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Saturday, April 30, 2011

Reactive Attachment Disorder and Neurofeedback

April 24, 2011 at 16:21:20

Neurofeedback: A Treatment for Reactive Attachment Disorder

By Sebern Fisher (about the author)

In 1939, John Bowlby began what amounted to a campaign for the recognition of the primacy of attachment in the development of the human infant. Near the end of his life, in 1991, he reportedly expressed some measure of satisfaction that his ideas were gaining acceptance. It has only been within the last decade that attachment paradigms have become widely enough accepted to encourage widespread research and an increasing body of literature on theories of attachment and disordered attachment. Attachment research is still under-funded. Findings remain controversial in the field of psychotherapy, and in the arena of public policy, their implications go unheeded. Reactive Attachment Disorder, although having gained some recognition in the DSM IV, is still a misunderstood and underutilized diagnosis. Neurofeedback has met something of the same fate. Traditional biofeedback practitioners, already feeling their work trivialized by mainstream medicine, have been slow to embrace this new modality. The psychotherapy community is, at best, wary and in many instances, hostile to the neurofeedback interloper. In the January 2000 issue of The Journal of Clinical EEG, Frank Duffy, MD of Harvard Medical School said, "The literature, which lacks any negative study of substance, suggests that [neurofeedback] should play a major role in many difficult areas. In my opinion, if any medication had demonstrated such a wide spectrum of efficacy it would be universally accepted and widely used." None-the-less, for reasons he goes on to explore, this has not yet become the case. As neurofeedback is increasingly understood and accepted, it may well be those in the field of attachment and attachment disorder that embrace it most readily.

The widespread failure to recognize Reactive Attachment Disorder (to be referred to as RAD) and the lack of understanding of neurofeedback make writing about RAD and neurofeedback a somewhat daunting prospect. It is, however, timely. Allan Schore has written a detailed study of the interaction between not only the psyche of mother and infant but between the brain of mother and infant. [Throughout this paper I will use mother instead of primary caretaker. Although I believe that attachment can and does occur between an infant and a primary caretaker other than the mother, it is the mother-infant dyad that is central in human attachment. Although these effects can differ widely, there are, none-the-less, effects on every child who has lost his mother.] In his exhaustive work on the mother-infant relationship, Affect Regulation and the Origin of Self, Schore argues that the mother's affective attunement is not only the path to emotional regulation but to the regulation of its infrastructure, the brain, and further that it is from within this regulation that the infant develops her sense of self and other.

The DSM IV describes the essential feature of RAD as "markedly disturbed and developmentally inappropriate social relatedness in most contexts that begins before age 5 years and is associated with grossly pathological care". It goes on to further classify: "There are two types of presentations. In the Inhibited Type, the child persistently fails to initiate and to respond to most social interactions in a developmentally appropriate way. The child shows a pattern of excessively inhibited, hypervigilant, or highly ambivalent responses (e.g. frozen watchfulness, resistance to comfort, or a mixture of approach and avoidance). In the Disinhibited Type, there is a pattern of diffuse attachments. The child exhibits indiscriminate sociability or a lack of selectivity in the choice of attachment figures. By definition, the condition is associated with grossly pathological care that may take the form of persistent disregard of the child's basic emotional needs for comfort, stimulation, and affection; the persistent disregard of the child's basic physical needs; or repeated changes of primary caretaker that prevent formation of stable attachments (e.g. frequent changes in foster care). The pathological care is presumed to be responsible for the disturbed social relatedness." The DSM IV describes the course of RAD: "The onset is usually in the first several years of life and, by definition, begins before age five years. The course seems to vary depending on individual factors in the child and caregivers, the severity and duration of associated psychosocial deprivation, and the nature of intervention. Considerable remission may occur if an appropriately supportive environment is provided. Otherwise the disorder follows a continuous course". And on prevalence, it says, ô Epidemiological data are limited, but Reactive Attachment Disorder appears to be very uncommon." Attachment therapists, most of whom would sadly disagree with the rarity of this condition, would add the following symptoms: lack of cause and effect thinking; lack of empathy; poor social cueing; lack of remorse; pre-occupation with blood and gore; fascination with knives; 'primary process lying' (lying about something that the other has witnessed); gaze aversion; tactile defensiveness; controlling behaviors; cruelty; explosive rages; impulsivity; instrumental relationships; insensitivity to pain; and co-morbidity with speech pathology, learning disability and Attention Deficit Disorder with Hyperactivity (ADHD).

Therapists also describe routine failure in treating these patients. The initial endeavor of psychotherapy does not necessarily require that a patient care about their treatment or about themselves. If these were requirements, then most therapies would fail. Therapy to succeed does require that the patient, in some way, care about the therapist. In this, RAD is self-defining as a disorder that cannot be treated. The RAD patient by definition lacks the capacity to care about the therapist. The therapist barely exists, and when she does, it is as a needs gratifying object or as a thin cognitive trace against a stark, usually unrecognized, backdrop of absence. He cannot care about the other because there is no other; in the absence of self there is absence of other. He lives as a child or adult within the mirrored reflection of the original infant state, one in which he had no experience of mother and, as a result, no experience of the reality of other or of self. Therapy with the unattached is a game of ghosts.

As suggested in the DSM IV description, RAD is a disorder of relational neglect, initially and profoundly, the mother's relational neglect of the child. Although many people with RAD have histories of trauma as well, the etiology of attachment disorder is not the trauma per se, but the trauma primarily as a further indicator of an environment of neglect. It is a disorder born from the significant failure of emotional and neurological attunement between mother and baby. Maternal depression can result in attachment disorders that are as profound as those that result from the mother's physical abandonment. The "passive" aspect of disorganized attachment is maternal non-presence. The "active" element is the installation of the mother's psychic state of abandonment. She is not psychically present and this evacuation of self becomes the object reality of the infant. Her state of absence becomes the state that the baby internalizes, the state of no one there. This mother is unable to recognize the reality of the "otherness" of her baby and in this lacks the capacity to protect or even wish to protect the infant whose survival depends on her. This psychic reality can and does exist even when the infant's basic physical needs are met, a fact that can make some situations of severe relational neglect difficult to discern.

Although maternal neglect and "pathological care" are the focus of this paper, it is not the only path to disordered attachment. The disruption to attachment that is inherent in adoption makes it a significant risk factor for attachment disorder, even when the baby is adopted at birth. There is growing evidence that the baby hears the mother's voice in utero, knows intimately the rhythms of her body and recognizes her smell and her voice immediately after birth. This sensorium of experience and expectation are the beginning of bonding and it is reasonable to consider that when this infant is put in different arms, and hears a different voice he feels an attachment shock. Like all shocks that children suffer, the good enough mother can soothe and mediate its power and she will be much more able to do so if she knows that a shock has occurred. "One gets the impression that children get over even severe shocks without amnesia or neurotic consequences, if the mother is at hand with understanding and tenderness and (with what is most rare) complete sincerity" (Ferenczi, 1931, p.138).

There is also the phenomenon of "bad fit". There are situations in which the temperament of the baby and that of the mother seem like magnetic poles, they cannot attract each other. "Bad fit", however, may have maternal or infant pathology hidden within it. The infant's contribution to bad fit is neurologically not psychologically determined. Some babies are born with severe tactile defensiveness, other cannot be soothed or cannot sleep and some are born autistic. These babies can profoundly discourage or even occlude the most devoted mother and the level to which they do this predicts the level of attachment disorder. Asperger's Syndrome and other more clinically demonstrative autistic disorders, which are all disorders of extreme overarousal, make it neurologically impossible for the child to emotionally comprehend the existence of the mother even in her adoring presence.

Although it is very important to understand problems that arise within the infant that can contribute to attachment dilemmas, I will be focusing on how attachment breaks affect the unimpaired infant. Further, there is growing clinical evidence, much of it from the practice of neurofeedback,that even in these extreme situations, beneath the press of the highly aroused nervous system there is the desire for attachment. Attachment is the fundamental drive in human beings. It is a drive that brings aggression and sexuality to its defense and to its enhancement, and it is the precursor to human love. It is gained through the delicate interplay of vocal tone and facial expression, through body to body communication, through the dyadic system of care that develops when the mother attunes to her baby. When attachment fails through the significant interruption or destruction of this system, the infant suffers not only what appears to be irreparable emotional harm but significant brain damage.

