I am a psychodynamic psychotherapist and I am a neurofeedback therapist. Slowly, I am integrating not only these two approaches to treatment and the implications each has for the other but also some fundamental challenges to my understanding of the nature of emotional disturbances, to the nature of those people who suffer from them and to my role as a helping professional. The thoughts that I will share in this presentation arise from my work on myself, with my own psyche and my own brain as well as my work with my patients.

As a psychotherapist incorporating neurofeedback, I see people who are suffering emotional distress, at times severe, and I have come to recognize that this suffering is embedded in the firing patterns of their brains. I recognized this experientially, first as a neurofeedback patient and subsequently as a neurofeedback therapist. After many years practicing psychodynamic psychotherapy I understood, and I think correctly, that deep psychic suffering arises within the context of key relationships, particularly relationships with parents. Psychic pain was relational pain, and the healing of psychic wounds was also relational. Although I work with and value insight, I agree with whoever said that insight and a dollar gets you a cup of coffee. Insight is important, but it is not enough. Over the years of my practice, I came to the conclusion that what is enough in psychotherapy is what is enough in all other areas of human development, a ‘good enough other’.

John Gedo, the prominent psychoanalyst, describes psychotherapy as "an unprecedented relationship" and a relationship that, when good enough, creates cellular change. (Presentation at Austin Riggs 1997). He was not being metaphoric. He was describing the neurobiology of relatedness, the affect of one on the other, most profoundly, in the case of psychotherapy, of the therapist on the patient. He was describing what can happen when the patient begins to experience him or herself as deeply touched, as deeply connected, as changed cellularly by the being of an other, the therapist. I am recruiting this concept of cellular change because it has the possibility of bridging an apparent gap between psychotherapy and neurofeedback, and because it can help us maintain a relational context when thinking about the benefits and mysteries of neurofeedback.

From within the context of psychoanalytic psychotherapy not neurofeedback, Gedo asserts that deep psychic change is cellular change. Since Gedo was being literal and not, at least admittedly, mystical, we are led to wonder where such cellular change occurs. Work with neurofeedback confirms his assertion as we witness what appears to be change at a cellular level in the brain.

Gary Schwartz (presentation at Future Health conference Feb. 1998) speaks to this phenomenon of connection at the neurological level. His research demonstrates that the EEG of one may be found recorded in the EEG of the other, and he feels it is reasonable to speculate that the more bonded the pair, the more demonstrable this will be. Extending both concepts allows us to hypothesize that the therapist’s brain state (represented in some crude way in these electrical tracings) will effect the brain state of the patient as much if not more than their insight. If the therapist’s state remains stable and steady over time, as it should, it may well begin to entrain the brain of the patient. This entrainment may be a crucial element in all human relatedness. As the patient becomes more stable the process of entrainment becomes increasingly reciprocal. Of course if the patient’s brain state holds sway from the outset, then, by definition, the therapy fails. The subset of patients I will be referring to throughout this paper, people who are deeply overaroused, require the holding environment of the therapist brain state. The brain of the therapist must cradle the brain of the patient. The state of the therapist’s brain is manifest in ways as seemingly disparate as the tone of his/her voice or the paintings selected for the waiting room, and it this state that is the holding environment. This is, of course, the paradigm of the mother-infant relationship as well as the deep structure of transference. In his immense work of scholarship on early attachment, Affect Regulation and the Origin of Self, Allan Schore sets out to prove that the "prefrontal cortex of the mother becomes the prefrontal cortex of the infant" . He describes attachment as the brain to brain, body to body, eyes to eyes, voice to ears installation of the mother’s brain state into her infant. This is incorporation. From the perspective of psychoanalysis, transference is the reenactment of this early relational dance, and the therapy is the new dance lesson. I am suggesting that the new dance happens through the interplay of brain states, not, at least primarily, through insight, behavior modification, et al. Although therapy is as wholly different as it is the same, the mother-child relationship is the closest analog for the ‘unprecedented relationship’. Just as Schore hypothesizes the neurological impact of mother on child, I am hypothesizing that the neurological, or state, impact of the therapist on the patient is central to the efficacy of psychotherapy. This hypothesis allows us to imagine what may be happening neurologically in a deep psychotherapeutic encounter and it can shed light on the notion of cellular change.

