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Why I Added Infraslow Frequency (ISF) Neurofeedback to my Psychotherapy Practice

Ray McGarty MS, MLADC, LCS

A number of things quickly become evident when you work with clients who have addictive disorders. First, you are confronted with the profoundly impaired self-regulatory processes which are a result of autonomic nervous system dysregulation. Secondly, you are faced with the fact that there is a very high prevalence of developmental trauma manifested by these clients. Finally, there is a very high rate of relapse that is clearly related to the above two issues.

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Substance use disorders and trauma, particularly developmental trauma, coexist in such prevalence that researchers consider the disorders to be “functionally linked.” That functional linkage is driven primarily by common brain mechanisms that play a central role in profound autonomic system dysregulation, and are highly sensitized to respond intensely to stress and psychoactive drugs. Ouimette et al, in summarizing the related research, stated:

By the time of treatment entry, the symptoms of substance use disorders and PTSD are…functionally linked…each disorder ultimately exacerbates the other…in the context of substance abuse treatment, PTSD treatment is expected to play a crucial role in maintenance of remission…the total number of PTSD counseling sessions…emerged as the single most significant predictor of remission [in a substance use disorder treatment group of clients]…

Teicher has written about the lifelong impact of early life developmental trauma, defined as chronic childhood abuse, neglect, or humiliation. He states that one is left with:

…physiological dysregulation leading to dramatic shifts between extreme states of hyper and hypo arousal, deficits in interpersonal relatedness, affect regulation, distress tolerance, ability to distinguish between internal and external reality, mindful awareness, ability to self sooth, tolerance of aloneness, regulation of self-hatred, shame and guilt, impulse control, ability to reflect rather than react reflexively, ability to mentalize (imagine how others might think or feel, and that such thoughs and feelings may be different form one’s own..

Schore also summarized the long term effects of early life attachment related developmental trauma as:

…enduring developmental impairment in critical dysfunctions of right brain…when stressed, show severe deficits in preattentive reception and expression of facially expressed emotion, the processing of somatic information, the social environment, the communication of emotional states, the maintaining of interactions with the social environment, the use of higher order defenses, the capacity to access an empathetic stance and reflective function, the psychobiological ability to self-regulate, either by autoregulation or interactive regulation, and thereby recover from stressful affective states…these dysfunctions represent pathological alterations of implicit, unconscious mechanisms…

When a client has a history of developmental trauma, which obviously predates psychoactive substance use, the substance use is a solution to the above deficits, a solution that becomes its own problem and ultimately worsens the original dysfunctions. If the individual tries to get clean and sober, all of the trauma related material begins to rapidly emerge. This usually triggers the person back into active substance dependence. To succeed, these clients, first and foremost, need an effective way of addressing the intense autonomic dysregulation that drives the symptoms. Pharmacological interventions may lessen symptoms in the short term, but since drugs cannot attenuate the underlying dysregulation, and in fact, over time, will often contribute to a further worsening of the client’s condition. These clients are significantly compromised neurologically, and manifest so many symptoms, that prescribed drugs just further complicate treatment, with the prescriber often quickly adding multiple drugs (and diagnoses), often to counteract the side effects of the initial prescribed drugs.

Various psychotherapeutic approaches are also limited in their usefulness in providing physiological stabilization, primarily due to the fact that cognitive and affective capacities are significantly impaired. In my own search for ways to address this profound autonomic dysregulation, I have pursued training in clinical hypnosis, cognitive behavioral therapy, psychodynamic therapy, EMDR, sensory motor psychotherapy, and numerous other approaches, all with limited results. Due to the intense bottom up hijacking by overresponsive, sensitized brain stem and limbic mediated brain areas that override top down, frontal and prefrontal executive regulating capacities, most traditional therapies are limited when used for stabilization, the first task in treating these clients. Right brain, bottom up emotional processes dominate and overwhelm these clients, in most cases, quickly precipitating relapse. Those that do not relapse, often are left to resort to self destructive defensive behaviors, substitute compulsions, or the numbness that often comes with certain prescribed medications.

When first introduced to neurofeedback I was excited about the possibility of directly impacting the brain in ways that would stabilize a client’s dysregulated autonomic system. I began to explore various approaches, power training, alpha-theta, zscore, HEG, etc. All these approaches proved somewhat helpful with this clinical population, however, ISF, from the moment I began using it, has consistently produced the most significant physiological shifts in my clients. As their autonomic system becomes more regulated, as evidenced by decreasing sleep problems, nightmares, flashbacks, drug cravings, and responses to trauma related triggers, they are more able to exert top down control of affective and emotional responses. This leads to an ability to respond reflectively rather than reflexively, which is a clear indication of both the quieting of the autonomic nervous system, and the improvement of the brain’s frontal executive function capacities. These clients become much more available and able to participate in psychotherapy. ISF has become the primary modality I use to bring about stabilization in work with a client population that is plagued by dramatic autonomic dysregulation.

