by four, provoked when she withheld a snack. He was returned to residential care until age 18 when he entered the correctional system. It was during this tenure in residential care, ages 13-18, that I was his therapist. It was T. who introduced me to attachment disorder. Nothing we did, including a course of holding therapy, affected him. He was unable to inhibit his aggressive impulsivity, he lacked cause and effect thinking, a fact that essentially made it impossible for him to learn emotionally, he could not generalize, and he felt no empathy or remorse. He was also unable to recruit empathy from others. Although he demonstrated some dependency on me, he never developed a real attachment to me or any other person in his network of care. He assaulted a female staff member, nearly choking her when he perceived her as taunting him; and on a camping trip to Maine with the program, he struck up a conversation with a family at a nearby site and left with them. This was more an act of indiscriminant attachment than running away. It never occurred to him (nor, evidently, to the others) that this might be a problem. He was in constant petty squabbles and unable, even with constant reminders, to understand the consequences of his actions.

During his most recent probation, at age 31, T. had a course of sixty neurofeedback training sessions. He felt it was the first thing that helped him. He never missed a session. Most importantly, he began to show the first stirrings of empathy and regret. After forty sessions, he called me to tell me he was worried about how he had treated a staff member. In all the time I'd known him, I had never heard him acknowledge the existence of another person (except as a tormentor) or any awareness that he had an impact on that person. He went on to say, "I still get angry, but it used to just keep going and going. Now, a half an hour later I am calling the person, apologizing and trying to make it right." Unfortunately, the training came too late as he had committed a second crime within two days of his release and was returned to jail. It is important to note, that I am the treatment control in this situation. For five years, I struggled with him in all known treatment modalities to little effect. He made significant progress in three months of neurofeedback, and he was able to recognize that this was the case.

The people in the system surrounding him expected the worst and felt burned out both by him and by their expectations of him. They were unable to discern the subtle changes in behavior and affect that were apparent to his therapist and to me. As T's arousal dropped, he began to feel an intense yearning that was difficult for him to articulate and which his psychodynamic therapist failed to recognize. Because he had re-offended, he was kept isolated, making this yearning even more unbearable to feel. His long-standing inability to recruit empathy and the lack of recognition of the awakening of yearning in him by his care providers undermined his recovery. From jail, he reports that he is better able to walk away from the taunts and provocations of other inmates and he may, for the first time, be truly suffering his incarceration. He is maintaining contact with me and with his neurofeedback therapist.

E. came to me after leaving a private psychiatric facility against medical advice. She was diagnosed with bipolar disorder, attention deficit disorder with hyperactivity, post-traumatic stress disorder, alcoholism, learning disability and borderline personality disorder. When I asked her mother whether she thought she was truly bipolar she responded, "If you think if you drive a car fast enough you can make it fly, would that qualify?" Although she had spent her first year in an orphanage, no one had considered the diagnosis of attachment disorder. She had multiple physical complaints including lack of co-ordination, clumsiness, chronic pain, irritable bowel, headache, constipation and asthma. She was unable to sit still during our first sessions together, reporting that she felt like she was coming out of her skin.

She reported that it was routine for her to drink to black out and wake up in the bed of an unknown man. She did not believe that she was an alcoholic but that she used alcohol to self-medicate, and she came to realize that she drank to allow herself to be held. In any other situation, she was touch aversive. She was unable to sleep, maintain relationships or work. She could not read, and not surprisingly, she was unable to concentrate. She had been in special education classes since she began schooling. In our initial sessions she talked of nothing but what man she was interested in, who was cheating on whom and complaints about the neglect of her parents, and all of this in a superficial and perseverative way. There was no room in this girl's state of chronic agitation and arousal for reflection or thoughtfulness, much less insight or connection with me. I was the vessel for her complaint. She was trying to manage a severely over-aroused nervous system in every way that she could, including men, alcohol and hospitalization. She was also prescribed, and was intermittently taking lithium and Paxil and Trazadone, but she felt they were of little use.

Within two months of beginning neurofeedback, E. had stopped drinking, and within three, no longer needed case management. She had stopped both the lithium and the Paxil with no ill effect. She established a relationship with a young man that has endured for three years. She was increasingly able to work regular hours, and she finished her college degree program. At one point during the therapy of 2 1/2 years and with over 150 neurofeedback sessions, she announced that she could now see what she was reading. I was astounded. I had no idea that she had been trying to read without the capacity to visualize. Neither, of course, did she. She also reported that one evening, while waiting for a movie she went into a batting cage with her boyfriend. She amazed herself (and him) by hitting 95% of the balls. She gradually became less explosive, and she warmed up, making it increasingly possible for her to engage in a sustained and emotionally deepened psychotherapeutic relationship.

E.'s therapy, however, was rocky. Neurofeedback presented us both with new clinical dilemmas. Most symptomatic behavior abated rapidly as she became neurologically, emotionally and physically more regulated. What emerged in its place were profound questions of identity. She said at one point, "I have never been more myself and never known less who I am.' E was beginning to experience affect regulation and it was, in fact, giving birth to a sense of self that was organizing so quickly that it took us both by surprise. She was familiar with the whirl of reactivity that had served her as a sense of self, but not with the core self that was emerging. As she began to wonder who she was, she also wondered who I was. I, too, was suddenly brand new to her, and she could not tolerate the transferential yearnings that were stirring in her. She turned the nearly intolerable yearning away from me and into her relationship with her boyfriend, with predictable complications.