Attachment research and the observation that psychic suffering can be relieved through the regulation of the brain with neurofeedback lead me to another important paradigm: all of psychotherapy relates to and profits from the regulation of the brain. And this is a regulation not unlike that which the good enough mother promotes in her baby. Unfortunately, when regulation of this order happens at all in psychotherapy it takes a long time, an uncommon measure of therapeutic presence and skill, and substantial emotional and financial resources on the part of the patient. These circumstances were always rare and are becoming rarer. With patients who are severely disturbed, the therapist is called upon to help stabilize profound disregulation (which always threatens to disregulate her/him), i.e. symptomatic behaviors, before, and while, undertaking the task of promoting a new homeostasis anchored in interpersonal regulation. This, I think is strongly analogous to the installation of prefrontal functioning as described by Schore.

Before talking more specifically about the impact of neurofeedback and brain regulation on the therapeutic relationship, I think it is important to acknowledge that there are many people in need of deep interpersonal connection who even in the presence of its possibility cannot pursue it. They are people who engage entirely in instrumental relationships, and at their worst, they are sociopaths. These are the patients who are routinely labeled as ‘untreatable’ and who are, increasingly, being identified as attachment disordered. Due primarily to early maternal absence or neglect, they are unable to use a therapy relationship because they lack a relational template. There was no experience of relationship encoded in their developing brains. Since the heart of the therapeutic endeavor is relational, there can be no therapy with someone who has no desire for relatedness. This group represents a daunting substrata of the mental health and criminal justice population, both in terms of prognosis and of numbers. They have brains that seem hard wired to resist the effects of the other’s state. These people, too, may be reachable with the intervention of neurofeedback even where all human intervention has previously failed. Even sociopaths may be able to experience the cellular change that has been the province of deep relatedness and in the process discover the reality of the ‘other’.

While the context of emotional disturbance is relational (or profoundly non-relational), it is affect that drives it. As the title of his book suggests, Score believes that an infant’s sense of self is formed within the mother’s capacity to mediate states of arousal. When a baby lives in the presence of his/her mother’s absence or neglect and arousal is unmediated, the baby’s arousal continues to escalate until the infant experiences a burned-out state. This is what you see in the look of the Romanian orphan. This level of attachment disturbance is at the far end of a spectrum of over arousal that manifests in a broad array of DSM IV diagnoses. But inherent in each condition of overarousal is fear. The pulse of emotional disregulation is fear. Fear is overseen by the right hemisphere of the brain and originates subcortically. It is, at its deepest core, survival fear, primitive, essential, and robust; felt or not felt, organizing or disorganizing depending on its particular individual manifestation. Unmodulated arousal in the infant becomes unregulated affect in the child and adult; and unregulated affect predicts psychopathology. Once we accept this premise, and there is good clinical and neurological reason to do so, then we can begin to construct hypotheses about the vitality of neurofeedback when used within the relational context of psychotherapy. Neurofeedback regulates the brain. Simply put, when the emotional problem is driven by fear, or overarousal too diffuse to still be called fear, we focus the neurofeedback intervention on the right hemisphere.

When the problem is depression or inattention, we characteristically focus on the left hemisphere. (Cognitive therapies demonstrate efficacy in the treatment of depression. This may be because the problem in much depression sits in the left hemisphere, the part of the brain that uses verbal language, the part of the brain you can talk to. No such claim to superior outcome is made with disorders of overarousal, like PTSD or Reactive Attachment Disorder.) When we are able to adequately assess for overarousal and then establish the protocol path to treat it, fear begins to dissipate and with it go the increasingly vast array of symptom clusters enumerated in the DSM IV. If all that neurofeedback did was alleviate symptoms, it would be equal to good psychotropic medications. But it facilitates a more profound process which may be exactly as Schore characterizes. Neurofeedback helps the patient learn to regulate affect and in so doing we can witness and by the therapeutic presence of our person help guide and enhance the blossoming of self.

Many of my adult patients have struggled to articulate the profound change they feel in their sense of self as a result of neurofeedback. They talk about enhanced capacity in every realm, cognitive, sensory, emotional and, not least, relational. Patients who have been organized by a deep pulse of fear describe living, quite suddenly and surely, in a different reality. As they experience their nervous systems calming, they begin to emerge from the background noise of overarousal.

Post-traumatic patients begin to inhabit a world that will not attack. Dissociative patients who were constantly being dragged back in time are able to achieve the present and, increasingly, to live there. The RAD patient begins to soften at the antisocial edge and first tentatively, then hungrily, turn toward relationship. The self-mutilator cannot stand to be hurt any more.

