Episode 12 – Neurofeedback therapy — with Andrew Nicholson, PhD

MIND BEYOND THE MISSION EPISODE 12: NEUROFEEDBACK THERAPY WITH DR. ANDREW NICHOLSON

Laryssa

Here we are again, recording another podcast episode which I’m pretty excited about, where you and I are in person this time, Brian, which is always good.

Brian

And I don’t have to talk about relationships today (laughs).

Laryssa

That’s right. Well, you never know where this is going to go. Before we get started with today’s episode, what I do want to say is we’re starting to get some feedback from listeners through email and just personal conversations, and we really appreciate that because it lets us know that we’re on the right track, that we’re talking about things that resonate with the community, with people who work with the Veteran and Family community. I think I just want to ask if you’re listening to the episodes and you’re appreciating them, let us know. Even on whatever platform you’re listening, hit like, put in a comment to start a conversation, because I think by the more that you do that, it’ll eventually start to reach more Veterans and Families who might find interest in the episodes. Yes, we’re hoping you’ll hit the like button.

Brian

We’ve got one of our specialists here with us today, Dr. Andrew Nicholson. Sometimes I get a laugh when I look at folks like him. I think back to myself being five, roaming around the playground, “I want to be a police officer. My buddy wants to be a fireman.” Then there’s Andrew: “I want to measure the responses of the amygdala.” How do you get into the job that you’re in, and when did you know you wanted to work in that field?

Dr. Andrew Nicholson

Yes, that’s a great question. First of all, thank you for inviting me to the podcast. I’m really excited to be here this morning. Yes, I think I, well, actually, when I was a kid, I wanted to be a chef, actually. I loved cooking. I loved the social component of that and cooking for my family. I’m the youngest of four. I loved that. Then I was really interested in biology and medicine. I think when I went into university, those were the only options I really knew of, medicine, going to medical school, or being a biologist and being a scientist thing. Then when I was at Western University, I was introduced to more the field of psychiatry and neuroimaging through a couple of classes there when I started working with Ruth Lanius at Western University.

It was so exciting because we, to be frank, don’t know that much about the brain and how mental illness can manifest and how we can actually, more importantly, help people heal and treat people with mental health conditions, right? It was a very exciting, I think, field to go into. When I started, I was surprised at how much meaning I derived from that work because you can really see the benefits of your research and how it helps people. Yes, I just think it feels like a hobby as well. I enjoy it every day. I’m excited to go to work every day, which, yes, it’s a good sign.

Brian

Five years ago, I didn’t know what neurofeedback is. All I know about it is by asking you. I think that, but to some degree, that’s the strength of our institute. That’s what we wanted, right? We wanted to bring in people with talent and then have Veterans and Family members be able to show them what we know and blend the two and get stuff done. A lot of people out there probably be Googling right now trying to figure out what it is, so help them out. What’s the shortest definition you could give that people could take out of this?

Andrew

Yes. Neurofeedback, just taking one step back, we know that the brain has adaptive shifts when exposed to things like trauma, right? It’s adaptive for certain areas of the brain to become very hyperactive for these fight-or-flight responses and for maybe the more cognitive, rational parts of the brain to be shut down. Because when you’re under a threat, you don’t have five seconds to think about something. You need to make a quick decision. The more reptilian brain structures, we call them, so the deeper brain structures that are really concerned with fight or flight and survival are coming online.

Sometimes in the aftermath of trauma, in the context of PTSD, people can get stuck in that hypervigilant state. We know the brain is capable of healing itself and moving towards a state of psychological safety if just given the right stimuli. This is what we try to do with neurofeedback. As I mentioned, we know some areas of the brain are showing either too much or too little activity. We measure those brain responses in real-time with different neuroimaging methods, and we present that to people as either a visual display, this can be a gaming interface thing, like a video game for your brain thing, or it can be an auditory stimuli. The point is people try to learn strategies that work best for them to control that signal and either decrease or increase activity in certain regions.