PET Scan studies reveal that men in the prison population who meet criteria for anti-social personality disorder have smaller right hemispheres than those of "normals". The right hemisphere is the part of the brain that is responsible for the regulation of affect and it is the hemisphere that develops most rapidly in the first 18 months. Schore argues that it is this part of the brain that most requires appropriate entrainment by the mother's brain to permit the development of affect regulation in the infant. Bonding involves the mother's modulation of her baby's affect through attunement to his needs for stimulation or arousal alternating with soothing and lowering of arousal. This process rides the waves of sympathetic and parasympathetic systems in both infant and mother and begins to encode the possibility of future self-regulation of state.

Psychoanalytic and dynamic theories have posited that babies internalize their mothers or their perceptions of their mothers. What is being suggested here is that babies not only internalize their mothers, they build their brains around them; that good enough mothers provide their babies with good enough brains. We may, in time, discover that unimpaired babies learn to fire their brains the way their mothers' brains fire and that without the organizing template of mother there can be no organization of firing patterns of higher order than limbic survival. (Interestingly, Gary Schwartz at the University of Arizona has been able to identify the EEG of the mother encoded in the EEG of the child and vice versa and speculates that the more bonded the pair the more pronounced the signal within a signal.)

One of Schore's core conclusions is that "the prefrontal lobe of the mother becomes the pre-frontal lobe of the baby". The prefrontal lobe sits behind the forehead and in the right hemisphere it is the part of the brain that organizes emotional agency. I am reminded of a film I saw in graduate school titled "Ben". In it, for purposes of the experiment, an emotionally attuned mother agrees not to respond to the smile of her well bonded six month old son. When he smiled, she made no expression. He looked momentarily bewildered and smiled again. She still did not respond. His face clouded and he began to look agitated but he tried again. This time when his mother failed to smile in return he looked alarmed and anxious and began to cry. His mother, who has been valiantly cooperative with the researchers up to that point, could stand it no longer. She picked him up and comforted him, holding and rocking him, cooing and mirroring his facial expressions. His equilibrium was rapidly restored. This entire interaction, as I recall, unfolded in less than two minutes.

Imagine, then, what it must be like for the child of a depressed or addicted or narcissistically absent mother who cannot provide this attunement and emotional repair. This child, too, will attempt to engage her mother; it is her nature. These attempts to recruit the mother could go on intermittently for weeks, months or even years. I am suggesting that, as was true for Ben, each failure heightens negative affect. The child experiences increasing levels of distress that, without predictable maternal intervention escalate into disorganizing anxiety until, finally, the baby gives up, affectively "burning out" and collapsing into a state of deep characterological despair. Her initial distress becomes fear that mounts into terror and then implodes into nothingness, a state beyond hopelessness, a state of no other and no self, a state too diffuse, too cellular, too absolute and too horrifying to any longer be recognized as fear.

Although she lives in this baseline state, the person with RAD rarely experiences either fear or grief. Just as empathy requires the recognition of self and other, learning to feel requires self and other. The baby develops her emotional repertoire in response to the responses of her mother. Joy, sadness, yearning, shame, and grief are dyadic emotions; they require the presence of the other. Fear and its second-level manifestations, anger and rage, are hardwired within the organism; they are affects of survival. In good enough mothering they are mediated by the soothing presence of the mother who teaches the baby that arousal can be mediated, and moment by moment and over time, how to mediate his own arousal. He internalizes her soothing presence. For those without this internalization, those with RAD, the only genuine affective state that survives is anger, an anger that readily escalates into rage. When the anger is cold, when even this aspect of the person is no longer warm, this is sociopathy, the unspecified "continuing course" of attachment disorder as described in the DSM IV.

These are the Romanian orphans, who need be neither Romanian nor orphans, the children whose faces look like bombed out buildings. They survive through instrumentality, often in the form of a superficial charm, but they fundamentally do not recognize the fact of the existence of the other, much less the needs of the other. Empathic failure is a significant manifestation of the state of 'no other' but it understates the extent of the damage. These are children and adults who live in barren, unpopulated internal landscapes. One adult patient of mine said, "I know this isn't possible but I live in a place without landmarks and without horizons. I don't know how I see it, but I do." She was describing the territory of motherlessness. Another described a dream in which she walked past her mother and saw that she, who looked at first three dimensional, was in fact only a cardboard cut out.

RAD then is the result of unmitigated affective arousal that obliterates the possibility of psyche. It occurs in the absence of the mother and in the installation of her state of absence. It is a disorder of stark overarousal, (in affective terms, unrelenting terror), and it is a disorder of the right hemisphere. It is a disorder of damage to the brain as well as to the psyche. The human being survives, but only as an instrument for survival. She is not harbored within the presence of the other or within a self.

Once we can begin to recognize RAD as a disorder in brain development in all realms, structure, chemistry and timing, we can also begin to see the possibilities for treatment through training the brain. This is vitally important. Attachment disorder in children predicts conduct disorder in adolescence and anti-social personality disorder in adulthood. To date, there has been no effective treatment developed to remediate RAD, particularly in its most severe forms. Traditional talk, play and behavioral therapies have failed this population because they do not and cannot address extreme emotional and neurological arousal. To date, there are no reliable psychopharmacalogical interventions. Even when a therapist recognizes the attachment issues before him, which is rare enough, there is little that he can do about the neurology of the disorder. Those RAD patients who regain awareness of sensation in their bodies describe feeling that they lack a sense of containment. It is as if their nerve endings do not stop at their skin but continue, unbearably, forever into space. There is no constraint on their nervous systems. In this light, it is not surprising that the controversial use of holding a child through the rage has claimed the most therapeutic success. Holding therapy has not, however, met with acceptance, as it is widely misunderstood as coercive and it triggers the current cultural fears around touching children.

To compound the problem of treatment, most young children with attachment disorders elude this diagnosis (unless they are in the small percentage who actually fail to thrive), often being diagnosed as ADHD or ODD. This means that most RAD kids are discovered in adolescence and often during the course of a criminal career. Their "treatment programs" are juvenile detention centers and then the prison system. Even if holding therapy demonstrated more efficacy than it has, this would not be a population that could use it. (It must be said here that although RAD is overly represented in the criminal justice system, not all people in prison are attachment disordered and not all RAD people are in jail. They are, sadly, well distributed through corporate boardrooms.)

Holding therapy, however, gives us a way to think about the neurological substrata of the attachment dilemma. Barry Sterman had successfully used neurofeedback to control seizures in cats. When he sought to replicate this work with monkeys, he ran into a predictable problem. His new subjects would pull the electrodes off their heads. This meant that they had to be restrained. After an initial struggle, at the point when they succumbed to the restraints, they produced a predominance of 12-15 Hertz, the very brain waves Sterman wanted them to make. Like the cats, they too learned to become seizure-resistant, and when they did, they also became calmer, more sociable and less aggressive. One has to wonder if this is also the mechanism, neurologically, that accounts for the successes of holding therapy. In the process of release into the hold, the child's brain begins to shift into a dominant 12-15 Hertz pattern, a pattern that is often described as the relaxation response. In this state shift, the child can begin to recognize the holding for what it is, rather than as a threat to her survival. She can begin to see her mother's face and may even begin to feel the yearning and grief that are the frozen feelings in RAD. It suggests that the key in successful holding is the induction of a change in brain wave activity that may mimic the brain activity of a relaxed infant, bonded to and held by her mother. It follows then that we can significantly impact people who suffer the ravages of brain disorganization that we call RAD if we can teach them how to produce these brain wave patterns. This is the potential of neurofeedback.

Neurofeedback is increasingly available as a clinical tool. It is a system through which people can learn to alter the timing and communication patterns in their brains through operant conditioning. Sensors are placed on the patient's scalp to record the real time EEG and then, as determined by assessment and protocol, they are provided feedback when they produce the desired brainwaves. People meeting criteria for RAD are often rewarded for increasing the amplitude of lower frequency brain waves from SMR (12-15 Hertz) to alpha (8-12 Hertz) in the right hemisphere of their brains. In this process, the RAD patient learns to change the timing of the right hemisphere and to reduce the arousal of the entire system. With the lowering of arousal come decreases in aggression and impulsivity. The individual not only begins to behave more pro-socially but to feel more pro-social. As the threshold of terror is reduced, he warms up, and he begins to feel a greater array of affective states. Over time this resetting of the brain's rhythms can translate into significant changes in state, and the state change translates into the person's perception of himself and others.

