EEG Biofeedback as an Adjunct to Psychotherapy with Borderline and Narcissistic Patients

by John A. Putman MA, MS, MFT

1999

Those of us who use EEG biofeedback with our patients have often observed major personal transformations. These shifts can occur even in those persons suffering from, what are considered to be, some of the most recalcitrant of all disorders by the mental health community -namely, the personality disorders. When used in conjunction with insight oriented psychotherapy and cognitive restructuring, the individual experiences this transformation as a movement towards his or her own essential self.

When performing brainwave training to increase the lower frequency activity (alpha and theta), there is a decoupling from the external world allowing for a shift towards a more internal focus of attention. This state of reduced arousal and inward focus appears to have some unique properties that are conducive to healing. Imagery and feelings related to early painful experiences may surface which can then be integrated from the perspective of the adult brain/ mind. A discussion of the possible mechanisms involved will be included later. One of the purposes of using EEG biofeedback as an adjunct to therapy is to create an internal sense of well being that is conducive to the lowering of psychological defenses. This is quite necessary if therapy is to succeed as it is quite difficult to penetrate the defensive fortress of certain persons with talk therapy alone due to the nature and severity of the pain they've suffered. Two of the most difficult types of clients to work with in this regard are those with Narcissistic and Borderline Personality Disorders. The following is a brief comparison of the two different personality types along with some of the common psychodynamic forces that are behind their suffering.

Working with the borderline or narcissistic patient can be an extremely difficult, slow moving and often times precarious undertaking. Generally speaking, both come into treatment seeking help for depression. Although depression is rather pervasive in both personality types, the narcissist does not usually share the same spectacularly self -destructive proclivities often seen in the borderline patient. The borderline generally does not have the carefully cultivated coping strategies of the narcissist as reflected in the greater discrepancy between the inner fantasy life (dreams of greatness, etc.) and the actual level of achievement in life (Lowen, 1985). What they do share however, is an almost intractable feeling of inner emptiness and disconnectedness. This lack of feeling is a result of the intense need to avoid pain.

The background of the narcissistic patient is usually characterized by some form of humiliation coupled with an experience of themselves as being special in the eyes of a primary caretaker (Lowen, 1985). This feeling of specialness provides the bedrock for the construction of the grandiose self-image which offers some degree of sanctuary from their depression. But the actual defensive architecture is, in fact, a response to the experience of deep humiliation and has as it's purpose, the warding off of further humiliation (-e.g. the boy who was praised for his athletic ability but ridiculed when he displayed any feelings). Such a person may develop an extreme need for control and dominance and make inordinately strong emotional investments in his accomplishments or attributes, such as golf scores or good looks in order to avoid deep feelings of inadequacy. Such a person can become enraged when any of these things are challenged, even inadvertently, by a colleague, friend or spouse. The anger response is usually disproportionate to the "insult" due to the fact that it is this reservoir of early anger that is being tapped which is related, in turn, to these early experiences of humiliation. Such outbursts generally present a sharp contrast to the narcissists usual well cultivated and emotionally restrained demeanor. The experience of pain is perceived as being humiliating and thus must be avoided at all costs. Therefore, control is of premium importance. This makes therapy particularly difficult since any sort of headway the patient makes is contingent on re-experiencing some of these feelings.