Symptoms remit, and universes change. Many patients have used exactly this language: "I live in a different universe." This universe is one of safety and color and living in it allows increasingly easy access to relatedness, which in turn revivifies the universe. And, of course, the therapy universe changes with it.

Therapy no longer has to concern itself with control of symptoms and, once freed of those often alarming constraints, can truly begin. (Of course, it could also end, a decision the patient can now more reliably make.) With changes this profound, it hardly seems sufficient to think of neurofeedback as a tool of psychotherapy. Although brain regulation is key, it is most key in terms of relationship with an other.

Patients using neurofeedback, even, or particularly, the most severely disturbed can report changes in state sometimes within weeks that are only rarely reported in psychotherapy after years of treatment. In both cases, however, successful neurofeedback and successful psychotherapy, the outcomes are similar: greater stability, both emotional and cognitive, increased relational capacity, and an enhanced sense of self. Both approaches work with the brain, and where, I think neurofeedback is most successful, both work within the context of relationship. Neurofeedback hastens the process, particularly and specifically in the arena of affect regulation, easing or prompting the patient’s brain and central nervous system to become unafraid and to open to the world around it. But it is the psychotherapy relationship that ultimately allows the patient to lay claim to their delayed inheritance, that of being in relationship, deeply and securely, with an other.

Practice

When I am engaged as a therapist in neurofeedback I have felt both like a tech and like a minor god. I have had to become at least minimally competent with the technology and constantly attentive to it, and I facilitate miracles once only the province of deity. As a neurofeedback therapist I stand at the mysterious, ineffable juncture where brain becomes mind.

The transition from stable brain to stable mind can begin within a day, but the speed at which change can occur is not always received as a gift. It is a truism that no one comes into therapy wishing to change. This is the reality of resistance. In psychotherapy the demand to change, the imperative to change, is constantly negotiated and renegotiated. Change is slow and paced, consciously and unconsciously, by the patient. Once neurofeedback is utilized, change comes quickly and the locus of control can be perceived as moving into the hands of the tech-god therapist. It is axiomatic that change is both welcomed and feared. When it is sudden and profound, it seems both more welcomed and more feared. Thankfully, along with the relatively rapid changes many patients experience, neurofeedback also seems to engender a sense of equanimity, a capacity that allows the patient to manage the confusion inherent in profound state changes and to relate to the new self that they must learn to inhabit. This is not easy. The therapist who has had his or her own experience with neurofeedback is much better able to prepare their patient for this eventuality and to help them cope with it when it occurs. The process of rapid change that leaves the patient contending with both a new identity and a new external reality threatens to isolate them from family and friends. It must not also threaten isolation from the therapist. Psychoanalysts have always been required to undergo their own analysis, not only so that they could better understand themselves but so that they could appreciate the inner workings of the process with which they were being entrusted. A psychotherapist who is also a neurofeedback practioner must observe the same ethical intent. Being deeply engaged in their own psychotherapy and neurofeedback training is the only assurance that therapists will be able to accompany their patients on their profound journey into neuronal regulation and transformation. I became a neurofeedback therapist because I had learned what it could do. After several weeks of training with a colleague, herself new to the process, I experienced a state change so profound I was hard pressed to describe it adequately except to say that I felt like I lived in a different brain. When my patients describe similar occurrences, I understand at least the basic structure of their experience. We have a common language for what is often impossible to describe. When they do not experience the shift in state that we are seeking, I am able to assure them that it is indeed possible to achieve. My assurance is not a matter of faith, although I have that as well, but of an experience that has within it the information of its own universality.

The introduction of the computers into my practice did not go smoothly. My enthusiasm for this process was repeatedly experienced by my patients as abandonment not only of the patient but of our common dynamic history and the meanings we had constructed. One woman’s terrible mood lability which creshendoed in rage-driven attacks was well explained and somewhat contained by a psychodynamic understanding of her relationship with her mother. When I began to shift my focus from psyche to brain, she felt the ground beneath her disintegrate. She experienced this paradigm shift as the catastrophic loss of all that held her. Now the problem was going to be located in the brain, not in the psyche, not in the transference and not in the relationship with her mother. She raged against me, against the intrusion of the machines, against what initially felt to her an obliteration of nearly genocidal proportions. I, of course, experienced the introduction of this technology as admittedly challenging but as entirely benign and having the potential to be profoundly positive.

For months the therapy had to turn toward clearing the path to NF. Throughout, I was guided, almost solely, by my own experience with it, an experience that gave me confidence that she would find it not only helpful, but essential. Without it, I have no doubt that I would have retreated entirely under her terror-stricken assault. She is now, several months later, increasingly stable as we train around an early injury to her right frontal brain, the exact spot that would predict emotionally lability.

In another instance, a man with RAD at first exhibited a clear preference for working with the machine over working with me, and this needed my human therapeutic intervention. He could not bond to a machine, much as he might wish to.

Another patient felt excluded from the computer age, hated the presence of the computers in my office and felt like she’d lost me to them as she had lost her mother to her younger siblings.*

These were complex transference reactions to the encroachment of computers, to my enthusiasm about neurofeedback, but even more profoundly, to a major shift in paradigm. Each in their own way feared losing me and the therapeutic home we had constructed and furnished together. Further, some feared that I would now reduce their humanity to the firing of their brains, and one patient even refused to allow mention of it in ‘her time’. I had to significantly slow the pace of its introduction. It became clear to me that I was introducing it to them as my experience of it had introduced it to me, as revelation. Revelation comes from within and does not come slowly or smoothly. It is sudden and startling. I had been startling them and in my revelation, I was blinded to what I was asking of them. I had to become honestly indifferent to whether or not they used it. Only then could they become less frightened of losing me, begin to be curious and then, slowly, begin the training of their brains.

But loss of me was not only a compelling transference issue but a real one, hour-to-hour. Our time was now spent doing neurofeedback rather than talking together. And the experience of rapid symptom reduction raised the fear that our relationship would quickly and prematurely end. Neurofeedback sped up and condensed a paradox that concerns many patients in intensive, transferential therapies: that achieving health means losing the relationship that made health possible. Particularly for those patients who have been searching their entire lives for this very relatedness, it is difficult to imagine ever leaving it voluntarily. It is left to the therapist to know, as the good mother knows, that the well-cared-for child will, one day, want to leave home, that deep connection allows independence. In psychotherapy, these fears are confronted and assured both verbally and by the perseverance of the relationship over time. In neurofeedback this reassurance is folded into the process itself as they begin to feel inherently safer and come to realize that symptom alleviation is not the same as therapeutic growth; that there is a world beyond the enclosure of psychic suffering and that there is an identity other than that which has coalesced around extreme pain.

Intense affect validates intense experience. For many patients who have lived and are living in invalidating environments, it is the indicator that they have relied upon to validate the impact of early experience (Linehan, Cognitive Behavioral Therapy for Borderline Personality Disorder). In some cases it is the only validation.

Neurofeedback mollifies intense affect which, while opening these patients to a new universe, also threatens to collapse the validity of the one they are leaving. The threat of invalidation, however, is short lived. Patients report the curious and compelling phenomenon of coming to know, in a way that is unperturbable, what happened to them. This is not an experience of factual recall or, necessarily, even of visual memory. They achieve a state free of doubt and in this, of resolution. They know what was true in what they’d imagined and, just as profoundly, what was not. At the same time that the affect subsides, they find they no longer require affect to validate their experience. These seem to be simultaneous psycho-neurological developments. I have talked a lot about sudden changes. This change is not so sudden; and although it is, at its base, enduring, it is often interrupted by post traumatic excursions, increasingly less intense but significantly felt, as some measure of clarity and equanimity come to predominate the psychic state.

One patient who had repeated hospitalizations during which she was diagnosed with Borderline Personality Disorder, lived with a vague, internally and externally invalidated sense that she’d been molested by her father. She also lived with the insistent dread that she would be abandoned. She felt equally haunted by the sense of molestation and by the doubt that anything had happened. Clearly, I could know no more than she did. Before using neurofeedback she was unable to resolve this painful stasis. After 60 sessions she said, "I thought I would have to go through all this awful stuff in remembering what happened, but I didn’t. I know what happened and it’s O.K. now."

This woman’s ‘memories’ were held in her body as vague, uncomfortable sensation, and they were integrated, using neurofeedback, with little, if any, reliance on visual recall. She had some strong visual imagery but no abreaction. Bessel VanderKolk, a trauma researcher at Harvard, recognizes how ubiquitous body memory is in those who have suffered childhood abuse, when he says "The body keeps the score". In my experience, the single most dramatic example of body memory during neurofeedback was that of a woman suffering severe post-traumatic stress disorder and dissociation who came into therapy after a difficult night. While talking to me, she suddenly saw herself standing in her crib, crying, her mother approaching with a raised toy bat in her hand and hitting her over and over across the head until she fell unconscious. The therapeutic task was clear. Our time was needed to talk about this horrific recall, for her to feel all that she needed to feel and, eventually, to grieve the life in which this could happen. More neurofeedback would wait. Later that morning, she kept her regular appointment with her physical therapist. Without her saying anything of the prior episode, he asked her what had happened to her head. The old injury was suddenly acute. The psychotherapist in these situations needs only to validate the truth of what both patient and therapist are experiencing in the present, not the facts of the past. One patient put this well, "I don’t know if what I am remembering is factual, but I know what I am experiencing is true".