Several case histories will help to illustrate the effects of neurofeedback. T. is a thirty-two year-old man who was abandoned at birth and raised in orphanages and residential treatment centers. At age ten, he was adopted by a family ill-prepared to parent an attachment disordered boy. The adoption was terminated after a series of assaults on the adoptive mother, the last of which was a blow across her head with a two by four, provoked when she withheld a snack. He was returned to residential care until age 18 when he entered the correctional system. It was during this tenure in residential care, ages 13-18, that I was his therapist. It was T. who introduced me to attachment disorder. Nothing we did, including a course of holding therapy, affected him. He was unable to inhibit his aggressive impulsivity, he lacked cause and effect thinking, a fact that essentially made it impossible for him to learn emotionally, he could not generalize, and he felt no empathy or remorse. He was also unable to recruit empathy from others. Although he demonstrated some dependency on me, he never developed a real attachment to me or any other person in his network of care. He assaulted a female staff member, nearly choking her when he perceived her as taunting him; and on a camping trip to Maine with the program, he struck up a conversation with a family at a nearby site and left with them. This was more an act of indiscriminant attachment than running away. It never occurred to him (nor, evidently, to the others) that this might be a problem. He was in constant petty squabbles and unable, even with constant reminders, to understand the consequences of his actions.

During his most recent probation, at age 31, T. had a course of sixty neurofeedback training sessions. He felt it was the first thing that helped him. He never missed a session. Most importantly, he began to show the first stirrings of empathy and regret. After forty sessions, he called me to tell me he was worried about how he had treated a staff member. In all the time I'd known him, I had never heard him acknowledge the existence of another person (except as a tormentor) or any awareness that he had an impact on that person. He went on to say, "I still get angry, but it used to just keep going and going. Now, a half an hour later I am calling the person, apologizing and trying to make it right." Unfortunately, the training came too late as he had committed a second crime within two days of his release and was returned to jail. It is important to note, that I am the treatment control in this situation. For five years, I struggled with him in all known treatment modalities to little effect. He made significant progress in three months of neurofeedback, and he was able to recognize that this was the case.

The people in the system surrounding him expected the worst and felt burned out both by him and by their expectations of him. They were unable to discern the subtle changes in behavior and affect that were apparent to his therapist and to me. As T's arousal dropped, he began to feel an intense yearning that was difficult for him to articulate and which his psychodynamic therapist failed to recognize. Because he had re-offended, he was kept isolated, making this yearning even more unbearable to feel. His long-standing inability to recruit empathy and the lack of recognition of the awakening of yearning in him by his care providers undermined his recovery. From jail, he reports that he is better able to walk away from the taunts and provocations of other inmates and he may, for the first time, be truly suffering his incarceration. He is maintaining contact with me and with his neurofeedback therapist.

E. came to me after leaving a private psychiatric facility against medical advice. She was diagnosed with bipolar disorder, attention deficit disorder with hyperactivity, post-traumatic stress disorder, alcoholism, learning disability and borderline personality disorder. When I asked her mother whether she thought she was truly bipolar she responded, "If you think if you drive a car fast enough you can make it fly, would that qualify?" Although she had spent her first year in an orphanage, no one had considered the diagnosis of attachment disorder. She had multiple physical complaints including lack of co-ordination, clumsiness, chronic pain, irritable bowel, headache, constipation and asthma. She was unable to sit still during our first sessions together, reporting that she felt like she was coming out of her skin.

She reported that it was routine for her to drink to black out and wake up in the bed of an unknown man. She did not believe that she was an alcoholic but that she used alcohol to self-medicate, and she came to realize that she drank to allow herself to be held. In any other situation, she was touch aversive. She was unable to sleep, maintain relationships or work. She could not read, and not surprisingly, she was unable to concentrate. She had been in special education classes since she began schooling. In our initial sessions she talked of nothing but what man she was interested in, who was cheating on whom and complaints about the neglect of her parents, and all of this in a superficial and perseverative way. There was no room in this girl's state of chronic agitation and arousal for reflection or thoughtfulness, much less insight or connection with me. I was the vessel for her complaint. She was trying to manage a severely over-aroused nervous system in every way that she could, including men, alcohol and hospitalization. She was also prescribed, and was intermittently taking lithium and Paxil and Trazadone, but she felt they were of little use.

Within two months of beginning neurofeedback, E. had stopped drinking, and within three, no longer needed case management. She had stopped both the lithium and the Paxil with no ill effect. She established a relationship with a young man that has endured for three years. She was increasingly able to work regular hours, and she finished her college degree program. At one point during the therapy of 2 1/2 years and with over 150 neurofeedback sessions, she announced that she could now see what she was reading. I was astounded. I had no idea that she had been trying to read without the capacity to visualize. Neither, of course, did she. She also reported that one evening, while waiting for a movie she went into a batting cage with her boyfriend. She amazed herself (and him) by hitting 95% of the balls. She gradually became less explosive, and she warmed up, making it increasingly possible for her to engage in a sustained and emotionally deepened psychotherapeutic relationship.

E.'s therapy, however, was rocky. Neurofeedback presented us both with new clinical dilemmas. Most symptomatic behavior abated rapidly as she became neurologically, emotionally and physically more regulated. What emerged in its place were profound questions of identity. She said at one point, "I have never been more myself and never known less who I am.' E was beginning to experience affect regulation and it was, in fact, giving birth to a sense of self that was organizing so quickly that it took us both by surprise. She was familiar with the whirl of reactivity that had served her as a sense of self, but not with the core self that was emerging. As she began to wonder who she was, she also wondered who I was. I, too, was suddenly brand new to her, and she could not tolerate the transferential yearnings that were stirring in her. She turned the nearly intolerable yearning away from me and into her relationship with her boyfriend, with predictable complications.

She also felt critically disappointed that life was like it was. She had imagined a Hollywood version, and the new dailiness of life and her ability to cope with it felt, in some ways, more disheartening than welcomed. As she grew bored with drinking and drugs and with this crowd, she also felt unbearably lonely. At the same time, she grew calmer, more mature, warmer and better able to both advocate and care for herself. Her interpersonal judgment improved and she became less impulsive in all areas of her life. Although in some ways left bewildered by all that has changed, E. reports that she feels smarter, more resilient, more understanding and more competent. Her self-esteem has improved dramatically.

I met S. when my young tenants took him in for foster care, and I have been a consultant to them on his treatment. S. is a five year-old boy with a history of profound neglect and abuse. He was the first child of two kids who were themselves foster children, and he came to the attention of the Department of Social services when he was hospitalized after a fall from a third-floor window. It was revealed that he had been hospitalized at 18 months for failure to thrive following an apparent seizure. One of his parents also had a seizure disorder. Investigators further discovered that S. was left for days in a crib alone. He was placed with his grandmother, who apparently sexually molested him, and when he was returned to his parents there was a new baby, a sister whom he tried to kill. Both children were removed to foster care when S. was three and he once again tried to kill his sibling. He had to be removed from the home. He was further physically abused in the next foster home, and he may have attempted to set it on fire. His placement across the driveway came as an emergency response to this situation.

S., as one could predict, was severely attachment disordered and traumatized. He did not fall asleep until after midnight. Once he did, he lapsed into night terrors, during which he crawled on his hands and knees screaming "no, no, no." He would come awake at five to begin a day that was hallmarked by non-stop and entirely disorganized activity, high risk behaviors like climbing a tree to the top, pinching the cats, hoarding food, throwing tantrums, breaking objects, defecating on the floor and showing no capacity to take direction or obey his new care takers. He expected sexual abuse and engaged in sexual reenactments. He had no language and grunted and gestured to make his needs known. He made no eye contact. When you did see his eyes, they were vacant and momentarily flecked with terror. He resisted physical comfort, and he was terrified to be held. As it grew dark each night, he screamed without let up until he fell into the half conscious terror of night.

S.'s treatment began immediately. It included allowing him to eat all that he wanted from a diet of no sugar, no wheat and no dairy. He ate constantly. The foster parents gave him a bottle whenever he wanted it. He loved the bottle but he had to learn how to suck. They did hours of holding therapy daily. His foster father describes the style they developed as "Nazi parenting". They did not allow him to move without their permission. And they started daily neurofeedback training.

Within a week, his sleep was normalizing. When he was finally able to sleep, he slept for twelve hours a night without night terrors. It seemed as if he was making up for a lifelong sleep deficit. He still had numerous nightmares, but he could be comforted. If his sleep had not changed and had not changed rapidly, the placement would not have survived. Over the succeeding weeks his appetite normalized, and he began to share food. He began to use words and to better tolerate the holding sessions. Eventually, he even began to request them. He stopped the screaming that greeted the dark almost immediately after beginning neurofeedback. Through a combination of all of these interventions, S. has emerged as a loving and emotionally compelling human being. Eight months into his treatment and new family life, he greeted me when I arrived home. He ran across the driveway and jumped into my embrace. I was wearing dark sunglasses and he leaned away, still cradled in my arms, looked at me and with real dismay said, "Seboin, I can't see your eyes".