The background of the borderline patient, on the other hand, is notably more unpredictable and chaotic. Thus the coping strategies tend to be more primitive since there was no consistent form of pathology with which to contend, unlike that of the narcissistic patient who was generally exposed to a more orderly, systematic form of abuse (the contradictory aspects of humiliation and specialness were more built into the fabric of the dynamic environment thus allowing for the congealing of a more refined, efficient array of defenses). Typically, the borderline patient's early relationship with a primary caretaker was fraught with instability and unpredictability (-e.g. a mother who may be loving and affectionate one moment and coercing and menacing the next without any apparent cause). Thus bonding between mother and child becomes obstructed leading to an impairment in the normal process of object integration.. In other words, it is less anxiety inducing for the child to see mother as 2 people (good mom / bad mom) rather than a complex, unpredictable, moody caretaker. This is the child's way of imposing order on a seemingly disorderly world thereby making it more predictable and less anxiety inducing. Unfortunately this pattern of fragmenting the world into predictable entities causes profound difficulties when it comes to maintaining relationships in adulthood. Borderlines have an immense capacity to sector off experience in order to suit their needs: " I know my boyfriend beat me up sixteen times, but he really does love me. He brought me flowers today". In a person such as this, the long history of abuse has no relevance since the feelings of hurt and anger are completely cut off from experience. With someone else they may be much more reactive and suspicious with little or no reference to that person's actual behavior and motivation. In other instances a single person can be shoved from one perceptual compartment to another ; being seen as a villain one moment and a saint the next, depending on which particular introject is being projected onto them. This defensive strategy provides testimony to the chaotic environment that persons with borderline features were subjected to as children.

A child who comes from a background characterized by unpredictability and emotional violence generally has to forfeit part of themselves in order to accommodate the precarious and unpredictable environment with which they are faced. This sort of chaos often results in personal boundaries that are never fully established. Often times we will see one of these adult patients come in with relationship difficulties where they have taken on all of the values, beliefs and interests of the significant other. They literally have no sense of who they are or what they want. The borderline patient's experience of inner emptiness and boredom is related, at least in part, to having been robbed of their internal real estate as a child. And so, when they are not "joined " with someone, they feel the void, causing them to seek distraction in substance abuse, impulse driven attachment to other persons or some form of self destructive behavior. Such a person lives a life that is largely devoid of true feeling due to the splitting off of pain from experience. This can seem a little deceptive when one considers the volatile emotional eruption that can occur when they are in crisis. However, this emotionality is more of a panic reaction brought on by the threat of split off feelings entering consciousness. The true feelings are generally drown in the emotional flood brought on by the fight- flight response. Attachment issues are really the central struggle in the borderline patient. It is clearer to think of an attachment injury as exactly that -an open wound .

One cannot cut a sharp line of demarcation between the two personality types as it is more clear to think of them as occupying different locations on the same spectrum. Although the method of wounding was different, the common spine running through these disorders is the absolute need to avoid painful feelings. The need to avoid pain of one sort or another seems to be at the root of virtually all forms of psychopathology. The manner in which one navigates around the pain in their life is catalogued as a particular disorder or personality type. And so, true health can only be attained through the re-integration of repressed pain into the experience of the individual. The more painful the trauma, the greater the psychic gravitational attraction between the split-off elements of the psyche and thus, the greater the forces of repulsion to keep them exiled from one another. Therefore, the agency of the repression needs to be addressed in some way.

There are essentially two theoretical models that attempt to explain (from an electrophysiological basis) what may actually occur when a person experiences a psychological -transformation.

During early childhood, the dominant frequency in the brain is theta (roughly 4-8 Hz) which is the brain wave state associated with the easy absorption of experiential information. As the child matures from infancy to adulthood, the dominant frequency shifts from the relatively low theta range into the faster alpha-beta range. This process is reflective of a natural trend towards order and higher levels of organization in the developing brain. When the child experiences a traumatizing event or situation, the memory and the associated emotional charge are stored against the particular EEG pattern that was active at the time. This is something that is referred to as state dependent learning and retrieval ( Cowan, 1993). Thus, early childhood experiences are associated with slow wave indices of storage. And so, as the dominant frequency in the developing brain moves into the higher ranges, these experiences are buried and then absorbed by the unconscious. In other words, all of the coping strategies that were created to deal with the emergency of childhood along with all of the inherent inferences about self worth and self concept are effectively congealed and sealed over as the dominant frequency moves into the higher bands. Emotional pain, being energetic in nature, is not destroyed but is instead buried along with everything else. This emotional energy will tend to re-emerge later on when the person experiences a situation or event that strikes a similar emotional tone or chord. There appears to be a kind of partitioning-off of information accessibility within the brain, where information that was learned in one state of consciousness becomes irretrievable while in another. Therefore, in order to access this buried material, one must re enter the state in which it was originally experienced (-i.e. the theta state).