I do not want, at least at this moment, to join in the debate over repressed memory. I want only to report the experiences I have witnessed. But I do wonder what I am witnessing. Is this a process that unlocks memory that has been laid down along a different pathway in a different state, as some theorize? It is one plausible explanation, and if it were true would suggest a different process than repression, perhaps something more akin to hypnotic memory. There is reason to consider this. Theta dominates the brain states of children under normal conditions and dissociation is normal under circumstances of unrelenting fear. Children who are being terrorized are already, developmentally in theta. Under such circumstances it is reasonable to consider that anything done or said to them would have the power of hypnotic suggestion even if there were no effort on the part of the abusers to engage in an hypnotic process. I can do nothing more than hypothesize, but I can say with absolute certainty that what these patients experience is genuine and profound.

I have only been able to share the barest outline of the impact of neurofeedback on the lives of my patients, but I think it is enough to give you a sense that training impacts identity. One man, a powerful CEO with reactive attachment disorder, described his problem on his initial consultation. " I have no feelings except anger and irritation. I can see that other people live differently, and I want to see if I can get there". "It is as if I am living without a central nervous system". After several neurofeedback sessions he said, "I can’t tell you what it’s like to live without constant fear. I didn’t even know I had been until I’m not anymore." He, like many others, struggled with the ineffable effect of this training. "I am a different human being" He related differently, reacted differently, thought differently, felt emotionally more quiet and cognitively more sharp. He felt radically changed and, at his core, continuous. He was completely changed and integrally the same.

One young woman who started neurofeedback the day after she left a mental hospital AMA, diagnosed as bipolar, borderline personality disorder, attention deficit with hyperactivity, alcoholic, post-traumatic and learning disabled (and who said "I am crawling out of my skin") now has to contend, calmly and deeply, with who she has become and what is now expected of her. She said recently, "I have never been more myself and I have never known less who I am."

Working with the issues of identity implicit in that astonishing statement is no small clinical endeavor. For this girl, who spent her first year in an orphanage, it is nothing less than the construction of an integral self in relation, first, to me. She has been in treatment for 18 months.

As one can imagine from these case vignettes, fears that neurofeedback will reduce individual richness to simple firings of the brain are quickly allayed. The relationship between brain regulation, psychic suffering and personality is manifest but the mystery of the relationship only gets deeper.

I have focused primarily on the demands that the introduction of neurofeedback make on the patient, but there are obvious demands made on the therapist as well. First and foremost, neurofeedback demands a major paradigm shift. It is not an ‘add-on’ to therapy as usual. It is not a tool. It is a gateway to the brain and to the psyche. Psychodynamic therapists have to begin to learn about the brain with all the energy that they have devoted to learning about the psyche. They have to begin to wonder, as I have been doing here, how it all fits together. They have to be willing to challenge everything they ever thought they knew about the way people function. They have to be skillful in the way they introduce neurofeedback. They have to, in many cases, overcome technophobia. Most importantly, I think, they have to learn to listen differently. They have to begin to discern the effects that the training is having and to teach their patients discernment.

Psychotherapy requires insight; neurofeedback requires discernment. My brain injured patient has a highly developed capacity for insight, but, particularly at the beginning, when she did not much believe in neurofeedback, she lacked discernment. She could not perceive, or could not assign the effects of training, even though she was clearly experiencing them, even reporting them. The central problem in learning discernment is state dependence. If you haven’t recognized that human beings are profoundly state dependent before doing neurofeedback, you will once you do. It would not be uncommon for a person to experience their situation at work as hopeless and themselves as incompetent as they begin to train and even thirty minutes later to feel it is all rather easy to manage. (Improper training can reverse that same scenario.) Many will not be aware of this state shift until reminded by the therapist. This is the act of discernment (not insight). Further, we believe the world view that our brain state dictates. State dependence is a concept familiar to psychotherapists. It is however so dramatic in neurofeedback that it can’t be doubted as a ubiquitous phenomenon. This training helps patients, over time, learn to discern the reality and the effects of state dependency. They learn not to believe all that their mind produces and they can discern the state that creates it.