His parents remained alarmed over his indiscriminate attachment. He seemed to seek comfort from strangers as readily as from his mother. This disturbed her and left her feeling unrecognized and, at times, hurt. Although those familiar with attachment disorder would not find this problem unusual, I mention it here because the solution to it was as simple as it was profound. His mother sat down with him and taught him that they were his parents and this meant that they were the ones that he was to come to when he needed things. This fact had entirely eluded him. She described a light going on in his awareness, and with that one instruction he seemed to immediately organize his sense of primary attachment. It all fell into place for him and the parents reported no further episodes of inappropriate reliance on strangers.

This compelling case underscores not only the parenting needs of children like S. but also the neurological substrata of RAD. Every successful intervention has been one that moved this little boy toward regulation. He was held, fed, nursed, directed, redirected, and disciplined, all to enhance the possibility of regulation that was so drastically absent in his infancy. It is unlikely that neurofeedback would have been as dramatically helpful were it not for this gifted parenting and by demands for regulation in every quarter. It is equally clear, however, that without neurofeedback S. would be untreatable. No parents, regardless of their devotion could have sustained this onslaught. He has now had 180 neurofeedback sessions, and he is beginning kindergarten. The transition into school has evoked separation anxiety and renewed fear of losing his mother. This means, of course, that S. has, in his psychic reality, a mother to lose. Further, we know that he is experiencing this fear because he is able to articulate it to his parents. The classroom is chaotic and, for him, disregulating. He willneed help to make it through this transition. Some of this help will come from a one-to-one aide and some through increasing the frequency of his neurofeedback training sessions. His foster parents have finalized S.'s adoption.


Neurofeedback training offers a remedy not previously available for reactive attachment disorder. It appears to address the core symptoms of sense of self and other, of emotional bonding, and of empathy,setting the stage for meaningful psychotherapy and reparenting. Reactive attachment disorder is, at its foundation, a disorder of brain regulation. Neurofeedback challenges the brain to regulate itself more competently in the emotional realm.

J.S. Grotstein, a psychoanalyst speaking from a psychodynamic perspective, was the first to propose a disregulation model for psychopathology. (Grotstein, 1986). His speculations raised the question about how the brain organizes itself in the domain of affect, a question that Davidson further elaborated (Davidson, 2000). Rodolfo Llinas found evidence for the disregulation model of certain neuropsychiatric syndromes with magnetoencephalography (Llinas, 1999). And McCormick proposed that certain neuropsychological disorders may be traceable to disregulations in thalamic rhythms (McCormick, 1999). Finally, Othmer and Kaiser describe how EEG neurofeedback can effectively normalize thalamic rhythmic activity and in doing so remediate certain psychopathologies, including autism, Asperger's, and RAD (Othmer, 1999). Jointly, these studies lay the theoretical basis for the results presented in this paper.

Neurofeedback is a technique of operant conditioning which directly changes brain function, in particular the timing of specific regulatory networks in the brain. It most dramatically affects arousal regulation. In so doing, this 'brain training' can normalize the propensity to high arousal seen as the hallmark of Reactive Attachment Disorder. More specifically, it can exercise the cortical-subcortical circuitry involved in emotional regulation and fear response. Theories that the brain organizes itself through regulation of timing supports clinical experience that neurofeedback addresses even the stark baseline fear which is the affective underpinning of RAD, as well as its multiple manifestations or co-morbidities: sleep disorder, hyperactivity, learning disabilities, explosive disorder, oppositional defiant disorder and conduct disorder. Clinical experience with neurofeedback further suggests that despite Schore's observation of a specific time window for the learning of emotional regulation, we are not dealing with a "critical period" in which such learning has to occur or it remains forever unlearned. The "wiring" for attachment (the drive) is in place before or at birth, and under the right set of conditions it can be activated. Neurofeedback has proven itself one of these conditions.

In RAD, the most devastating reality is the absence of the other, the internal experience of no other. In every case I have seen to date in which neurofeedback has been used, the person with RAD begins to recognize the existence of an other. Their internal landscapes develop horizons, and they find three-dimensional people there. As their arousal set point comes down, and they begin to recognize the existence of the other, they begin to experience a new organization of self in relation to the other. As I have suggested above, this is not without its hazards, but it makes treatment of these hazards possible through more traditional interpersonal psychotherapies. My experience and that of many others suggests that the introduction of neurofeedback makes Reactive Attachment Disorder a condition that can be, finally, successfully treated.


Davidson, Richard J.; Putnam, Katherine M.; Larson, Christine L., Dysfunction in the Neural Circuitry of Emotion Regulation---A Possible Prelude to Violence. Science, 289, pp591-594, 28 July, 2000

Grotstein, J.S. (1986). The psychology of powerlessness. Disorders of self-regulation and interactional regulation as a new paradigm for psychopathology. Psychoanalytic Inquiry, 6, 93-118.

Llinas, Rodolfo R., Ribari, Urs; Jeanmonod, Daniel; Kronberg, Eugene; Mitra, Martha P. Proceedings of the National Academy of Sciences, 96, #26, pp. 15222-15227, December 21, 1999.

McCormick, David A. Are thalamocortical rhythms the rosetta stone of a subset of neurological disorders? Nature Medicine, 5, #12, pp1349-1351, December 1999.

Othmer, Siegfried; Othmer, Susan; Kaiser, David A. EEG Biofeedback: An Emerging Model for its Global Efficacy. In Introduction to Quantitative EEG and Neurofeedback, Evans and Abarbanel, editors, Academic Press, 1999, pp. 243-309.

Schore, Allan N., Affect Regulation and the Origin of Self, Lawrence Erlbaum Associates, Publishers, 1994.

Sebern F. Fisher
34 Elizabeth Street
Northampton, Ma 01060

Image from youtube video

reprinted from eegspectrum.com

Sebern Fisher is a psychodynamic psychotherapist with a primary interest in the importance of secure attachment throughout the life span. She incorporated neurofeedback into her clinical practice in 1997. The effects of brain training that she (more...)

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Sunday, April 17, 2011

Mother Nature Gets Naughty: Eco-Friendly Sex Toys

On The Issues Magazine Online link to current issue homepage

The Ecology of Women issue of On The Issue Magazine

Mother Nature Gets Naughty: Eco-Friendly Sex Toys
by Elizabeth Black

I am a copywriter for a sex toys company in England, and, for several years, I've written articles reviewing new products for American and English sex toys company magazines. Consumers today are demanding that manufacturers make sex toys from healthier materials, and now companies are beginning to respond.

The problem with sex toys arises because many popular sex items are made from phthalates, a jelly-like material that has been identified as a possible health risk. Since you insert sex toys into your body, you are directly exposing not only your outer body to phthalates, but also your internal organs, especially your sex organs. If you are pregnant, you could be exposing your fetus to toxic chemicals, a particular risk to in utero development.

You'll find phthalates – sometimes referred to as plasticizers -- in many products you take for granted, including sex toys. You can conduct a first-step screening of your existing cache of sex toys for phthalates. Stephanie Iris Weiss, author of the book Eco-Sex: Go Green Between The Sheets And Make your Love Life Sustainable, explains: "(G)ive it a good sniff – does it smell like a vinyl shower curtain? If so, you can bet your bottom dollar that it's full of stuff you don't want in your nether regions." What you're smelling are the effects of “off-gassing" – remember that new car smell? -- in which products leak toxic gasses into the air. In the case of sex products, that means that these products that are also leaching inside your or your partner’s body.

As described in January 2011 Canadian news report, announcing restrictions on the use of six phthalates in new children’s toys and certain child-care projects in Canada, phthalates can be found in a wide range of consumer items, including perfumes, nail polish, vinyl floors, detergents, lubricants, food packaging, soap, paint, shampoo, toys, air fresheners and plastic bags. They are used to hold color and scents in products. You also may be exposed to phthalates through the chemical leaching into your food or through the general environment.