The other (somewhat more accepted) explanation involves the relationship between excitatory and inhibitory neural activity in the brain. The brain operates via 2 neural transmission strategies: excitation and inhibition. The 2 neural systems that are involved are antagonists of one another. Where the excitatory system does exactly that- "excite" the individual neuron resulting in impulse transmission, the inhibitory system prevents transmission -thereby keeping the excitatory system from getting out of control. These 2 complimentary systems are driven by different sets of neurotransmitters: dopamine, serotonin, acetylcholine and norepinephrine for the excitatory system; GABA (gamma amino butyric acid) for the inhibitory system. There is well over 200 times as much GABA present in the brain than all of the excitatory neurotransmitters combined) -which provides a rough indication of the importance of neural inhibition in the brain (Cummings, 1992). There are specific inhibitory nerves called Purkinjie cells originating in the cerebellum. The pyramidal cells in the cortex have both inhibitory and excitatory projections attached to them to either influence discharge or inhibition of the nerve cell.

The evolution of inhibitory activity in the brain involves the need for neural transmission specificity. This specificity is achieved through something called lateral inhibition. Lateral inhibition helps to keep a neural impulse on track so that it lands on the correct location on the sensory cortex -otherwise you end up with a kind of neural impulse cascade effect. For example, when someone sticks your toe with a pin the impulse travels up the ascending nerve pathways where it arrives at the medulla and thalamus and on to the somatosensory cortex. In order to prevent a wave of runaway neural discharges (resembling a "geometric progression"), inhibitory impulses must come into play. Without it, a pin stick on your toe might feel like diving into a swimming pool full of needles -where the entire sensory cortex would light up.

Schizophrenia, for example, can really be considered a disorder of inhibitory regulation. When a schizophrenic moves his or her arm, different parts of the cortex show an increase in activity, something not seen in normal persons. In addition, the ordinary inhibitory buffers that exist between the speech formulation area (Brocas) - left side anterior and the auditory processing center (Werneckes) -left side posterior , do not exist or are at least inefficient in schizophrenics. Thus ones own speech formulation is experienced as a voice from the outside. This suggests an insufficient and unstable inhibitory system.

And so, when the inhibitory system is taken off line, the excitatory system is essentially free to run amok -causing the brain to make connections not usually associated with normal waking consciousness. Some familiar examples of situations that cause inhibitory system shut down are LSD trips, hypoxia and near death experiences. In all of these cases, the person experiences similar sensations and feelings such as: being flooded by vivid childhood images, seeing intense white lights, experiencing sensations of movement through a tunnel and visions of "heaven", etc. One can also experience something called "synesthesia" -which is a form of sensory spillover (e.g. smelling colors and seeing sounds). Most of the above situations involve oxygen deprivation, which can trigger inhibitory nervous system shutdown. Critically low levels of oxygen appear to affect the temporal and frontal lobes first which tends to explain the feelings of dissociation that often accompany hypoxia, high G loads (high rates of acceleration) and near death experiences. Similarly, the person undergoing alpha -theta enhancement training can often experience these same sensations -although they are usually considerably less intense.

Cortical surface potentials (what we collectively refer to as the EEG) are actually mediated by the thalamus and the brainstem. The thalamus is a part of the forebrain that serves as the "pacemaker" for and primary orchestrator of EEG activity in the cortex. In essence, inputs from the brainstem, relayed through these thalamocortical circuits, serve to desynchronize the low frequency activity in the cortex thereby pushing the dominant frequency into the higher ranges during normal waking consciousness. This increased input to the cortex tends to prevent the associations that would lead to an integration of traumatic memories from occurring. The normal chatter of everyday consciousness may serve as a buffer which inhibits entry into awareness of these traumatic or troubling -subcortically stored memories. Alpha- theta training suspends (or reduces) brainstem and thalamocortical regulatory input thereby allowing the brain to make the associations and connections that it doesn't make ordinarily. This state of "disinhibition" creates a window of opportunity for the stored subcortical material to manifest and ultimately become integrated into consciousness. Reducing this sensory input (via alpha theta enhancement training) essentially creates a stimulation void in the cortex thereby allowing an opportunity for unconscious/subconscious material to be experienced. A/T training creates a state of "relative disinhibition", as M. Barry Sterman puts it, which then allows (ordinarily) suppressed associations to occur.