I am first, and primarily a psychotherapist. My point in doing this posting is to speak to other therapist working with trauma and/or substance use disorders. ISF, no doubt, has improved my clinical effectiveness. For a while it consumed all of my clinical time, to the point where I was doing very little psychotherapy. Numerous colleagues began sending clients for the stabilization I was providing with ISF, and the neurofeedback practice swamped me. I have since brought on some staff to help with the neurofeedback, so that I can maintain a balance between continuing to explore the capacities of neurofeedback, and in particular ISF, and psychotherapy. ISF neurofeedback and psychotherapy are not distinct and exclusive of one another, since ISF, more than my experience of other forms of neurofeedback, demands clinical skills. Clients usually have physiological and emotional responses from the beginning of their treatment, necessitating interpretation and interactive framing for the client. These reactions are also critical to identifying treatment decisions from session to session. As a result, becoming an ISF practitioner has been a comfortable fit for me as a therapist. It has also become the single most important tool I use for the majority of my clients.

Ouimette, P. and Brown, P. Trauma and Substance Abuse
Schore, A. Affect Regulation and the Repair of Self
Teicher, M.H. Sticks and Stones and Hurtful Words: Relative effects of various forms of childhood maltreatment.

Rewiring the Brain

Mark Llewellyn Smith LCSW, BCN, QEEGD

Imagine for a moment your sessions with developmentally traumatized clients. What words come to mind? Challenging? Frustrating? Overwhelming? What if you had a tool that made each session more productive? What if this tool promoted less reactivity, more emotional stability, better sleep, and more flexibility in the way your client reacted to triggers to her past? All this is possible through an intervention that has been hiding in plain sight for the last 50 years called neurofeedback.

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But saying neurofeedback helps with trauma is like saying medication helps with illness. Neurofeedback like medication is a big category with many different kinds of interventions. Most “traditional” neurofeedback approaches apply a conditioning paradigm to the client and after several sessions behavioral change begins to take place. Infraslow Neurofeedback Training (ISF) is especially helpful with trauma clients because it is an immediate state altering intervention. The effect is more rapid than other neurofeedback interventions. The client is moved from an uncomfortable affective state to a more focused and relaxed state in session. This is possible due to the behavioral impact of the Infraslow frequencies within the human cerebral cortex.

The infraslow frequencies, defined as < 0.1 Hertz, have been identified in neuroscience as a coordinating rhythm responsible for the organization of neuronal networks that play an integral role in many forms of human behavior. Recently evidence has accumulated that delineates a primary role for the Infraslow Rhythm and physiological systems that include the relationship between the heart and the brain, the coordination of the blood brain barrier, and information flow between the stomach and the brain (Bao et al., 2015; Grooms, 2015; Gudmand-Hoeyer, Timmermann, & Ottesen, 2014; Hashimoto et al., 2015; Hiltunen et al., 2014; Lecci et al., 2017; Tso et al., 2017; Zanatta et al., 2013). It should not be a surprise then that research has also confirmed the Infraslow band’s significance to the Autonomic Nervous System (ANS). This organ system has central significance to human behavior, especially trauma.

The central organ system of the ANS is directed by the Hypothalamus. The earliest exploration of Infraslow frequencies identified their behavioral centrality in the reaction to threat in animal research(Aladjalova, 1957). The Hypothalamus of rabbits slowed down in frequency but increased in amplitude as a response to “wounding.” More recent work has associated these slow processes with hormone concentrations related to the Hypothalamic-Pituitary-Adrenal axis (HPA) in humans. Since the HPA axis maintains basal and stress related homeostasis of the central nervous system, cardiovascular, metabolic, and immune functions; dysregulation of this axis is implicated in many behavioral, circulatory, endocrine/metabolic, and immune disorders. The HPA-axis coordinates the fight, flight or freeze response to threat in mammals. Researchers have noted the similarity of HPA hormone secretions to the Ultradian Rhythm of one to three times per hour (Gudmand-Hoeyer et al., 2014).