Brian

When we spoke earlier, you mentioned, I was expecting to hear that there can be hyperactivity. Obviously, I think for myself, what I look back at as being the appropriate level of awareness in a rough place is no longer the right amount of awareness if I’m in Surrey or Ottawa. That’s what’s going on. I was a little shocked to hear though that sometimes your work shows that people are hypo. They’re not having what we would consider the right amount to that effect. I wasn’t expecting to hear that. How common is it?

Andrew

Yes, so it’s interesting because I think this speaks to some of the difficulties in treating post-traumatic stress disorder because we know it’s so heterogeneous. There are many different ways someone can present with PTSD, over 600,000 different ways based on DSM-5. That’s very micro. On a more macro level, we have even just two different subtypes of PTSD, dissociative subtype and the more classic presentation. What you mentioned now, this hypoactivation and a shutdown of emotion centers, this is more the dissociative subtype. People who develop this subtype of PTSD are more likely to have more chronic trauma exposure earlier in life, childhood trauma. It’s more common among males as well. This is where instead of this hypervigilant fight or flight hyperarousal response, dissociative subtype also has this emotional shutdown, emotional numbing, things like depersonalization where someone becomes disconnected from their body, or derealization where they feel like their environment is dreamlike or unreal.

This is that shutdown of emotion centers that we see actually in the brain. It’s related to the emotion regulation errors of the brain coming online too much and really shutting down the emotion centers

Laryssa

When we were prepping for the podcast, I know for myself, there’s a couple of goals I’m hoping to achieve here. Number one, I said to you is that you’ve broken every stereotype of a researcher that I had. You even mentioned a bit in your introduction about wanting to improve outcomes for people, like a lot of what you’re talking about was altruistic. I just wanted people to understand that, particularly when we’re talking to Veterans and Families who I think know so little about research and researchers. The other thing I think I’d like Veterans and Families to understand is there seems to be more acceptance for physical ailments that happen below the neck.

You’re talking a little bit with neurofeedback, almost about the brain regenerating and rewiring in some ways. When people are talking about the brain rewiring or the neuroplasticity and the fact that it can be measured and observed through neurofeedback is exciting for me because I’m hoping people will lessen the stigma and be interested in treatments such as neurofeedback and the type of work that you do as well.

Andrew

Yes. I think actually our neurofeedback studies, a lot of patients who have participated in that clinical trial actually report that, yes, that study gave them a lot of hope because the brain is plastic and it is capable of healing itself through different treatment interventions, particularly when they’re neurobiologically informed, I think. A couple of points I wanted to touch on. I think, yes, neuroimaging particularly, I think, is a great tool to help expose those invisible wounds that can be post-traumatic stress disorder. Some people maybe want to participate in our neuroimaging studies when they first get in contact with us. We’re building trust and it can be seen as maybe a stigmatizing thing of studying someone’s brain in the context of mental illness.

Actually, when we have a further discussion with participants and when they participate in our studies, they actually find the opposite. It can be quite validating, I think. It’s quite humbling and really nice to see that a lot of our participants are extremely motivated to participate in our study. They find it— it’s very important for them to be able to contribute and help other people who are suffering from something similar, especially when many of our clients have tried many different treatments and it hasn’t worked for them, unfortunately. They feel really strongly about that.

Ailments below the neck have somehow more-people see that as more valid thing. Through neuroimaging, I think we, and by studying the brain, we could help reduce stigma of mental illness and better understand it. Then the third component is actually, especially in PTSD, it’s not just about the brain and the mind. It’s the brain-mind-body connection. That’s what we’re also expanding on in a couple of our new treatment interventions is incorporating bottom-up approaches to treatment and how can we regulate someone in their body and help people re-inhabit their body in the aftermath of trauma.

Brian

One of the things that I find promising is I think a lot of this work can change stigma from a different point of view, the self-stigmatizing side of it, right? I know for me and a lot of other folks I’ve talked to, when you first hear about mental health, you think you’re going to be in a room on an oversized couch, a bunch of weird plants, and some guy asking you to talk to you about your feelings. While that has its role, it gives this idea that it’s not measurable, it’s all subjective, it’s just, something you can’t put your finger on. Yet there we were the other day, and I’m wearing some of the equipment that Atlas has invested in, and I’m watching on the screen, and I’m not going to pretend to know what the lights mean and what the graph means, but lights and graphs means you’re measuring something. There is something measurable here. I don’t know if everyone in the community knows that because I certainly didn’t.

Laryssa

It makes it less invisible. That’s what you were saying about people feeling validated. Theoretically, I’m thinking if you can look at it, it actually is visible and it validates that experience more. I think you were, Brian, where you were going the other day was like, if you had the equipment on, Brian, Andrew, as an example, and Brian was triggered or stimulated by whatever thing, an image or something that you provide without him telling you, can that?

Brian

It’s also related to what you just said about neck down, right? Torn ligament shows up, broken tibia shows up, we’ve got the scales in the way of measuring that. I think there’s a belief that everything above the neck is just arbitrary, just an idea or a feeling. I think people might actually take something out of going, “Okay, this is being measured.” One of the other things that we talked about after speaking to you last is when you are talking and you’re explaining these processes to me, I’m thinking of a completely other form of therapy than you are.

One of the things you’re explaining is, “Well, we’re going to measure and then we’re going to see how you react. Then we’re going to see if we can get the person’s mind back to center in a self-controlled way.” I hear equine therapy. I hear the dog program. When you speak to people that have gone into those kinds of programs, the handlers will tell you, “Until the horse accepts you, this ain’t progressing.” The horse makes you get back to center. Dog handlers, Vets with dogs, they’ve said exactly the same as like, the dog knows there’s a problem before I do, tells me there’s a problem. I get myself back to center. I carry on with my day. I’m always intrigued by that.

It’s like I hear the science side of it. Then I wonder, well, from the layman’s point of view, it sounds to me like we do this in other ways. Is there a chance that dogs and horses are the first neural feedback machines?

Andrew

I love that analogy, actually. I might use that moving forward.

Yes, I think in the end, it’s about emotional regulation, right? It’s about grounding someone, allowing them to be present in their body. The thing with neurofeedback is why I think this may be a promising adjunctive treatment for PTSD is the flexibility. You can do neurofeedback by itself. People can just try to regulate certain areas of their brain while they’re in a resting state, which means they’re just seated comfortably. You could also pair that with exposure-based interventions, so prolonged exposure, where you may present trauma reminders to a person, and then they try to regulate certain areas of their brain.

Additionally, we are doing a clinical trial right now where people do neurofeedback right before a talk therapy session as a way to resource someone, get someone in an ideal frame of mind before engaging in that talk therapy, because we know some of the barriers to effectively engaging in cognitive-based therapies is if someone’s too anxious, dissociated, or dysregulated. Really just getting someone into an optimal state before engaging in certain talk therapy, and that’s what your example reminds me of, actually, because we have, for example, canine-assisted psychotherapy, and it’s similar in that way.

It’s just resourcing, allowing someone to be, or scaffolding maybe someone to effectively engage in other therapies. Where I see it as a bit different is neurofeedback could also be standalone for some people, but I say standalone with air quotes because I think neurofeedback is always important to pair that with a good psychotherapist, right? Because as you’re regulating and recalibrating some brain networks, things come to the surface that need to be processed for sure. I just wanted to highlight that.

Brian

One of the things that works for me in the world of grounding is I’m a West Coast guy, I love barbecuing. I actually had a while, my doctor had me carrying around a small sandwich bag with a wet piece of cedar in it, because that reminds me of smoking salmon. Imagine I’m working with you, or probably the other way around, I’m the patient and you’re conducting your work on me here, and we create a situation where I’m going to be stressed out. Say I looked at an image from my past that’s bothersome, and then I bring out my cedar and I start smelling it. Would you actually be able to see me getting better? Is that something that you’d be able to notice, and would you notice it in real-time? Yes, absolutely. I think we see in the brain when someone is triggered by their trauma, those reptilian brain structures in the brainstem, so they’re coming online, these are the fight or flight, they’re just concerned with survival, right? The amygdala as well, this is that emotion hub, one of the hubs of the brain coming online. Then some of the more evolutionarily recent, let’s say, brain areas in the cortex, those are going to decrease in activity, actually. Those are also the emotion regulation centers. This is where we’re really having deep thought, I would say, or cognitive thoughts, that would decrease. Then probably as you’re grounding yourself and using this strategy, it’s going to be opposite.

Laryssa

We’ve been talking to you a little bit as a neurofeedback specialist, if I can call you that. Maybe we can talk a little bit more specifically about research. What chose you to do research in the particular field of mental health, but also Veterans and Families?

Brian

Why do you like us?

Andrew

[laughs] Yes, as I mentioned before, I started my journey at Western University in London, Ontario. For me, it’s really important having, I don’t know, a job, a career that’s meaningful, and I’m helping people. This is why I want to go into medicine. Then I, as I mentioned, kind of gone to research at Western. During my PhD, I started working with Ruth Lanius at Western University. For anyone who knows Ruth or has met her, her energy is very contagious. She’s super passionate. Yes, I started working with her and I loved neuroimaging and developing new treatments for psychiatric disorders. As I mentioned before, we just have so far to go. There’s so much to discover. It’s really exciting to be in that field. It’s also really rewarding, both from helping individuals with mental illness, but also from a mentorship perspective mentoring the grad students I work with and other trainees. During my PhD, Ruth is primarily a PTSD trauma researcher, that’s how I got into that field, and PTSD I would say is unique in the sense of how, as I mentioned before, how heterogeneous this disorder is, right? You never have just PTSD in real life, right? It’s often common to have depressive symptoms or anxiety, sometimes substance use, sometimes sleep issues, chronic pain as well. A lot of that psychosomatic type of—

Brian

Intestinal stuff?

Andrew

Yes, exactly. PTSD is so complex and it’s of course very difficult to treat. I think because of that though, yes, I don’t know. There’s so much meaning behind this work, right?

Brian

One of the things that came up when we were chatting the other day, I see stigma in a whole lot of different places. One is sometimes the Canadian Forces as a whole get stigmatized, but actually you mentioned, they’re one of the first consumers of this work, right? How did that actually come about? Because a lot of people, there is sometimes an image of the military is resisting this stuff. You’re saying to me the other day, “No, like they’re at the front trying to get more of it.”

Andrew

My experience has been the Canadian military has actually really catalyzed and enabled some really exciting, emerging research and treatment interventions. For example, things like neurofeedback. We did proof of concept pilot studies, 10 years ago, with support from the Canadian military. That whole research program just expanded since then. We recently, a couple of years ago did a clinical trial in neurofeedback as well. We’re continuing that work with Atlas.

Laryssa

For me as a Family member supporting someone with PTSD, that’s so exciting in that there’s promise and there’s hope and treatment and intervention and people not hopefully in the future, not struggling as long. Maybe I’m sort of answering my own question and I don’t mean to do that, but I want to ask you why is research important? Because for me, until I came to Atlas, I didn’t have a heck of a lot of interest in research. Like I said, I had a picture in my mind. I thought, “There’s people in cubicles doing this and then it’s, they publish a report and it sits on a shelf,” but it’s not that. Yes. Why is research important?

Brian

With that, I hear a lot from the community saying, “Enough research, just go do things.” You opened up here by saying, “We don’t know all that much about what’s going on. We know a fair amount, but there’s still tons to do.”

Andrew

Yes. research is important because again, PTSD is so complex if we’re talking about that, but mental health conditions in general, we, there’s a lot, a far way to go in terms of better understanding the risk factors for how these symptoms may come about, how these conditions can manifest both in the brain and the body. Then also, how do we go about, helping to intervene and treat those symptoms and how do we leverage resiliency factors as well? I think there’s so far to go. I think a lot of our clients we work with, they recognize that and they feel that, especially when unfortunately some people we work with can feel actually quite discouraged about their experience so far in a treatment setting. That’s why it’s so important for them and meaningful for them to contribute to our research. Then the second component to my answer would be actually why I think Atlas is so-as such an exciting place to work.

Previously I was a researcher and professor at McMaster University. Then last year I moved to the University of Ottawa and I’m working as the director of clinical research at Atlas. It’s been such a different experience and such a positive experience because typically, researchers are siloed, right? You mentioned before, they’re publishing, publishing, and it’s sitting on a shelf. I think that’s what’s so unique about Atlas is that we have our research teams, we have the knowledge mobilization and translation teams, who work with the research teams to really get that information out there and other avenues besides publications in scientific journals, right? Making sure that information is accessible, available, and really reaching the people who it needs to reach. Additionally, the Lived Experience team at Atlas as well is so unique.

Brian

Yes, they are. Tell us more.

Laryssa

I was going to say, this has been a paid promotion.

Brian

Go on.

Andrew

The ecosystem Atlas has set up too, in terms of lived experience, helping or collaborating and co-creating projects, and deciding what’s really the question we should be asking. When the research is done, how do we leverage this and how do we get it to the people that we need to? Yes, for example, some of our studies in neurofeedback were published earlier this year. This is just one example. This is what we do typically, a clinical trial wraps up, we publish it in a scientific journal. With the help of the Communications team and Knowledge Mobilization team at Atlas, we organize this whole webinar.

We’re able to create a lot of resources on neurofeedback, make it accessible to really a wide range of people. Including service providers, members of the community, Veterans and Family members, and academics as well. From there, as we’re discussing about how we can work with other portfolios at Atlas to implement trainings on neurofeedback for service providers. Because that was one of the main feedback we got from the webinar is, service providers were really excited about that, but how do we get training? That’s another thing Atlas can help with, right? It’s such a unique ecosystem, I would say. Coming from a researcher perspective who typically we’re just at the university, I am really, honestly, every day, I’m really grateful to be part of Atlas because it’s bringing all of the key players to the table. That’s what’s really important.

Laryssa

Just quickly, it must be really rewarding for you because you can observe in a shorter time your work making a difference. There’s that opportunity.

Brian

One thing that I can tell you, like Veterans expect us to train the community out there that’s trying to help them, right? How do you make somebody better? I’m not going to go teach a bunch of doctors, but what I can do is teach you maybe the parameter and context of the experiences of the people we’re working with. My theory is, and why we built this place, is that makes you better and you make me better. That was the theory behind it in the end. This is it just working, right? To some degree, I do want to touch on one thing before we part ways is that back when you’re talking about hyper and hypo in terms of somebody reacting, if I’m the person that’s reacting and I’m reacting hyper and this is my sister, what is she noticing about me that would be different from normal? Because she’s not reading this graph and she can’t interpret what you can. What would she see?

Andrew

It depends. There’s a lot of different areas of the brain that can show too much or too little activity. Could be things like, as I mentioned before, hypervigilant symptoms, it could be hyperarousal, nightmares, could be feeling angry even. The hypo are things more like emotional shutdown, feeling disconnected, those dissociative symptoms. Those out-of-body experiences or feeling disconnected from your body, as well as feeling like maybe the situation isn’t happening or it’s a dream. Especially those dissociative symptoms, those can also have significant impacts as the others, but particularly dissociation on interpersonal relationships. If someone’s so emotionally shut down and disconnected, of course, that will affect interpersonal dynamics, right? Those are some of the symptoms that are maybe associated with those changes in activation.

Brian

What’s exciting in the future? What’s coming up in your work?