In the spring of 1991 a study was published that had massive implications for the future of psychotherapy. A controlled study was conducted testing the effects of alpha- theta EEG biofeedback on a group of Vietnam veterans with post-traumatic stress disorder (Peniston, Kulkosky, 1991). The majority of those in the experimental group (80%) showed dramatic improvement in their symptoms (-i.e. a marked reduction in anxiety provoking flashbacks and nightmares). Of the 15 persons in the experimental group, only one had been re-hospitalized over a 2 year follow up as compared to the control group where all 14 had to be readmitted to the hospital on two or more occasions. In addition, the experimental group showed significant improvement on the Minnesota Multi-phasic Personality Inventory (MMPI) particularly on the SC (schizophrenia), D (depression) and PD (psychopathic deviate) scales. No such changes occurred on the MMPI scores of the control group. More recent results have tended to confirm these initial findings (White, 1994). This research, as well as additional clinical evidence compiled since, tends to challenge the long held notion that fundamental aspects of personality are "hard wired" and hence unchangeable. When used in conjunction with other therapies, brain wave training seems to create an internal climate that is conducive to personal transformation.

The case of RK:
RK, an aspiring actress who supported herself through her work as a sales clerk, came into therapy due to relationship difficulties and depression. She had a long history of very quickly becoming involved with someone only to have the relationship end, sometimes violently, after only a few months. Her family background was characterized by parental divorce, violence, sexual abuse and alcoholism which imbued the world of her early childhood with a frightening atmosphere of unpredictability, chaos and crossed boundaries. As an adolescent she was in and out of trouble at school due to disruptive behaviors and substance abuse. As an adult she has managed to recreate a similarly threatening environment for herself in both her personal life as well as her professional life as a struggling actress. The unpredictable and sometimes brutal nature of show business causes her to re-experience her childhood feelings of powerlessness and vulnerability causing her, in turn, to seek the perceived sanctuary of a relationship in order to feel safe and "grounded". Due to the impulsive nature of these attachments, the relationships were generally quite dysfunctional and fraught with instability and violence -averaging about 3 months in duration. Paradoxically, it was the volatile and impulsive nature of these relationships that provided a certain familiarity for her, which she experienced as a form of security (albeit a tenuous one). After several months of psychotherapy, she was still having relationship problems and was still quite depressed and so decided to try EEG biofeedback. Although the training was offered to her early on, she stated that she didn't wish to have therapy with a "damn machine". Psychotherapy was continued along with the training. Within the first few training sessions she began to experience some of her buried feelings of anger regarding the physical and sexual abuse by other family members as well as the lack of protection she received by her mother. These reactions were brief and not accompanied by the usual explosive histrionics. The reason for this (as described by several patients) seems to be that EEG training allows one to experience the feelings of anger and hurt from the position of the empowered adult witness . This is different from the typical flashback where the victim re experiences the powerlessness of the helpless child along with the memories -thereby triggering a panic reaction. Such persons are, in effect, re traumatized by their own memories. After approximately ten sessions RK's depression had lifted completely and she was noticeably more energetic as well as much less reactive with other persons, including myself. She had broken off her relationship with her latest boyfriend and for the first time in her life felt completely satisfied not to be involved with anyone. It was almost astonishing to hear her say that for the first time in her life she finally knows who she is. She had become the significant other in her life.