She also felt critically disappointed that life was like it was. She had imagined a Hollywood version, and the new dailiness of life and her ability to cope with it felt, in some ways, more disheartening than welcomed. As she grew bored with drinking and drugs and with this crowd, she also felt unbearably lonely. At the same time, she grew calmer, more mature, warmer and better able to both advocate and care for herself. Her interpersonal judgment improved and she became less impulsive in all areas of her life. Although in some ways left bewildered by all that has changed, E. reports that she feels smarter, more resilient, more understanding and more competent. Her self-esteem has improved dramatically.

I met S. when my young tenants took him in for foster care, and I have been a consultant to them on his treatment. S. is a five year-old boy with a history of profound neglect and abuse. He was the first child of two kids who were themselves foster children, and he came to the attention of the Department of Social services when he was hospitalized after a fall from a third-floor window. It was revealed that he had been hospitalized at 18 months for failure to thrive following an apparent seizure. One of his parents also had a seizure disorder. Investigators further discovered that S. was left for days in a crib alone. He was placed with his grandmother, who apparently sexually molested him, and when he was returned to his parents there was a new baby, a sister whom he tried to kill. Both children were removed to foster care when S. was three and he once again tried to kill his sibling. He had to be removed from the home. He was further physically abused in the next foster home, and he may have attempted to set it on fire. His placement across the driveway came as an emergency response to this situation.

S., as one could predict, was severely attachment disordered and traumatized. He did not fall asleep until after midnight. Once he did, he lapsed into night terrors, during which he crawled on his hands and knees screaming "no, no, no." He would come awake at five to begin a day that was hallmarked by non-stop and entirely disorganized activity, high risk behaviors like climbing a tree to the top, pinching the cats, hoarding food, throwing tantrums, breaking objects, defecating on the floor and showing no capacity to take direction or obey his new care takers. He expected sexual abuse and engaged in sexual reenactments. He had no language and grunted and gestured to make his needs known. He made no eye contact. When you did see his eyes, they were vacant and momentarily flecked with terror. He resisted physical comfort, and he was terrified to be held. As it grew dark each night, he screamed without let up until he fell into the half conscious terror of night.

S.'s treatment began immediately. It included allowing him to eat all that he wanted from a diet of no sugar, no wheat and no dairy. He ate constantly. The foster parents gave him a bottle whenever he wanted it. He loved the bottle but he had to learn how to suck. They did hours of holding therapy daily. His foster father describes the style they developed as "Nazi parenting". They did not allow him to move without their permission. And they started daily neurofeedback training.

Within a week, his sleep was normalizing. When he was finally able to sleep, he slept for twelve hours a night without night terrors. It seemed as if he was making up for a lifelong sleep deficit. He still had numerous nightmares, but he could be comforted. If his sleep had not changed and had not changed rapidly, the placement would not have survived. Over the succeeding weeks his appetite normalized, and he began to share food. He began to use words and to better tolerate the holding sessions. Eventually, he even began to request them. He stopped the screaming that greeted the dark almost immediately after beginning neurofeedback. Through a combination of all of these interventions, S. has emerged as a loving and emotionally compelling human being. Eight months into his treatment and new family life, he greeted me when I arrived home. He ran across the driveway and jumped into my embrace. I was wearing dark sunglasses and he leaned away, still cradled in my arms, looked at me and with real dismay said, "Seboin, I can't see your eyes".

His parents remained alarmed over his indiscriminate attachment. He seemed to seek comfort from strangers as readily as from his mother. This disturbed her and left her feeling unrecognized and, at times, hurt. Although those familiar with attachment disorder would not find this problem unusual, I mention it here because the solution to it was as simple as it was profound. His mother sat down with him and taught him that they were his parents and this meant that they were the ones that he was to come to when he needed things. This fact had entirely eluded him. She described a light going on in his awareness, and with that one instruction he seemed to immediately organize his sense of primary attachment. It all fell into place for him and the parents reported no further episodes of inappropriate reliance on strangers.

This compelling case underscores not only the parenting needs of children like S. but also the neurological substrata of RAD. Every successful intervention has been one that moved this little boy toward regulation. He was held, fed, nursed, directed, redirected, and disciplined, all to enhance the possibility of regulation that was so drastically absent in his infancy. It is unlikely that neurofeedback would have been as dramatically helpful were it not for this gifted parenting and by demands for regulation in every quarter. It is equally clear, however, that without neurofeedback S. would be untreatable. No parents, regardless of their devotion could have sustained this onslaught. He has now had 180 neurofeedback sessions, and he is beginning kindergarten. The transition into school has evoked separation anxiety and renewed fear of losing his mother. This means, of course, that S. has, in his psychic reality, a mother to lose. Further, we know that he is experiencing this fear because he is able to articulate it to his parents. The classroom is chaotic and, for him, disregulating. He willneed help to make it through this transition. Some of this help will come from a one-to-one aide and some through increasing the frequency of his neurofeedback training sessions. His foster parents have finalized S.'s adoption.

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Sebern Fisher is a psychodynamic psychotherapist with a primary interest in the importance of secure attachment throughout the life span. She incorporated neurofeedback into her clinical practice in 1997. The effects of brain training that she (more...)

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