Because phthalates fall into a category of chemicals that can act as endocrine disruptors, they may interfere with the proper functioning or development of hormones. In brief, this means that they also can affect reproductive systems. (Articles in this edition of On The Issues Magazine by Michelle Chen and Laura Eldridge describe in more depth research on the risks of endocrine disruptors to human health.) Some of the male adverse health effects being linked to phthalates in animals include hypospadias (a defect in which the opening to the penis is not at the tip), smaller penis size, small scrotum, low sperm count, lack of sperm mobility and sperm damage; and in females, early puberty in girls and breast cancer.

Sex toys companies are eliminating possible hazards

With the growing science indicating that phthalates are hazardous to your health, consumers and sex toys companies are looking to eliminate possible hazards from their sex play products.

If you are unsure of the materials in your sex toy, don't merely put a condom over your questionable sex product. It's best to replace them with toys made of newer, safer materials that do not include phthalates. Older toys were "porous and leaked chemical goo," according to Weiss, and since they were and continue to be labeled as novelty products, unlike children’s toys, their ingredients have largely gone unregulated. If a sex toy is cracked or has lost its sheen, it’s time to put it aside, especially if made before alternative materials became available.

Body Safe

Fortunately, there are now better options. The American sex toys companies Babeland and Good Vibrations have completely phased out sex toys containing phthalates. Instead, they sell pleasure devices made from safer materials, such as medical-grade silicone, glass, elastomer rubber, stainless steel, and even wood. Silicone and rubber are substituted for jelly to make sex toys skin-safe for those with allergies, and the other materials are much healthier than plastic.

Some sex toy manufacturers, such as Lelo, JimmyJane, Vixskin, Coco de Mer, Luxotiq, We-Vibe, Fun Factory, Tantus, and Couture Toys. are producing only phthalates-free sex toys.

Read the packaging materials closely, suggests Weiss. Several phthalates are of concern for risk to human health, according to the environmental health and safety website, Is It In Us?: di-2-ethylhexyl (DEHP); benzylbutyl phthalate (BzBP), dibutyl phthalate (DBP; diethyl phthalate (DEP). If you see one of these items listed on packaging, it’s not the way to go.

Weiss says that consumers should beware of sex toy packaging that claims a toy is safe or that says it is "hygienically superior" (or similar quality claims), or that use fancy names for materials to hide what is actually used in the product. Sometimes companies use deceptively similar spellings on products -- “silicon" instead of “silicone." Other packaging uses a sleight-of-hand, for instance, identifying a sex toy as being made of silicone, but, in actuality, the toy contains only a minute amount of silicone, while being chock full of much less healthy ingredients. One tip, says Weiss: products that are not using the genuine materials often place a trademark or registered symbol after the name of product material because they are made-up marketing terms. Those using the actual safe and genuine ingredients, such as silicone or stainless steel, will not bear a trademark because those materials, like silver or pearls, can’t be “owned" or subjected to name ownership.

“And if you're buying new, of course, go for something long lasting, with rechargeable batteries and designed to last," recommends Weiss.

Disposing of old sex toys in an eco-friendly fashion can be an even more daunting project than buying them. Instead of throwing old products in a landfill, sex toy recycling programs offer an alternative, but they are hard to find, especially in the U.S. “The UK is way ahead of us in this regard (check out Love Honey)," said Weiss in an email. She hasn’t found U.S. companies to be reliable in this regard. "I await better news from the industry," said Weiss. “So for now, I'd say hold onto what you've got, and hopefully someone will take the helm."

The biggest eco-sex pet peeve, Weiss said in an interview in MindBodyGreen.com, is the mistaken belief that people may think being eco-friendly will take all the fun out of their sex play. "I hate that people think going green in the bedroom is a bummer -- it's just the opposite," Weiss said. "Going green enhances one's sex life and relationships -- it brings you into closer touch with your sensual self and heightens your awareness. What could be more conducive to getting more pleasure?"

Most important of all, enjoy using your sex toys alone or with a partner. Remember, your sexual health is an important part of your life.

Elizabeth Black was the sex columnist for the British pop culture e-zine, nuts4chic, until it folded in 2008. Her articles about sex, erotica, and relationships have appeared in Good Vibrations Magazine, Alternet, CarnalNation, the Ms. Magazine Blog, Sexis Magazine, On The Issues Magazine, Sexy Mama Magazine, and Circlet Press blog. In addition, she pens erotic fiction, including erotica and erotic romance. Her books may be found on her web site

Also see: Adding Environmental Footprints to Birth Control Choices by Laura Eldridge in this edition of On The Issues Magazine

Also see: Little Girl Lost: Early Puberty Hides Environmental Injustice by Michelle Chen in this edition of On The Issues Magazine

Visit The Café of On The Issues Magazine for new stories and updates.

You Can't Beat Sustainable Green Sex


TH!NK post

Climate Change Through Responsible Sex

The Conferences of Parties promising little, the MDGs proposed by UN are probably the best thing we have for us. Despite disappointing achievent of these goals by many countries, these are, at least where the world generally has an agreement. I see these MDGs as an orientation course for the world leaders and population for the ensuing changes of life and emergence of a new sustainable order of our growth and existence. Of the eight goals almost all are based on some common principles like: improved quality of life, empowerment of women, lower child mortality, better health and awareness. Environmental Sustainability also figures as one of the goals, but in my opinion the whole concept of MDGs is deeply rooted in sustainability – these are not interim goals in any sense.

However, I wish to add one additional goal to this list of eight. I would call it ‘Responsible Sex’.

Sex is one human activity that has the potential to affect our collective future in a more profound way many of us would want to care. A good friend of mine (who happens to be a nun by profession) says: if one cannot create, at least one can procreate! While it is well known that good consummating sex keeps a society healthy, energetic and positive to life, wanton practice of it make a huge number of teen-aged girls world over bogged down with unwanted pregnancy at untimely age. Apart from the risk of STDs, this makes a youthful, productive and creative section of population constrained with possible future obstretic complications, psychological trauma and emotional baggage. Medical Termination of Pregnancy is only an ‘end-of-pipe’ cure and reports of suppression of the ‘face losing’ pregnancy, quack-handling of abortions and religious guilt feeling do not help at all. Even when two consenting adults copulate, there is always a probability of ushering in of a new life in this world where teeming billions are competing for consuming finite resources. Sex is fun but it is a responsible fun where its consequences are properly evaluated and taken care of.

I am fully aware that by saying this I run the risk of being dabbed a ‘killjoy’ and a perfect doomsayer (oh my god, can we not f*** in peace?). I am not against sex, hell no, I am no saint myself. But please think about it. If we extend the scope of sex to the inevitable conception and gestation, this is one activity which is heavily and almost unfairly tilted towards the females and females should have a ‘say’ on it. Look at the world and tell me, excepting very few low-population and ‘developed’ countries, do the females have so much of a say on this? I find the idea of ‘safe sex’ a bit hollow in this juncture. Is there anything such as ‘safe sex’? Condoms? Pills? Biologically the idea of sex for procreation is preordained in us, genetically and under great evolutionary pressure. Humans are the only animals having no mating season, no mating territory. ‘Safe sex’ seems to me an oxymoron, playing dangerously with nature with uncertain payoff.

Responsible sex is the need of the day. Depopulation is a hated word to many but just by hating the word our problems do not vanish. One baby per couple can as quickly bring the population back to a bearable level because the exponential function works equally efficiently either way – explosion and implosion. That with a responsible and smart sexual orientation can solve half of our problems. Thailand is an interesting case in point. Still about a decade ago, this country was bogged down with poverty, runaway childbirth rates, high child mortality rates and all population related vices. Thailand being traditionally liberated regarding sex, it almost attained the status of a ‘nursery state’ of the world. Please check here the inspiring talk by Mechai Viravaidya about how Thailand solved the crisis by just bring in a condom revolution. In order for that revolution to happen in Thailand they had condoms ‘blessed’ by holy men and traffic police handing out condoms to traffic violators.

However what was good for Thailand may not necessarily be good for China, India or US. Disposal of condoms is a bit tricky. Most condoms are made of latex, which is moderately bio-degradable, but disposing condoms by flushing through toilets is a big ‘no no’. Firstly because latex does not bio-degrade under water and secondly because they can choke your sewer with embarrassing efficiency. In recently concluded Common Wealth Games in Delhi there had been several instances of sewer chokages by discarded condoms from games village ( looks like it had been one great interracial free for all!). Female condoms are mostly polyurethane which does not bio-degrade at all. Lambskin condoms are bio-degradable but not effective against STDs. So a global condom revolution is fraught with largescale pollution. It remains the challenge for the technologists to find a eco-friendly birth-control device that is cheap, efficient and has a ‘coca-cola’ like reach for common people (everyday there is roughly 1.3 billion servings of coca-cola all over the world).

Sex is a touchy issue. It is an expression of love, commitment, relationship and emotion. When it is such, it is responsible sex. We need to cut the rest as crap. The Climate Change will be sincerely tackled with a sensible population.

Category: Sustainable Development, | Tags:

The Real Reason for Sexual Behavior: It Feels So Fine


What if everything we've ever learned about our basic motivation to have sex — the procreation of the species — is unequivocally wrong?

What if everything we’ve ever learned about our basic motivation to have sex — the procreation of the species — is unequivocally wrong? What if making babies is a byproduct of the real purpose of our couplings?

The standard explanation for our sexual choices for the past twenty years has been Sexual Strategies Theory: women are choosy about their partners because they need someone strong and resourceful to take care of their offspring, a guy likely to stick around during those tumultuous child-rearing years. Men, on the other hand, have an evolutionary drive to propagate their seedlings far and wide, preferably in young, fertile wombs belonging to faithful partners. This pits the genders (I use that word in the traditional sense, no insult intended to queers) against one another, creating dysfunctional mating and marriage patterns.

But Madsen’s journey is confirmation that something besides procreation drives our dalliances. A happily married mother of teenage boys enjoying weekly visits with her Therapist-cum-Adonis Sacred Intimate is looking for something, but it ain’t a papa for her brood.

And if baby making was the reason for our factories in the first place, how do we explain all our non-productive humping? Humans have very “unproductive” sex by evolutionary standards, on the odds of hundreds of couplings per successful insemination.

Forget the phrase, screwing like bunnies: if people were truly like the majority of animals, we’d hook up during estrus only. Instead, we are a decidedly horny species capable of extreme sexual acts. And the female orgasm is bar none an experience to behold with many paths — clitoral, vaginal, g-spot, etc. — shaking our booties and bedrooms. There’s more than genetic strategizing going on behind closed doors.

Picky Lovers

That women are “choosier” than men is scientifically verified. A commonly referenced 1989 study, by psychologists Russell Clark and Elaine Hatfield, asked female college students to introduce themselves to a male colleague and offer sex. In those trials, up to 75 percent of the guys said yes. When the roles were reversed, not a single woman was interested in casual sex with the guys.

On face value, this supports the Sexual Strategies Theory, but not why so many women engage in hanky-panky on the side. Female infidelity is often blamed on hormonal cycles: we choose the nurturing beta male as a primary mate, but are drawn to the squared-jawed alpha when we are ovulating. One problem with this scenario is that under differing circumstances, one woman’s beta is another one’s alpha. Our mate selection and bodies’ responses to sexual stimuli are often at odds with what we’ll admit to, as compared to males. Female sexuality is a hot consommé of desire, attraction and lust, which keeps punching holes in this French letter.

Girls Just Wanna Have Fun If…

More nuanced explorations are patching things up. Terri Conley, a University of Michigan psychologist with a keen interest in gender differences in sexual behaviors, dismantled some of the assumptions in the 1989 studies in her recently published work. For starters, the Juliettes in the original protocols were better at soliciting casual sex than the Romeos, thereby skewing the results in ways some have suggested reinforced the ideals of modern family structure ala 1950s. It wouldn’t be the first time science was accused of massaging the data towards particular outcomes.

Conley also factored in a solicitor’s good looks; by offering subjects attractive vs. unattractive potential lovers (Angelina Jolie and Rosanne Barr for the men, Johnny Depp and Donald Trump for the women) she discovered a more level casual sex playing field. If women really wanted a sugar daddy, The Donald would have secured himself some hypothetical pootie tang. But Depp was the preferred aphrodisiac. Another key difference was introducing women past childbearing as potential partners (Christie Brinkley). Men, it turned out, are eager for beaver if the cougar is hot. With regard to casual sex, both men and women were almost equally as likely to accept an offer if the proposer was attractive, and reject the offer from an unattractive but famous individual.

Conley’s conclusion? Gender differences towards casual sex be damned. “The extent to which women and men believed that the proposer would be sexually-skilled predicted how likely they would be to engage in casual sex with this individual.”

Turns out, girls want to have fun as much as the boys…under the right circumstances. Which brings us back to Madsen and every other women opening up her envelope to would-be lovers. We aren’t motivated by procreative evolutionary success but are seeking, quite simply: Pleasure.

Pleasure Theory

This brings us to a significant juncture in our understanding of how we choose the lovers we do, and why men are less picky than women. Given the chance to sleep with someone, males can pretty much count on sexual satisfaction: orgasm and ejaculation, while not synonymous in men, are highly probable, the first and most times with a lover.

Women, on the other hand, have the greater capacity for overall sexual pleasure, but reach orgasm more slowly and less often, in general. But during first time encounters, women orgasm only about a third of the time. And finally, there’s the matter of social stigmas and personal safety: unlike men, women’s sexuality is politicized, and we are often compelled to make sure our potential lover is trustworthy (even if he is a stranger).

Pleasure Theory is a revolutionary evolutionary sexplanation for why we make love that accounts for the hiccups inherent in Sexual Strategies Theory. It suggests that the pursuit of pleasure is the central motivating drive for human sexuality, and that reproduction is a byproduct of our sexual acts. We are making love, not to pass on our genes, but because it feels so damn good — with the right lover, of course.

Monday, April 11, 2011

Progressive Brains Have More Gray Matter


A new study shows liberals have more gray matter in a part of the brain related to understanding complexity, while the conservative brain is bigger in the section linked to fear.

April 10, 2011 |

Everyone knows that liberals and conservatives butt heads when it comes to world views, but scientists have now shown that their brains are actually built differently.

Liberals have more gray matter in a part of the brain associated with understanding complexity, while the conservative brain is bigger in the section related to processing fear, said the study on Thursday in Current Biology.

"We found that greater liberalism was associated with increased gray matter volume in the anterior cingulate cortex, whereas greater conservatism was associated with increased volume of the right amygdala," the study said.

Other research has shown greater brain activity in those areas, according to which political views a person holds, but this is the first study to show a physical difference in size in the same regions.

"Previously, some psychological traits were known to be predictive of an individual's political orientation," said Ryota Kanai of the University College London, where the research took place.

"Our study now links such personality traits with specific brain structure."

The study was based on 90 "healthy young adults" who reported their political views on a scale of one to five from very liberal to very conservative, then agreed to have their brains scanned.

People with a large amygdala are "more sensitive to disgust" and tend to "respond to threatening situations with more aggression than do liberals and are more sensitive to threatening facial expressions," the study said.

Liberals are linked to larger anterior cingulate cortexes, a region that "monitor(s) uncertainty and conflicts," it said.

"Thus, it is conceivable that individuals with a larger ACC have a higher capacity to tolerate uncertainty and conflicts, allowing them to accept more liberal views."

It remains unclear whether the structural differences cause the divergence in political views, or are the effect of them.

But the central issue in determining political views appears to revolve around fear and how it affects a person.

"Our findings are consistent with the proposal that political orientation is associated with psychological processes for managing fear and uncertainty," the study said.

Sunday, April 10, 2011

Empathic Listening


Empathic Listening

By Richard Salem

The Benefits of Empathic Listening

Empathic listening (also called active listening or reflective listening) is a way of listening and responding to another person that improves mutual understanding and trust. It is an essential skill for third parties and disputants alike, as it enables the listener to receive and accurately interpret the speaker's message, and then provide an appropriate response. The response is an integral part of the listening process and can be critical to the success of a negotiation or mediation. Among its benefits, empathic listening

  1. builds trust and respect,
  2. enables the disputants to release their emotions,
  3. reduces tensions,
  4. encourages the surfacing of information, and
  5. creates a safe environment that is conducive to collaborative problem solving.

Though useful for everyone involved in a conflict, the ability and willingness to listen with empathy is often what sets the mediator apart from others involved in the conflict.

Even when the conflict is not resolved during mediation, the listening process can have a profound impact on the parties. Jonathon Chace, associate director of the U.S. Community Relations Service, recalls a highly charged community race-related conflict he responded to more than 30 years ago when he was a mediator in the agency's Mid-Atlantic office. It involved the construction of a highway that would physically divide a community centered around a public housing project. After weeks of protest activity, the parties agreed to mediation. In the end, the public officials prevailed and the aggrieved community got little relief. When the final session ended, the leader of the community organization bolted across the floor, clasped the mediator's hand and thanked him for being "different from the others."

"How was I different?" Chace asked. "You listened," was the reply. "You were the only one who cared about what we were saying."[1]

William Simkin, former director of the Federal Mediation and Conciliation Service and one of the first practitioners to write in depth about the mediation process, noted in 1971 that "understanding has limited utility unless the mediator can somehow convey to the parties the fact that [the mediator] knows the essence of the problem. At that point," he said, "and only then, can (the mediator) expect to be accorded confidence and respect."[2]

Simkin was writing about more than the need to understand and project an understanding of the facts. Understanding "is not confined to bare facts," he said. "Quite frequently the strong emotional background of an issue and the personalities involved may be more significant than the facts." He suggested that mediators apply "sympathetic understanding,"[3] which in reality is empathic listening.

How to Listen with Empathy

Empathy is the ability to project oneself into the personality of another person in order to better understand that person's emotions or feelings. Through empathic listening the listener lets the speaker know, "I understand your problem and how you feel about it, I am interested in what you are saying and I am not judging you." The listener unmistakably conveys this message through words and non-verbal behaviors, including body language. In so doing, the listener encourages the speaker to fully express herself or himself free of interruption, criticism or being told what to do. It is neither advisable nor necessary for a mediator to agree with the speaker, even when asked to do so. It is usually sufficient to let the speaker know, "I understand you and I am interested in being a resource to help you resolve this problem."

While this article focuses on mediation, it should be apparent that empathic listening is a core skill that will strengthen the interpersonal effectiveness of individuals in many aspects of their professional and personal lives.[4] Parties to unassisted negotiations -- those that do not involve a mediator -- can often function as their own mediator and increase their negotiating effectiveness through the use of empathy. Through the use of skilled listening these "mediational negotiators" can control the negotiation by their:

  1. willingness to let the other parties dominate the discussion,
  2. attentiveness to what is being said,
  3. care not to interrupt,
  4. use of open-ended questions,
  5. sensitivity to the emotions being expressed, and
  6. ability to reflect back to the other party the substance and feelings being expressed.

The power of empathic listening in volatile settings is reflected in Madelyn Burley-Allen's description of the skilled listener. "When you listen well," Burley-Allen says, "you:

  1. acknowledge the speaker,
  2. increase the speaker's self-esteem and confidence,
  3. tell the speaker, "You are important" and "I am not judging you,"
  4. gain the speaker's cooperation,
  5. reduce stress and tension,
  6. build teamwork,
  7. gain trust,
  8. elicit openness,
  9. gain a sharing of ideas and thoughts, and
  10. obtain more valid information about the speakers and the subject."[5]

To obtain these results, Burly-Allen says, a skilled listener:

  1. "takes information from others while remaining non-judgmental and empathic,
  2. acknowledges the speaker in a way that invites the communication to continue, and
  3. provides a limited but encouraging response, carrying the speaker's idea one step forward."

Empathic Listening in Mediation

Before a mediator can expect to obtain clear and accurate information about the conflict from a party who is emotionally distraught, it is necessary to enable that party to engage in a cathartic process, according to Lyman S. Steil,[6] a former president of the American Listening Association. He defines catharsis as "the process of releasing emotion, the ventilation of feelings, the sharing of problems or frustrations with an empathic listener. Catharsis," he continues, "basically requires an understanding listener who is observant to the cathartic need cues and clues. People who need catharsis will often give verbal and non-verbal cues, and good listeners will be sensitive enough to recognize them. Cathartic fulfillment is necessary for maximized success" at all other levels of communication.

"Cathartic communication," Steil continues, "requires caring, concerned, risk-taking and non-judgmental listening. Truly empathic people suspend evaluation and criticism when they listen to others. Here the challenge is to enter into the private world of the speaker, to understand without judging actions or feelings."

Providing empathic responses to two or more parties to the same conflict should not present a problem for a mediator who follows the basic principles of active listening. The mediator demonstrates objectivity and fairness by remaining non-judgmental throughout the negotiation, giving the parties equal time and attention and as much time as each needs to express themselves.

Parties to volatile conflicts often feel that nobody on the other side is interested in what they have to say. The parties often have been talking at each other and past each other, but not with each other. Neither believes that their message has been listened to or understood. Nor do they feel respected. Locked into positions that they know the other will not accept, the parties tend to be close-minded, distrustful of each other, and often angry, frustrated, discouraged, or hurt.

When the mediator comes onto the scene, he or she continuously models good conflict-management behaviors, trying to create an environment where the parties in conflict will begin to listen to each other with clear heads. For many disputants, this may be the first time they have had an opportunity to fully present their story. During this process, the parties may hear things that they have not heard before, things that broaden their understanding of how the other party perceives the problem. This can open minds and create a receptivity to new ideas that might lead to a settlement.[7] In creating a trusting environment, it is the mediator's hope that some strands of trust will begin to connect the parties and replace the negative emotions that they brought to the table.

Mediator Nancy Ferrell, who formerly responded to volatile community race-related conflicts for the Dallas Office of the U.S. Community Relations Service, questions whether mediation can work if some measure of empathy is not developed between the parties. She describes a multi-issue case involving black students and members of a white fraternity that held an annual "black-face" party at a university in Oklahoma. At the outset, the student president of the fraternity was convinced that the annual tradition was harmless and inoffensive. It wasn't until the mediator created an opportunity for him to listen to the aggrieved parties at the table that he realized the extraordinary impact his fraternity's antics had on black students. Once he recognized the problem, a solution to that part of the conflict was only a step away.

Ferrell seeks clues that the parties will respond to each other with some measure of empathy before bringing them to the table. Speaking of conflicts between parties who had a continuing relationship, she said, "One of my decisions about whether they were ready to meet at the table was whether or not I could get any glimmer of empathy from all sides. ... If I couldn't get some awareness of sensitivity to the other party's position, I was reluctant to go to the table. ... If you can't create empathy, you can't have a relationship. Without that, mediation is not going to work."[8]

George Williams, who was a volunteer mediator at Chicago 's Center for Conflict Resolution after he retired as president of American University, recalled an incident in an entirely different type of dispute in the mid-1980s. The conflict was between a trade school and a student who had been expelled for what appeared to him to be a minor infraction of the rules, shortly after paying his full tuition. After losing his internal appeal, he considered a lawsuit, but chose mediation. The young man fared no better at mediation, yet later profusely thanked Williams for being "the first person who listened to what I had to say."

Listening: A Learnable Skill

As many mediators, including myself, have come to understand, listening is a learnable skill. Unfortunately, it is not typically taught along with other communication skills at home or in school. I spend more time listening than using any other form of communication, yet as a youngster I was never taught the skill. I spent long hours learning to read and write and even had classroom training in public speaking, but I never had a lesson in listening or thought of listening as a learnable skill until I entered the world of mediation as an adult. While some may have had better experiences during their formative years, for many listening is often treated the same as "hearing." We do not ordinarily receive instruction in using our other senses -- smell, sight, touch and taste -- so why give lessons in hearing (sound)? A message that listening was an important skill to learn would have fallen on deaf ears when I was a child. Perhaps now that peer mediation is being taught in many classrooms across the nation, when children are taught to "Listen to your elders," they also will be taught by elders who model good listening skills.

Guidelines for Empathic Listening

Madelyn Burley-Allen offers these guidelines for empathic listening:

  1. Be attentive. Be interested. Be alert and not distracted. Create a positive atmosphere through nonverbal behavior.
  2. Be a sounding board -- allow the speaker to bounce ideas and feelings off you while assuming a nonjudgmental, non-critical manner.
  3. Don't ask a lot of questions. They can give the impression you are "grilling" the speaker.
  4. Act like a mirror -- reflect back what you think the speaker is saying and feeling.
  5. Don't discount the speaker's feelings by using stock phrases like "It's not that bad," or "You'll feel better tomorrow."
  6. Don't let the speaker "hook" you. This can happen if you get angry or upset, allow yourself to get involved in an argument, or pass judgment on the other person.
  7. Indicate you are listening by
    • Providing brief, noncommittal acknowledging responses, e.g., "Uh-huh," "I see."
    • Giving nonverbal acknowledgements, e.g., head nodding, facial expressions matching the speaker, open and relaxed body expression, eye contact.
    • Invitations to say more, e.g., "Tell me about it," "I'd like to hear about that."
  8. Follow good listening "ground rules:"
    • Don't interrupt.
    • Don't change the subject or move in a new direction.
    • Don't rehearse in your own head.
    • Don't interrogate.
    • Don't teach.
    • Don't give advice.
    • Do reflect back to the speaker what you understand and how you think the speaker feels.[9]

The ability to listen with empathy may be the most important attribute of interveners who succeed in gaining the trust and cooperation of parties to intractable conflicts and other disputes with high emotional content. Among its other advantages, as Burley-Allen points out, empathic listening has empowering qualities. Providing an opportunity for people to talk through their problem may clarify their thinking as well as provide a necessary emotional release. Thomas Gordon agrees that active listening facilitates problem-solving and, like Burley-Allen's primer on listening,[10] Gordon's "Leadership Effectiveness Training"[11] provides numerous exercises and suggestions for those seeking to strengthen their listening skills.

