What follows is a report by the first author of a 55 year old US Army veteran who had been diagnosed by the VA with combat related PTSD. His background included having graduated from the US Military Academy at West Point, the American army's premier training school for officers. After 10 years of active duty in various non-combat assignments, he left active service for law school. While building a career in law over the next 20 years, he remained active in the US Army Reserve and National Guard. In 1990 during Operation Desert Storm his National Guard Military Police Unit was deployed to Saudi Arabia to handle Iraqi prisoners of war. His unit was again called up for active duty during the Balkan wars in 1995, this time for base security of NATO installations. Since neither of these two active-duty assignments had any combat components, he returned each time physically and mentally in good shape.
Due to his unique background in the law and training skills, he was recalled with rank of Colonel to active duty in 2008. He was tasked to command a Task Force to train Afghan Police units to be law enforcement officers in rural Kandahar Province. This was the most contested part of Afghanistan and the twelve 15-man training teams, and their trainees often came under fire. In contrast to combat units in the area, his teams had not had casualties for the first 11 months of their 1-year tour of duty. Indeed, the men in his task force came to believe that they were in a divine protective bubble. Then just 2 weeks away from the end of their tour in Afghanistan "the shit hit the fan" (his words), and two of his men lost their lives while five more were seriously wounded. He felt responsible for their deaths and berated himself for exposing them to danger "needlessly" before their scheduled return home. In what is known as survivor guilt (Kubany et al.,), he felt he should have been killed instead of the men. He felt especially guilty about the death of one his most valuable non-commissioned officers, who drowned when his Humvee ran off the road during a night mission and overturned in an irrigation canal.
He said that initially he had tried to "sort things out" by himself for a year, thinking that with time he would get better. When his symptoms persisted, and he feared that his wife would leave him, he signed up for standard care with the two nearest Veterans Administration (VA) centers. He was promptly diagnosed with PTSD and comorbid depression and anxiety. He went to weekly individual counseling, and twice weekly support group meetings with fellow veterans with PTSD. He was also prescribed a handful of medications for depression, anxiety, ADHD, and sleep.
After 2 years, and seeing little improvement in his PTSD symptoms, he embarked on an online search for alternatives. He came upon Neurofeedback as a remedy for PTSD and found that I was the only VA-accredited therapist providing this intervention in West Virginia. Because the VA was not offering this therapy in-house, he applied for a referral to me through the Community-Based Care program. After getting VA approval we began Neurofeedback training on May 25, 2012.
On intake, he filled out the PCL-5, the standard instrument used by the US military to assess PTSD. His score was 71, which falls into the category of moderate to serious. To further assess his PTSD as well as other issues, he also filled out the 150 item Symptom Rating Scale3. The high-rated symptoms relating to PTSD were "nightmares, flashbacks, anxiety attacks, sleeplessness, migraines, angry outbursts, problems with focusing at work, depression, and lack of connectedness." In addition, he listed "numbing, problems of relations with coworkers and his wife, and pretty much everything."
Evidence of his determination to recover was that he committed himself to 10 Neurofeedback sessions in 5 weeks. Although working full time as Assistant Prosecuting Attorney, he faithfully made the 3-h roundtrip twice weekly and attended all 10 sessions. Each session was about 50 min long and consisted of debriefing on inter-session progress by reviewing the identified major symptoms. This was followed by 30 min of ILF Neurofeedback. The primary placements were at T4-P4 for calming his hypervigilance and high arousal issues, followed by T3-T4 for system stability. To restore prefrontal control of his emotions, especially anger and rage outbursts, we used T4-Fp2, followed by T4-P4. He made rapid progress, as attested to by his own inter-session reports, and his wife. She came in at the fifth session, wanting to know what we were doing because, "I now have my husband back."
After the tenth session on June 29, he retook PCL-5 and his score was 59; a reduction of 12 points in 5 weeks4. He claimed that his most troublesome symptoms had disappeared and that he was titrating off his medications. He penned a testimonial saying that he had received more benefit from 10 sessions of Neurofeedback than from 2 years of VA care. He e-mailed it to each of his VA therapists and prescribing doctors. However, he knew he was not "cured," and so he opted to continue with the Neurofeedback sessions, though at lesser frequency. First, we reduced it to twice a month, then to once a month as his work duties as Assistant Prosecuting Attorney increased. Being busy kept him from ruminating on his survivor guilt and he continued to see progress in his day-to-day activities and behaviors. He was still having some nocturnal flashbacks and nightmares. That was a sign that we needed to work on resolving the deep-seated trauma memories.