Once training has begun, the therapist must hear everything as relating both to the brain and the brain wave training and to the psyche. Crying all night may be grief that had to be felt, but it could also be an indication of a poor training. It could be both. As the variables compound, so does the responsibility of the therapist to be extremely attentive, to practice discernment and to stay aware of his or her own biases in terms of interpreting the patient’s reports and behavior. What were symptoms before neurofeedback may now be training effects and must be first passed through that screen. I ask my patients to accept that from here on in everything will be considered a training effect until we rule that out, so they need to tell me of any change regardless of how seemingly insignificant or how easily understood in a preexisting paradigm.

At the same time as they are engaged with the neurological changes, therapists must not forget that there is an ongoing dynamic process. A brief case vignette captures this beautifully. One young woman with a dire early attachment history needed almost exclusively right side training but always needed a small amount on the left as well. When I trained too much on the left, she would drop things and bump into things, a problem that had plagued her her entire life. She was telling me, one day, about being in the supermarket and dropping a bottle that smashed when it fell. Too much left side training, I thought - the response of the neurofeedback therapist. The psychotherapist asked what she had dropped. It was a jar of gourmet pickles, favored by her mother. Her face lit up with recognition of the unconscious agenda at this moment, in this dropping.

Research has not revealed how psychotherapy works. It remains a mystery. We are still far from sure how neurofeedback works, and even as we get clearer, we will only further elucidate the mystery. Both processes, as well as spiritual ones like meditation, unarguably effect the brain. Pinker, the consciousness writer, says that "the mind is what the brain does". Neurofeedback makes it clear that it has become the job of psychotherapists, not only of theorists and neuroscientists, to address the brain as well as its creation, the mind.

CONCLUSION

The implications of the paradigm shift initiated by the introduction of neurofeedback are staggering and, ultimately, beyond the scope of this paper. I want to outline a few.

Neurofeedback highlights the centrality of state dependence in human psychology. Before our eyes, in relatively brief time frames, we witness how a shift in brain state can change fundamentally one’s sense of self and world view. One man came to training and was by self-description paranoid, racist, mean and self-hating. He was predominantly anti-social. After training, he was, by his description "a nicer person". He was no longer paranoid and no longer racist. He was also no longer ruled by fear.

Which brings me to the next implication: Affect drives psychological state. As suggested by the cases cited above, when patients report and exhibit a reduction in affect, they also experience significant state shifts. Further, it could be speculated that it is some constant rehearsal of state that we have come to call personality, and that when one regulates the affect that drives the state, one alters personality; that personality is a reification of state which in turn is determined by affect. Personality, then, is not hardwired nor are personality disorders, which in this light, could be seen as personalities distorted by unregulated affect. In some real way, neither personality nor personality disorders exist. Even the construct of hard wired temperament is called into question. These aspects of our humanness are all more plastic than we have assumed, and yet there is some enduring core of self identification that even in the midst of enormous personality change goes undisturbed.

My experience with neurofeedback confirms the sense that I have developed as a psychotherapist that neglect, particularly in the first year, significantly disables the brain - particularly in the development of the right hemisphere. Further, symptoms of PTSD, those that have resulted from abuse, remit more quickly than those secondary to emotional and physical neglect. There is, presently, a great deal of interest in trauma and a paucity of attention given to the consequences of early neglect. Experience with neurofeedback suggests that neglect causes even greater and more enduring harm than abuse, and that we must attend to it. The societal as well as personal implications are vast.

What heals in psychotherapy? Clearly content and process are of great importance but perhaps even more fundamental is what sets up between the two brain states, the ineffable neurological underpinnings of relationship.

Neurofeedback may help to elucidate traumatic memory. If there is some analog of hypnotic suggestion at play, then we would need to revisit the concept of repression. We might also wonder, in this same vein, if reenactment is, to some degree, inevitable.

The DSM I was a slim volume, more like a poem than a text. DSM IV rivals the phone directory of a mid size city. Diagnoses of mental or emotional problems dissolve when you begin to work with the brain - except as descriptions of a particular ordering of overarousal, underarousal, or instability between the two.

Neurofeedback allows hope for the hopeless cases, most particularly for those whose mental health system is a correctional facility. And last, but not least, neurofeedback challenges the primacy of medications to regulate brain function.

As a psychotherapist and a neurofeedback therapist, I am neither tech nor god but an astronaut exploring the infinity of inner space. I cannot imagine a more privileged position.