[1] Richard Salem, "Community Dispute Resolution Through Outside Intervention," Peace & Change Journal VIII, no. 2/3 (1982)

[2] William Simkin, Mediation and the Dynamics of Collective Bargaining (BNA Books, 1971)

[3] Ibid.

[4] Books on effective listening cited in this paper primarily address the topic in one-on-one situations and use examples in both personal and professional settings. Three books by Thomas Gordon all use the same communication models in a variety of settings. They are Gordon's Leadership Effectiveness Training, (Bantam Books, 1977), Teacher Effectiveness Training, (1974), and Parent Effectiveness Training.

[5] Madelyn Burley-Allen, Listening the Forgotten Skill, (John Wiley & sons, 1982). Burley-Allen is a former president of the American Listening Assn.

[6] Lyman K. Steil, "On Listening...and Not Listening," Executive Health, (newsletter, 1981). Dr. Steil is a former president of the American Listening Assn. See also, "Effective Listening," by Steil, Barker and Watson, McGraw Hill, 1983 and "Listening Leaders," Beaver Press, forthcoming, 2003.

[7] Labor mediator Walter Maggiolo wrote that the effective mediator performs the following four essential tasks: (1) Understand and appreciate "the problems confronting the parties;" (2) Impart to the parties "the fact that the mediator knows and appreciates their problems;" (3) create "doubts in the minds of the parties about the validity of the positions they have assumed with respect to the problems;" and (4) surface or suggest "alternative approaches which may facilitate agreement." W. Maggiolo, "Techniques of Mediation," 1985.

[8] Nancy Ferrell, Oral History, Civil Rights Mediation Project, available at http://www.colorado.edu/conflict/civil_rights/.

[9] Ibid, 101-102.

[10] Ibid.

[11] Thomas Gordon, Leadership Effectiveness Training, (Bantam Books, 1977). See also, Thomas Gordon, Teacher Effectiveness Training (1974).

Use the following to cite this article:
Salem, Richard. "Empathic Listening." Beyond Intractability. Eds. Guy Burgess and Heidi Burgess. Conflict Research Consortium, University of Colorado, Boulder. Posted: July 2003 <http://www.beyondintractability.org/essay/empathic_listening/>

Sources of Additional, In-depth Information on this Topic

Additional Explanations of the Underlying Concepts:

Online (Web) Sources

Active Listening.
Available at:
Active listening is designed to overcome poor listening practices by requiring parties to listen to and then restate their opponent's statements, emphasizing the feelings expressed as well as the substance. The purpose is to confirm that the listener accurately understands the message sent and acknowledges that message, although the listener is not required to agree.

Conflict Research Consortium Staff. Communication Improvement.
Available at:
This page briefly discusses the impacts of misunderstanding in social conflicts and goes on to make suggestions about how to improve communication between parties.

Dialogic Listening.
Available at:
Dialogic listening is similar to active listening, although it emphasizes conversation as a shared activity and stresses an open-ended, playful attitude toward the conversation. In addition, the parties focus on what is happening between them (rather than each party focusing on what is going on within the mind of the other), and it focuses on the present more than on the past or the future.

Gallozi, Chuck. Misunderstanding.
Available at:
This article discusses misunderstanding, how it arises, and what people can do to eliminate it. Specifically, the author promotes empathic listening as the way toward ending misunderstanding.

Practicing Listening Skills.
Available at:
A one-page list of tips on how to be a better a listener.

Offline (Print) Sources

Salem, Richard. "Community Dispute Resolution Through Outside Intervention." Peace & Change 8:2/3, January 1, 1982.
This essay describes how third parties, through the use of empathetic listening, can help resolve or transform community conflicts.

Thomas, Milt and John Stewart. "Dialogic Listening: Sculpting Mutual Meanings ." In Bridges Not Walls. Edited by Stewart, John, ed. New York: McGraw-hill, 1995.
The authors define and identify three problems with active or empathic listening. They go on to contrast dialogic listening to active or empathic listening and uncover four distinctive characteristics of dialogic listening. Click here for more info.

Steil, Lyman K. Effective Listening: Key to Your Success. Addison Wesley Publishing Company, December 1982.

Madelyn, Burley-Allen. Listening: The Forgotten Skill: A Self-Teaching Guide, 2nd Edition. John Wiley & Sons, February 1995.
This guide details the key points of effective listening, and explains how one can not only acquire, but also productively use this skill to enhance your business and personal life.

Gordon, Thomas. Parent Effectiveness Training: The Proven Program for Raising Responsible Children . New York: Three Rivers Press, October 2000.
"P.E.T., or Parent Effectiveness Training, began almost forty years ago as the first national parent-training program to teach parents how to communicate more effectively with kids and offer step-by-step advice to resolving family conflicts so everybody wins. This beloved classic is the most studied, highly praised, and proven parenting program in the world -- and it will work for you. Now revised for the first time since its initial publication, this groundbreaking guide will show you: How to avoid being a permissive parent; How to listen so kids will talk to you and talk so kids will listen to you; How to teach your children to "own" their problems and to solve them; How to use the "No-Lose" method to resolve conflicts." -Amazon.com

Burch, Noel and Thomas Gordon. Teacher Effectiveness Training: The Program Proven to Help Teachers Bring Out the Best in Students. Three Rivers Press, August 26, 2003.
T.E.T. (Teacher Effectivness Training) can mean the difference between an unproductive, disruptive classroom and a cooperative, productive environment in which students flourish and teachers feel rewarded. You will learn: What to do when students give you problems; How to talk so that students will listen; How to resolve conflicts so no one loses and no one gets hurt; How to best help students when they?re having a problem; How to set classroom rules so that far less enforcement is necessary; How to increase teaching and learning time. (Amazon) Click here for more info.

Maggiolo, Walter. Techniques of Mediation. New York: Oceana Publications, December 1985.
This work spells out four essential ingredients a mediator needs to bring to the labor negotiation table: know the problem; let the parties know you understand the issues and their concerns; caste doubt on the soundness of each parties position; and suggest alternatives that each side can live with. It also highlights the importance of not just listening to each, but listening with understanding.

Examples Illustrating this Topic:

Online (Web) Sources

Monroe, Cynthia, Gene Knudsen Hoffman and Leah Green. "Compassionate Listening: An Exploratory Sourcebook about Conflict Transformation." , August 2001
Available at:

This piece covers Gene Knudsen Hoffman's reconciliation process Compassionate Listening. Descriptions of projects in Israel/Palestine and Alaska are described, and lesson plans for training in compassionate listening are included, on topics such as forgiveness, hatred and denial. Also available on website as several, smaller HTML files.

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Teaching Materials on this Topic:

Online (Web) Sources

International Listening Association (ILA).
Available at:
The International Listening Association promotes the study, development, and teaching of listening and the practice of effective listening skills and techniques. Their "resources" page lists several listening exercises.

Offline (Print) Sources

Gordon, Thomas. Leader Effectiveness Training (L.E.T.): The Proven People Skills for Today's Leaders Tomorrow. Perigee, October 9, 2001.
"L.E.T. has changed countless corporations and private businesses-including many Fortune 500 companies-with its down-to-earth communication and conflict resolution skills. Now, this indispensable source has been newly revised with updated research and timely case studies." -Amazon.com

Beyond Intractability Version IV
Copyright © 2003-2010 The Beyond Intractability Project
Beyond Intractability is a Registered Trademark of the University of Colorado
Project Acknowledgements

The Beyond Intractability Knowledge Base Project
Guy Burgess and Heidi Burgess, Co-Directors and Editors
c/o Conflict Information Consortium (Formerly Conflict Research Consortium), University of Colorado
Campus Box 580, Boulder, CO 80309
Phone: (303) 492-1635; Fax: (303) 492-2154; Contact