Andrew

Yes, so how much time do you got? We have a couple of exciting projects in the pipeline. We’re expanding our neurofeedback work to look at the benefits of regulating specific areas of the brain and how that may lead to unique symptom changes in PTSD. That’s a clinical trial we’re doing. We’re also expanding our work to look at the effects of something called secondary traumatic stress symptoms. This is through a process called vicarious traumatization. Really this study is looking at the effects of trauma, not only on Veterans, but Family members. We’re using, again, neuroimaging methods to help expose, see some visible wounds.

I think we’re hoping actually this will be, again, Laryssa, I think you mentioned the word validating, right? By looking at these very measurable biological changes to, yes, validate these experiences that PTSD is not just affecting individuals, it can have far-reaching effects, particularly on Family members.

Laryssa

It’s something, you and I have had lots of conversations about this, Andrew, and it’s something that I’m personally very curious about, because, I’ve been with my spouse for a number of years and hopefully supported him well, sometimes better than others. I find, I can almost see in myself, reflecting some of his behaviors, in certain places, I’m hypervigilant, I’m sitting with my back against a wall, I call that type of stuff.

Brian

You might even get more protective than he needs to, right?

Laryssa

Yes, absolutely.

Brian

I’ve seen this in our community is, people get used to some of our triggers, then they get oversensitive to them, and they might even sense them when we’re fine.

Laryssa

Yes. Then, yes, I’ve been wondering, okay, does that mean that there’s changes in my brain as well? That’s an exciting study coming up. Thanks for sharing that.

Andrew

Yes, absolutely.

Laryssa

I think one thing that I did want to ask is, in my community, I’ve seen a lot of Veterans feel, I guess I’m going to say cynical or jaded about participating in research, they’ve been subjected or asked to participate in tons of research and might be hesitant to participate for a number of different reasons. Maybe they didn’t feel it made a difference, or they were never looped in back to know what it was, or they didn’t have an investment, maybe in what they were participating in. Yes, I wanted to ask you, why should Veterans and Families participate in research?

Andrew

Our experience has been that actually, some of our studies are quite— it’s a big ask for people, right? Especially, time, if there’s some exposure piece, that can be for sure, uncomfortable for people, right? Some of our studies are quite long or complex. It is a big ask of people. We’ve actually found that although people may be even discouraged with their treatment trajectory so far kind of thing, but they feel very committed to participating in research, because I think a lot of members of the community know how much these studies can impact the treatment approach of trauma and related disorders, and how we better understand those disorders.

Laryssa

Yes, just my observation, a lot of the people that I know are, and I don’t want to paint the broad brush, but many people I know who served have, there’s an altruistic component to that, choosing to serve to help others really, essentially.

Brian

Training, right, is experimentation. You’re trying, maybe not trying out a new scientific technique, but you’re certainly trying a tactical one. The vast majority of soldiers’ lives is not operational. It’s getting ready to be operational. We’ve been experimented on. It’s not a good feeling, right? Even we find that as, we really have to explain to people what we’re trying to do, and not only that, that we actually see that there’s something we could possibly do with it on the other end. Even I look at a lot of the stuff out there and I can’t see what people expect that they’re going to do with it, but I can see that here.

Laryssa

Yes. I think that’s where it’s helpful is to know that there’s a potential positive outcome and it might not be for you, for example, as a retired warrant officer, but it might make a difference for private bloggings.

Andrew

One thing we do actually in our studies is we reach out to participants actually throughout the project, letting them know interim or preliminary results, which we’ve received a lot of positive feedback from that actually of, “Thank you for participating. Thank you for all your time. This is what we’re learning and this is what we’re doing with it as well.” We share, if we’re presenting at a meeting or a community engagement type of session or conference, we always let people know, but we share those findings throughout the project. I think that’s really important for people.

Brian

Before we part ways today, I want to thank you. Specifically, you could have taken your talents anywhere. You took them here and you’re working for what I consider to be my friends. It’s a big deal, for any other institutes that are listening, you can’t have them. We got them first, go away. This has been an exciting episode for us of Mind Beyond the Mission being joined by our colleague, Dr. Andrew Nicholson. Thanks for joining us.

Laryssa

Thanks, Andrew.

Andrew

Thanks.