Case Studies From The Field Part Three
By: Sebern Fisher, MA, BCIA
sebern.fisher@verizon.net
413-586-4230
As discussed, in Part Two of this series on neurofeedback, attachment disruption is a profound event in the life of an infant, with normal brain development and affect regulation at stake. This disruption is most clear and perhaps most poignant in adoption. These children, by definition, have lost their mothers. Many adopted children have spent a good part of the critical first 18 months in institutional care or with their incapacitated biological mothers. As previously discussed, without a regulating mother, or in the presence of a disregulating or abusive mother, no one can fully develop the regulating capacities of her or his brain. Clearly, most adopted children learn to regulate affect through the relationship with their adoptive parents. However, for some, the early relational deprivation was too long or too abusive. They cannot learn to trust their care to their new parents or care takers, no matter how kind and loving these adults may be. This is reactive attachment disorder.
However, adoption is not the only precursor to attachment difficulties and disruption in right hemisphere development. The sustained absence of the mother due to illness, depression and/ or drug abuse, can contribute to the baby's attachment stress and ultimately to his or her impaired ability to self-regulate. Unresolved attachment and regulation problems in the mother's history also routinely result in these same problems in her baby.
While I was the clinical director of a residential program for severely disturbed adolescents, I worked with a young teen, who among other things, set fire to his foster home. As he was assessed prior to admission, the staff related his behavior to an incident of sexual abuse. He was groped by a cousin at the age of ten. There was little else to explain his behavior, but this wasn't the explanation. The incident was minor, and after the adults learned what happened they protected the boy. Those assessing him missed the devastating effects of his mother's seven-year post-partum depression. An alcoholic, his father was not able to help his wife or take over the care of his son.
It was clear to all of us at the center that his mother loved him, and in a cognitive way, this was even clear to the boy himself, but he had no experience of her. She visited and gave him gifts, but she was not real to him. He had no internalized model of her or of anyone else, due directly to his mother's psychological absence during her long depression. She was unable to engage with him, she could not cradle him in her attunement or sing to him in a mother's way. She was lost in depression, and thus incapable of helping her infant son to build the brain structure and circuitry he needed. She wasn't there, and as a result, neither was he.
I wrote in one report that to treat this boy, we would first have to create him. Even with no history of abuse and no overt neglect, this boy was one of the most dangerous residents I had ever treated. He had no capacity for empathy or remorse and lacked cause and effect thinking and conscience. After several months in residence, his mother requested his release. Over my objections, the program released him. He left home two weeks after his discharge. Shortly thereafter, he became infected with HIV and made it his business to infect as many people as he could. This boy did not suffer. He did not have the 'self" or the capacity to suffer. He caused immense suffering, but I could not treat him effectively. There was no approach available to me at that time. Neither I, nor his mother, really existed for him, and without a therapist, there can be no therapy.
Neurofeedback Case Studies:
After I discovered neurofeedback in 1996, I wanted to issue a "recall" for all the kids we had not helped, and this boy would have been at the top of my list. With neurofeedback, I would have had a chance to help him and the others who failed treatment, reorganize the most plastic area of their brains, the ROC. Since I was not real to him and because he had such impaired cause and effect thinking, this was just not possible with either talk therapy or behavior modification. With sufficient training, we could reasonably anticipate that he would begin to recognize the reality of the other and when that was possible, that he would be able to feel empathy, remorse and trust. His newly activated right hemisphere and right orbito-frontal cortex (ROC) could learn to inhibit aggressive impulses. Using Schore's framework, his affect regulation would give birth to a sense of self and other.
Neurofeedback alone cannot do this. To be most effective, training should be integrated into a therapeutic relationship. Neurofeedback can calm fear and help a person to regulate his or her affect. It cannot provide someone for them to become attached to; the child needs to be connected to a therapist, the caretakers within the residential milieu or optimally, with their own parents.
Unfortunately, I never had a chance to issue this recall. However, I have subsequently used neurofeedback to train four young adults who were my patients in the center as adolescents. All of them had severe histories of abuse and neglect. One young woman, diagnosed with Dissociative Identity Disorder and PTSD, came to see me directly after her discharge from residential care. Like many who are this fragmented, she was frightened of the prospect of personality integration, but she had come to trust me and she was willing to try neurofeedback. After 60 sessions, she reported that she could no longer dissociate and she now had "garden variety PTSD." When events occurred that would have triggered dissociation, she described feeling it begin in her brain, "but then it just stops," as if the impulse had no circuits available to it. As I maintained in Part Two, I believe that fear and reactivity are the core issues in psychopathology. This girl was becoming much less afraid, and as she gained control over her over-active amygdala, she seemed to lose the capacity and the need for dissociation.
Another former resident called me because she was afraid she would kill someone, and she did not want to "end up in the pokey." Since she had come to the center from "the pokey" after an attempted murder, I took her concern seriously and saw her for training the next day. Within three sessions of neurofeedback, she felt that she was no longer at risk of killing her co-worker. Shortly after she started training, her mother, from whom she was estranged, became fatally ill. She was able to manage her mother's hospitalization, stay with her, make necessary decisions and mourn her death. She told me that she thought neurofeedback had helped her to "keep it all together" during this very sad, stressful and evocative time. This appeared to be the case.
A woman now in her mid-thirties called to see if neurofeedback could help her. She was tired of living with PTSD. She had endured incest on a daily basis from shortly after her birth until she was placed in residential care at age 16. After discharge, she found an older man who was bipolar and sexually disturbed, and they had two children. She had a series of unstable relationships with men and multiple psychiatric hospitalizations. Two of these were for post-partum depression after the birth of her children.
When she came for neurofeedback, she was in another abusive relationship, and both of her kids were having significant emotional problems. Almost from the beginning of training, she felt her fear level drop dramatically and while in training, she became pregnant with her third child. She told me that this baby was constantly doing somersaults, was rarely quiet and kicked her hard. When we renewed the training and I shifted protocols to address her amygdala, she calmed down further and so did her baby. After the birth, the mother suffered no post-partum depression, and the baby was unusually well regulated.
The last of the four, a man, also in his thirties, was less successful but still felt some positive effects from neurofeedback. He had been abandoned at birth by his alcoholic, homeless mother, and his father's last known address was Folsom Prison. He was removed from his adoptive home at age 12 after a series of dangerous assaults on his foster mother. It was this 12-year-old, who taught me about reactive attachment disorder. He looked right through me with his wild unknown desire for a mother. He was not psychotic, but he might as well have been for how well he could perceive the reality of the other or his impact on another. He improved some with years of residential supervision and intensive treatment, but even at the point of discharge, I barely existed for him. No one did. Moreover, he did not learn. He needed a Jiminy Cricket on his shoulder to remind him that there would be negative consequences to negative actions.
His developmental brain injury, his lack of ability to self-regulate and to learn, seemed permanent and dangerous to him and others. He has been in and out of jail many times. (Thankfully, he has never committed a violent crime, something that he was on his way to doing before treatment.) During one of his probation periods, he tried neurofeedback. He told me, "I still get angry, but it goes away quicker and I call the person and tell them I am sorry." Like most people with attachment disorder, this man was a champion blamer. I was heartened to hear that he was beginning to get some control over his rage and to accept some responsibility for his actions. However, he was arrested again on a probation violation, and his training was prematurely terminated.
Unlike the first boy, I wrote about, the standard treatments had been somewhat successful with these young adults, but all were still in substantial turmoil when they sought me out and each has had significant positive change with neurofeedback training. Their histories make a terrible claim on them, but training made therapy more meaningful and eased the impact of horrific childhoods. With the training, they were all better able to calm their driving fear. Out of the four, three are living meaningful lives with no further hospitalizations or imprisonments. Their relationships are better.
The practice of neurofeedback leads me to the inescapable conclusion that early childhood neglect and trauma are deeply etched, not only in the psyche but also in the circuitry of the brain. To a much greater extent than I had reason to expect, we can change the impact of these histories through appealing to the frequency domain of brain function. We can ease fear and reduce reactivity. Any child in residential care would benefit from training his or her brain. For those with attachment disorder or histories of severe trauma, neurofeedback could mean the difference between life and death.
About the Author:
Sebern F. Fisher, MA, practices psychodynamic psychotherapy and neurofeedback in Northampton, MA. She trains professionals nationally and internationally on neurofeedback, neurofeedback and attachment disorder, and the integration of neurofeedback with psychotherapy. Fisher was also the Clinical Director of a Residential Treatment Center for 10 years. She is presently consulting with the Sandhill Center in Los Lunas, NM, on the integration of neurofeedback into their treatment milieu.
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