The case of LC
LC was an aggressive corporation executive who hailed from a very strict, military upbringing where feelings were perceived as a sign of weakness and therefore, not allowed. The father's credo was "kick ass, take numbers, then kick their ass again -just to be sure". Although the father took pride in his son's accomplishments, there was no tolerance for his feelings of hurt or anger. In order to please his father, LC had to learn to "kill' with efficiency whether on the football field, the battlefield or the marketplace. This required a massive denial of feeling. In order to be aggressive in this way, one needs to reduce all living beings to inanimate objects to either be controlled or crushed. When a person is cut off from the pain of their own inner wounds, empathy is virtually obliterated and if a person exercises their denial defenses enough, they become quite muscular and tend to be used in broad strokes across the panorama of their life. Thus, women and wives become sex objects and possessions, and children become extensions of the self. Needless to say, LC's family life was an emotional shambles. His children were ready to leave home and his wife was talking about divorce. And so, at the age of 55 he came into treatment because he was depressed at the perceived "loss of control" over his life. After several months of therapy and brain wave training he was able to experience his feelings of hurt and anguish at having lost his childhood at the hands of his domineering and controlling father. He stated that for all of his efforts to please and impress his father, he never really felt loved by him. He was even able to talk in depth about the deep feelings of insecurity and inadequacy he would experience in the presence of his father. And because LC was able to experience his feelings of pain and discovered that he would not be destroyed by them, the need to have absolute control over all things in his immediate universe began to dissipate. He was even able to express a certain degree of grief over the hurt he had inflicted on others and understood that his ruthless behavior was a manifestation of the rage he felt for his father. He began to listen more to his family and became markedly less concerned about "being right". There was also a perceptible shift in his overall energy level. He took up aerobics and began to meditate on a regular basis. His behavior during psychotherapy sessions changed as well. Previously he would attempt to control the course of therapy by discussing and debating various concepts in the field of psychology. I would have to remind him that we were not here to play "College Bowl". Following the training, he was much more comfortable talking about what he referred to as "more pertinent issues".

Dr. Deepak Chopra, author and endocrinologist tells us that " The process of transcending, or 'going beyond', detaches the mind from its fixed level and allows it to exist, if only for a moment, without any level at all. It simply experiences silence, devoid of thought, emotions, drives wishes, fears or anything at all. Afterward, when the mind returns to its usual pitch, it has acquired a little more freedom to move."
Psychologist Nancy White states that " With alpha-theta training, we are working with an interactive system of mind/brain, body, psyche, spirit." "...in this state much of the ego is relinquished (- i.e. the adapted self and its defenses). The autonomic nervous system's bracing is loosened creating what might metaphorically be called a state of suspended animation. We move into the emptiness of space where we are conscious and aware but not aware of being aware until we return to the thinking mode. It is here that we encounter the non local reality where we transcend ordinary space and time as we know it, a world behind the scenes that is beyond the world of objects and persons. In this state, there is often an experience of a 'pure being state' with no consciousness of a body or life 'drama' ".

Entering these deeper states of consciousness, with its access to areas of emotional repression, creates a window of opportunity that allows us to experience and integrate these unprocessed energies of psychic pain. Virtually all children experience some form of emotional trauma in their lives leaving them with these dislocated psychic energies and unresolved core issues around which form a person's beliefs, self concepts, coping strategies and emotions. When these core issues are addressed and resolved by giving citizenship to split off feelings of pain, there is a shift in all of these areas towards self acceptance, health and well being. The process of psychotherapy is then expedited since the person has been allowed to experience a state of consciousness that doesn't require the deployment of defenses, thus creating a medium in which old programming can be released .

References

Chopra, D. (1993). Ageless Body, Timeless Mind. New York: Harmony Books.

Comings, D.E., (1990). Tourette Syndrome and Human Behavior, Hope Press, Duarte, CA

Cowan, J. (1993). Alpha-Theta Brainwave Biofeedback: The Many Possible Theoretical Reasons for Its Success. Biofeedback, Vol. 21, No 2, pp. 11-16.

Lowen, Alexander, MD. (1985). Narcissism. New York: Collier Books.

Peniston, E.G. and Kulkosky, P.J. (1991). Alpha-Theta Brainwave Neurofeedback for Vietnam Veterans with Combat- Related Post- Traumatic Stress Disorder. Medical Psychotherapy: An International Journal 4:47-60.

White, N. (1995). Alpha-Theta Training for Chronic Trauma Disorder, A New Perspective. Megabrain Report, Vol. 2, No 4, pp. 44-50.