We added two channel sum training at Fz + Pz at 0.05 mHz, and this was helpful for him. His wife reported that a drunken driver had crashed his car into the stone retaining wall in front of their house, but that her husband wouldn't bother to get up, saying the police could handle it. She commented that if this had happened before he started Neurofeedback, he would have been up immediately with the two guns he kept under his pillow to "deal with the threat." Since nightmares were still occurring, albeit infrequently, this indicated that the deep-seated state memories of the trauma had not been resolved. He also reported that he was still uncomfortable in crowds and avoided social gatherings. "Suspicious looking packages" still triggered a physiological arousal response.
We decided to add two-channel sum Alpha Theta training with alpha frequency set at 10 Hz and theta set at 7 Hz, to aid in psychological resolution. There is a choice of scalp locations for this kind of training. In his case, after successful calming and restoring brain stability, we used P3 + P4, alternating from session to session with O1 + O2. A recorded guided imagery induction was added to engender a deep relaxation state. After one session, he said that he had "seen" the trauma sequence during his session, which he described as "movie scene without the emotional soundtrack." Immediately after the session he was able to calmly verbalize what had happened during the trauma incident for the first time. This was evidence that he had successfully decoupled the state memory and could now see the historical memory without triggering physiological arousal (See Figure 1).
This veteran continued a schedule of monthly "refresher" sessions. Eighteen months into his rehabilitation from PTSD, he announced that was going to campaign for the position of Prosecuting Attorney, which he won. He acknowledged to me that he could never have campaigned or spoken in front of crowds prior to Neurofeedback training. He and his wife have continued to come for occasional joint sessions to "keep the stress down."
In summary, this client was highly motivated to overcome the burden of his PTSD symptoms. This is not true for all the veterans I have trained with Neurofeedback. Some who live at some distance were unwilling to commit themselves to the intensive regimen to which this veteran agreed. Other veterans who depend on the VA disability checks had quit therapy because they feared losing their benefits if they got well. The determination and resiliency of this veteran, his trust in me, and faith in the method clearly contributed to his success. As the training proceeded, I could observe the visible change from the man who appeared pained, depressed, and hopeless when he first came in, to the person who found life to be interesting, challenging, and enjoyable. He and his wife have revitalized their marriage. They display affection and an easy back and forth humorous banter every time they come in for a "refresher session" more than 10 years after his initial visit.
Neurofeedback is a non-invasive behavioral training that trains neuronal networks to improve self-regulation. It thereby ameliorates symptoms of PTSD while simultaneously reducing comorbidities. The above brief review of select programs are proof of concept that addictions, PTSD from combat or from torture, as well as mTBI and their dysregulating sequelae can be successfully remediated with the combination of ILF Neurofeedback and Alpha-Theta training. Each of the programs reviewed had shown positive results in a relatively short time along several dimensions:
- Neurofeedback dramatically improves retention in existing drug/alcoholism rehabilitation programs, reduces recidivism, and promotes abstinence in PTSD/substance abuse comorbid veterans, and is free of from side effects and withdrawal issues of pharmaceuticals.
- Neurofeedback training demonstrates positive influence in restoring dynamic functional connectivity in the principal resting state network, the Default Mode Network (DNM) as well as improved functional connectivity overall (Lanius et al.,). This attests to the positive impact of Neurofeedback on global functioning of the brain. It speaks both to the interconnectivity of neural networks, and neural plasticity of the brain.
- The concomitant release from fear based hyper-vigilance, anchored in the trauma memories embedded in the physiology of the body, can bring positive transformative behavioral and emotional changes.
- The development of the infra low frequency protocols has proven to be a highly successful improvement for the use of Neurofeedback as shown by the success of the last four studies cited above (Othmer and Othmer,).
- Alpha-Theta Neurofeedback training has proven to be an effective method for opening a window into traumatic memories without emotional abreaction. This allows those unresolved memories to be released and processed with less risk of client re-traumatization that is common in talk or exposure therapy (Lake,).
- Neurofeedback has proven to be superior to so-called "evidence-based" PTSD treatment in terms of effectiveness, temporal efficiency, and cost (Fragedakis and Toriello,; van der Kolk,).
- A collateral benefit is the reduced risk of secondary trauma for the clinician.
Collectively, clinical experience has demonstrated that trauma of whatever source can be successfully remediated with Neurofeedback, particularly when ILF NF is combined with more standard EEG-band protocols. Given the success as illustrated above, it is to be hoped that ILF Neurofeedback and Alpha-Theta training become accepted as part of an integrative and holistic approach for treating survivors of trauma.