This corresponds with the so-called “minimal model” of the HPA-axis that considers the Ultradian Rhythm (Infraslow Rhythms associated with human behavior) an inherent element of the Autonomic Nervous System. In plain terms these slow rhythms are the organizing nexus of the HPA-axis/Autonomic Nervous System. These frequencies correspond to the lowest third of the training band in ISF neurofeedback. The ability to train these slow frequencies in neurofeedback has proven very useful in clinical populations whose salient dysregulation involves the HPA-axis. Operantly conditioning the fear response in PTSD, RAD, anxiety and depression is a useful tool for many of our clients, particularly those who cannot or will not use medication(M. L. Smith, 2013; M. L. Smith, Collura, Ferrara, & de Vries, 2014; M.L. Smith, Leiderman, & de Vries, 2017).

Recent work by Ledoux (LeDoux & Pine, 2017) suggests that the feelings of fear and anxiety are reactions to threat but are not created by it. That is, one can respond to threats in the environment without the feeling of fear or anxiety. This is how elite athletes are able to respond to potentially injurious activity with elegant athletic control that avoids the threat without the affect of anxiety or fear. Conversely, as all therapists are acutely aware, clients may experience fear or anxiety in the absence of an objective threat. This happens because the experience of anxiety and fear are mediated in

different brain circuits than the reaction to fear. There is not one “fear circuit” but in fact there are two. One regulates a physiological reaction to threat and the other determines the affective response. These systems can function independently from one another or in tandem. How they are coupled and decoupled explains “normal” from pathological behavior.

In clinical practice, we use Infraslow neurofeedback to calm the reactivity of the ANS so that traumatized clients are less vulnerable to triggers to their past trauma. But we are also able to help those clients who are Dysautonomic or Alexithymic to become aware of their emotions through the reintegration of limbic and sensory networks in cortex. More recent research has defined the Infraslow frequencies a the “superstructure” of the brain that regulate both the integration within and decoupling between concurrently active neuronal networks(Palva & Palva, 2012). We are able to optimize the interplay between the two fear circuits with the processes of the larger limbic and sensory networks. So for instance, a recent client was able to identify the slight facial flush, chilling hands, and butterflies in her stomach as the first stages of low level anxiety in a cue to her past trauma. This allowed her to function successfully in a high stress atmosphere. In the past, largely unaware of these early, subtle cues, she would only become aware of her developing response to threat as she succumbed to a panic attack.

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Aladjalova, N. A. (1957). Infra-slow rhythmic oscillations of the steady potential of the cerebral cortex. Nature, 179(4567), 957-959.

Bao, Y., Pöppel, E., Wang, L., Lin, X., Yang, T., Avram, M., . . . Zhou, B. (2015). Synchronization as a biological, psychological and social mechanism to create common time: A theoretical frame and a single case study. PsyCh Journal, 4(4), 243-254. doi:10.1002/pchj.119

Grooms, J. K. (2015). Examining the relationship between BOLD fMRI and infraslow EEG signals in the resting human brain. (M.S. Masters), Georgia Institute of Technology.

Gudmand-Hoeyer, J., Timmermann, S., & Ottesen, J. T. (2014). Patient-specific modeling of the neuroendocrine HPA-axis and its relation to depression: Ultradian and circadian oscillations. Mathematical Biosciences(0). doi:

Hashimoto, T., Kitajo, K., Kajihara, T., Ueno, K., Suzuki, C., Asamizuya, T., & Iriki, A. (2015). Neural correlates of electrointestinography: Insular activity modulated by signals recorded from the abdominal surface. Neuroscience, 289(0), 1-8. doi:

Hiltunen, T., Kantola, J., Abou Elseoud, A., Lepola, P., Suominen, K., Starck, T., . . . Palva, J. M. (2014). Infra-Slow EEG Fluctuations Are Correlated with Resting-State Network Dynamics in fMRI. The Journal of Neuroscience, 34(2), 356-362. doi:10.1523/jneurosci.0276-13.2014

Lecci, S., Fernandez, L. M. J., Weber, F. D., Cardis, R., Chatton, J.-Y., Born, J., & Lüthi, A. (2017). Coordinated infraslow neural and cardiac oscillations mark fragility and offline periods in mammalian sleep. Science Advances, 3(2). doi:10.1126/sciadv.1602026

LeDoux, J. E., & Pine, D. S. (2017). Using Neuroscience to Help Understand Fear and Anxiety: A Two-System Framework. American Journal of Psychiatry, 0(0), appi.ajp.2016.16030353. doi:doi:10.1176/appi.ajp.2016.16030353

Palva, J. M., & Palva, S. (2012). Infra-slow fluctuations in electrophysiological recordings, blood-oxygenation-level-dependent signals, and psychophysical time series. Neuroimage, 62(4), 2201-2211. doi:

Smith, M. L. (2013). Infra-slow fluctuation training; On the down-low in neuromodulation. Neuroconnections, Fall.

Smith, M. L., Collura, T. F., Ferrara, J., & de Vries, J. (2014). Infra-slow fluctuation training in clinical practice: A technical history. NeuroRegulation, 1(2), 187-207. doi:doi:10.15540/nr.1.2.187

Smith, M. L., Leiderman, L., & de Vries, J. (2017). Infra-slow fluctuation (ISF) for autism spectrum disorders. In T. F. Collura & J. A. Frederick (Eds.), Handbook of clinical QEEG and neurotherapy.

Infra-slow Fluctuation Neurofeedback—A Novel Experience

Thomas Collura, PhD

just completed 3 days learning and experiencing ISF (infra-slow fluctuation) neurofeedback, in a workshop presented by Mark Smith.  Both the learning experience and the neurofeedback process were eye-opening, to say the least.  The theory has to do with cortical activation, shifts in parasympathetic response, and achievement of a new mental state.  What I found is that, by listening to a simple tone that told me when my “infra-slow” brainwaves shifted one way or another, I could be led into these states effortlessly.

ISF is not only operant conditioning, it is pre-operant conditioning.  In “traditional” neurofeedback, information is presented to the brain with the expectation that the brain will discern the difference between states (generally “reward” and “no reward”), and thus learn to self-regulate.  However, this approach assumes that the brain is ready to learn, and is interested in learning.  I am not referring to the individual thinking he or she is interested in learning.  I am referring to the fundamental ability of the brain to respond to stimuli in a manner that facilitates self-control.  In many cases, the brain is not ready, or even interested, at a fundamental level, in learning.  We call such situations being “stuck.”

Stuck patterns can involve power, power distributions, connectivity, or other aspects of EEG properties.  There is a common underlying mechanism to the control of variability and modulation, and this mechanism involves not only neurons, but also glia, other supportive tissues, and the entire body.

The initial experience, with settings of 0.0001 to 0.0030 Hz, was relaxing, yet alert.  The tone replaced a mantra, so that a meditative state could be achieved with external focus on the sound.  The cadence of the feedback sound became familiar, and its effects were positive.  When the frequency band was changed to 0.0001 to 0.0035, a very different experience ensued.  Within 30 seconds, I was aware that this was not the same cadence, or familiar pattern that I had just experienced and appreciated.  After less than 2 minutes, my left thigh began to twitch once, then twice, then again.  I decided this was enough of .0035 for me.  I had my partner switch back to the 0.0030 setting and restart.  Again, within 30 seconds, a profound change was apparent, and I once again experienced the familiar and reassuring cadence that I had come to recognize.

Neurofeedback at infra-slow frequencies does not mean that a cycle occurs with a very long period, as has been suggested.  This criticism is based on ignorance of the fundamental signal dynamics and principles, combined with never having seen the practice in action.  In reality, these filter settings serve to block out all of the cyclic activity above a certain range, but still pass the minute fluctuations that arise due to the slowest regulatory processes.  During feedback training, a sound is heard that is either lower (signal going down) or higher (signal going up), as the ISF slgnal fluctuates ever so slightly.  Changes as small as 0.01 microvolt can be seen, and the fluctuations are continuous.  A signal may change 1, 2, or even more times per second, or it may hold on for just a few seconds.  If it does not change at all, then the brain is “stuck” and little flexibility is possible.

In order to optimally control, or self-regulate, this signal, my experience was that when the fluctuations got as small as possible, in my case as low as 0.05 microvolts in shift, or smaller, then the modulation was maximally responsive.  By keeping brain activity poised on a knife-edge between states of activation, it experiences what it is to be in control, and to achieve balance.  What seems to come with this is a sense of harmony, peace, and as one participant put it, “feeling like I’m the person I’m supposed to be.”

Individual responses are finely tuned to the ISF frequency bands used.  Increase the frequency and there will be more activation, agitation, or as I experienced, even a bodily sense of unrest and some motor activation.  Lower the frequency, and reduced, even depressed, states can be fostered.  This is what gives ISF its power in a practical setting, and makes it important that practitioners do not simply follow a “plug and go” approach, but remain close to their clients.

ISF appears to be an ideal entry point for mental health professionals who are truly interested in their clients, and are used to working with client reactions, individual differences, and idiosyncrasies.

Mark has an excellent article online at: