Research Proposal Assignment

Volume 4 1 /Number 3/July 2019/Pages 242-259/https: 11 ioi.org! IO.I7744/mehc.4l .3.04

NEUROCOUNSELING

Fostering Intrinsic Resilience: A Neuroscience-Informed Model of Conceptualizing and Treating Adverse Childhood Experiences

Eraina Schauss Greg Horn

Frances Ellmo Tegan Reeves Haley Z e ttle r

Debra Bartelli Pam Cogdal

Steven West

An increasingly common dialogue among mental health professionals revolves around adverse childhood experiences (ACEs) and developmental trauma. ACEs can occur in a number of ways with a myriad of potential outcomes, often making treatment choices difficult. During critical stages of neurodevelopmental growth, trauma makes a mark on the brain and body at a physi­ ological level. Although the National Institute of Mental Health’s Research Domain Criteria have been used to address this brain-body impact, the far-reaching scope of implications needs grounding in a theoretical framework. The current paper discusses developmental trauma and proposes a new reciprocally determinant model that advocates for neuroscience-informed coun­ seling interventions such as neurofeedhack therapy. Clinical implications and considerations for counselors are discussed.

Eraina Schauss, Department o f Counseling, Educational Psychology and Research, The University o f Memphis: Greg Horn, Department o f Counseling, Educational Psychology and Research, The University o f Memphis: Frances Ellmo, Department o f Counseling, Educational Psychology and Research, The University o f Memphis: Tegan R e e ve s, Department o f Counseling. Educational Psychology and Research, The University o f Memphis: Haley Zettler, Department o f Criminology and Criminal Justice, The University o f Memphis: Debra Bartelli, School o f Public Health, The University o f Memphis: Pam Cogdal, Department o f Counseling. Educational Psychology and Research, The University o f Memphis: Steven West, Department o f Counseling, Educational Psychology and Research. The University o f Memphis. This research is supported by a Memphis Research Consortium Grant (Grant #2 3 2 0 0 0 ) to the University o f Memphis in partnership with the University o f Tennessee H ealth Science Center. This article also acknowledges Kristi Nobbman in the conceptual development o f the reciprocally determinant b ra in - body model. Correspondence concerning this article should be addressed to Eraina Schauss, Department o f Counseling, Educational Psychology and Research, Patterson H all Room 123, The University o f Memphis, Memphis, TN 38152. E-mail: eschauss@memphis.edu

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Mental health professionals increasingly seek information on approaches to childhood maltreatment in terms of the prevention and treatment of trau­ matic response. Counselors seeking applicable information often find theories and approaches siloed within specialties and fields of practice. For instance, social, interpersonal, and biological theories each provide useful explanations, yet are limited in explaining how such variables interact. The model we present provides insight into the concept of developmental trauma by examining the reciprocal interaction of clients’ environment, behavior, and personal factors and a regulatory self-system (Bandura, 1978) that includes biological and neu­ rological processes. This theoretical framework aims to bridge important fields of research including developmental psychology and neuroscience.

ADVERSE CHILDHOOD EXPERIENCES AND DEVELOPMENTAL TRAUMA

Adverse childhood experiences (ACEs) include abuse (emotional, phys­ ical, and sexual), household challenges (e.g., witnessing parent-to-parent violence, household substance abuse, mental illness in household, parental separation or divorce, incarcerated household member), and emotional and physical neglect (Felitti et ah, 1998). Since Felitti et al. (1998) found in their seminal study that ACEs were linked to chronic illness in adulthood and early morbidity, research examining the profound impact of ACEs has become a priority for the Centers for Disease Control and Prevention (2018) and other research organizations. In the past two decades, this extensive field of research has established early childhood maltreatment as a significant etiological factor for a wide range of health and psychological conditions. A comprehensive review of this literature is beyond the scope of this article; however, to summa­ rize, children and adolescents who experience a high number of ACEs tend to manifest an increased num ber of psychiatric conditions (Giaconia et al., 1995) and a multitude of behavioral and health-related complications throughout their life span (Schilling, Aseltine, & Gore, 2007). Research also indicates that ACEs are more common among youth with juvenile justice involvement (Zettler, Wolff, Baglivio, Craig, & Epps, 2017). The long-term physiological response to trauma appears to link ACEs and chronic health problems (van der Kolk, 1994). Specifically, a dose effect was found linking greater ACE exposure in children and adolescents with greater instances of obesity, diabetes, heart disease, maladaptive sleep patterns, autoimmune disorders, and inflammation, ultimately leading to a lifetime of chronic physical and mental illness (Felitti et al., 1998).

Felitti et al. (1998) further theorized a causal link between ACEs and early death mediated by three categories of factors in a linear fashion. According to

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their model, ACEs lead to social, emotional, and cognitive impairment, which, in turn, leads to the adoption of health-risk behaviors, often resulting in dis­ ease, disability, and ultimately early death. This explanation, which admirably accounts for social and psychological factors, represents the medical model, which tends to identify (and treat) the root cause of pathology in a linear fashion. The medical model is the long-standing dominant model in health care (Engel, 1977), has many strengths, and is clearly an appropriate model for understanding the factors that lead to early death.

However, the medical model also has significant limitations, especially when applied to dynamic social and interpersonal processes. For instance, due to the assumption of cause and effect, when applied to ACEs, the medical model can imply that “what is done is done” and suggest a sense of hopeless­ ness to clients and a subsequently defeatist and challenging position for coun­ selors. In addition, the scale used to measure ACEs assigns the same weight to each type of adverse experience (Felitti et ah, 1998). However, research shows that not all childhood maltreatment has an equal effect; some adverse experiences are more traumatizing than others (Schwartz & Perry, 1994), and the degree of long-term traumatic effects can depend on subjective mediating factors such as loneliness (Shelvin, McElroy, & Murphy, 2015) or social sup­ port (Allbaugh et ah, 2018). The medical model does little to acknowledge the subjective experience of an individual. In addition, the ACE scale is additive, as researchers have argued that they are interested in the cumulative effect of ACEs (Thompson, Richards, & Gaysina, 2017). However, an additive measure of adverse experience does not acknowledge possible interaction effects. In such instances, 1 + 1 does not necessarily equal 2 when adverse experiences compound one another and have an exponentially greater negative effect for the child. For example, consider a child whose father is incarcerated and who is physically abused by his overly stressed single mother, with no other adult support to help cope with the physical abuse. Clearly, adverse experiences can have an effect on each other, with the resulting impact being greater than the sum of its parts. Finally, the medical model does not address how previous adverse experiences can make individuals vulnerable to future adverse expe­ riences. For instance, failure to identify traumatic response behaviors as such can exacerbate intense emotions and lead to application of stigmatizing labels such as oppositional, rebellious, unmotivated, or antisocial (van der Kolk, 2005, p. 404), which can have long-term effects on self-concept (Rockett, Murrie, & Boccaccini, 2007).

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VIEWING ADVERSE CHILDHOOD EXPERIENCES THROUGH A RECIPROCAL DETERMINANT LENS

Social, interpersonal, and attachm ent theories have offered explanations for the sequelae of childhood maltreatment and have addressed many of the issues the medical model could not (Siegel, 2012; van der Kolk, 2015). The concept of reciprocal determinism from Bandura’s social learning theory, in our view, provides a particularly useful means by which to address the complex­ ity of issues that arise from ACEs. Bandura (1978) postulated the self system within his reciprocal determinism model to describe cognitive mechanisms by which the individual uses perception and assessment of past or potential future experience to regulate behavior. This process was theorized to involve bidirectional relationships among behavior, person, and environment. Thus, the self system is used as an analytical self-regulatory process and describes the psychosocial interactions within the individual (Bandura, 1978).

Whereas the medical model is limited in that it does not account for reciprocal influences, Bandura’s model is limited in that it does little to address physical and neurological processes in the body. In this paper we propose an expansion of a theoretical model that incorporates an understanding of neurological process in the context of developmental trauma and ACEs. O ur model will be discussed in detail, and implications for clinical practice will be presented.

RESEARCH DOMAIN CRITERIA

An impetus for change in understanding and conceptualizing develop­ mental trauma is the rise of the Research Domain Criteria (RDoC) project, a National Institute of Mental Health (NIMH) movement to develop research frameworks incorporating neurobiological, genetic, behavioral, and cognitive influences on the classification of mental disorders. The RDoC initiative emphasizes neural circuitry, levels of arousal, regulatory systems, social pro­ cesses, cognitions, developmental trajectories, and the dynamic interaction between an individual and their environment. The rise of the RDoC move­ m ent emphasizes the desire for a precision medicine approach, “an emerging approach for disease treatment and prevention that takes into account individ­ ual variability in genes, environment and lifestyle for each person” (National Institutes of Health, as cited in Adams & Petersen, 2016, p. 787), to mental health treatment.

The RDoC paradigm shift comes at a critical time in mental health care. RDoC seeks to foster a more precise way of conceptualizing and treating m ental disorders that will transform treatment and public health outcomes

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through four main objectives. The first strategic objective of RDoC is to define the mechanisms of complex behavior. The second objective is to identify and characterize sensitive periods of brain development across the life span with a goal of determining “the points in time during which the brain is most sensitive to intervention and the underlying molecular and system-level mechanisms responsible for this sensitivity” (NIMH, 2015, p. 32). The third strategic objective of RDoC concerns the areas of treatment, prevention, and cures. The objective seeks to integrate neuroscience, genomics, and evidence-based behavioral science methodologies into more precise treatments. Additionally, a need exists to develop new interventions and tailor current treatments to indi­ vidualized symptoms. The fourth and final RDoC objective is to strengthen the public health impact of NIMH-supported research (NIMH, 2015).

The current ideological shift is to understand and integrate basic neuro­ science findings into evidence-based clinical practice and interventions with the ultimate goal of delivering the most accurate diagnosis at the earliest point, followed by precise and individualized treatments. To pave the way for a pre­ cision medicine approach in mental health counseling, additional diagnostic evaluations must be incorporated into treatment, which examine symptoms, behaviors, cognition, genotype, physiology, environmental exposures, cultural background, and family dynamics (NIMH, 2015). As such, the task of answer­ ing the call of the RDoC must include counselors and not solely medical professionals and scientists.

Our unique counseling perspective brings a much-needed focus on holis­ tic wellness, individualized treatment, and social justice considerations and provides the opportunity to change the way other helping professions concep­ tualize mental health.

INTEGRATING NEUROSCIENCE AND COUNSELING

Given the RDoC emphasis on precision medicine, neuroscience is a logical field for mental health counselors to embrace in order to understand the complex mechanisms underlying mental health disorders. The field of neurocounseling, the “integration of neuroscience into the practice of coun­ seling” (Russell-Chapin, 2016, p. 93), although in its infancy, has already shed new light on how counselors conceptualize and treat clients. Neuroscience findings have profound implications for the field of counseling and provide a heuristic for counselors to use evidence-based treatments with clients with a history of ACEs (Navalta, McGee, & Underwood, 2018). Neuroscientists have identified forms of psychosocial engagement, such as nurturing and caring, healthy behaviors, and environmental enrichment, that promote neuroplasti-

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city (Gonqalves & Perrone-McGovern, 2014), the brain’s ability to reorganize structural neural connections.

One way the brain does this is through a process called memory recon­ solidation. According to Tronson and Taylor (2007), memories that have been learned, or achieve neuronal consolidation, can become labile when activated. During this labile phase, a memory can become either reconsolidated or transformed if contradictory information is presented within a window of time. Tronson and Taylor (2007) argued that this process is distinct from the extinc­ tion process in classical conditioning. This finding has clear implications for emotionally learned processes such as phobias, trauma-related disorders, and some aspects of other anxiety disorders.

In addition, neurons are understood to fire when people feel, think, and behave. Interestingly, neuroscientists have found that mirror neurons fire in a similar pattern when we observe others feeling, thinking, and behaving (Ivey & Zalaquett, 2011). Mirror neurons have implications for counselors’ use of empathy and for work with clients who have difficulty empathizing with oth­ ers. The study of brain networks in neuroscience has strengthened the theory that the brain does not work in isolated sections, but in functionally connected regions. This paradigm has led neuroscientists to hypothesize “pathways” that communicate among the brain’s structures. Some of the brain networks that have been proposed are the default mode network (resting state), attention network, social cognition network, motivational network, and emotional regu­ lation network (Gongalves & Perrone-McGovern, 2014). As implied by these names, these networks facilitate (or do not facilitate) many of the functions addressed in counseling.

Though these neuroscience concepts have clear implications for coun­ seling, counselors may still be at a loss for what to do with them. One concern is that integrating neuroscience into counseling would be reductionist. For instance, neural bases have been used to explain mental health disorders such as posttraumatic stress disorder (PTSD), depression, and anxiety disorders (Grawe, 1997). Some may be tempted to localize a disorder to a specific cere­ bral region and neglect social, cultural, and interpersonal factors. However, neuroscientists have long viewed the brain as a dynamic system with complex networks (Cole, 1978), and more recently as a system that informs and is shaped by the social and interpersonal environment (Siegel, 2012). Though it may be tempting to reduce mental health conditions to a specific region of the brain, research supports a reciprocal view of the interaction between the brain and the environment. Therefore, a comprehensive and pragmatic model is needed, one that integrates social and regulatory factors that counselors can use to inform assessments, hypotheses, and treatment decisions.

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Linear counseling models have been offered to consider the complex neural processes that occur during the counseling process and how these processes affect or are affected by the environment. Decety & Jackson (2004) outlined the parallel neural processes that occur during key components of empathy, such as self-awareness, mental flexibility, and emotion regulation. Gonsalves and Perrone-McGovern (2014) presented a linear model that posits the interpersonal and environmental factors that influence the psychological process, which in turn affect brain networks, which impact developmental tasks. Though these models effectively integrate neuroscience and counseling, they fail to address the reciprocal interaction between the brain and the envi­ ronment.

THE RECIPROCALLY DETERMINANT BRAIN-BODY MODEL

Our approach extends the reach of current counseling interventions that address the aftermath of ACE exposure and acknowledges the interactive influence of environment and behavioral patterning within the brain and body. This addition to current family and social systems approaches assumes a reciprocal relationship among environment, behavior, person, and physiology (brain-body).

Regarding research on neurobiophysiological factors of development (Siegel, 2012; van der Kolk, 2015), we extend the model of reciprocal deter­ minism to include physiology, or the brain-body connection. This extended neurobiophysiological model of reciprocal determinism provides a theoretical framework for research examining how integrated therapies, such as neuro­ feedback (NEB), facilitate the regulation of brainwave activity, emotional and behavioral self-regulation, and physiology. Further, the model provides a con­ text for diagnosing maladaptive stress responses that may present as a myriad of symptom clusters and/or co-occurring disorders.

In our model, neurobiophysiological functioning such as the vagal response (i.e., fight, flight, or freeze; Porges, 2011) and neuro-maladaptation (Siegel, 2012) influences the interaction of the person, environment, and behavior. When the self-regulatory system does not adequately develop or is interrupted by environmental demands, hyperarousal becomes chronic (Levine, 1997), which in turn affects perception and behavior toward the current environment. Responses during developmental experiences involve neurological and physiological changes in the central and peripheral nervous systems (Porges, 2011). Based on an understanding of research addressing the brain-body connection, the use of cognitive and behavioral therapies appears insufficient to address maladaptive responses, as these therapies only focus on change in one aspect of the self system and not the entire system.

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Person An individual’s personality and temperament have a bidirectional rela­

tionship to behavior and environment. An individual who has been exposed to trauma during a developmentally sensitive period may have maladaptive patterns of coping and dissociation that can lead to poor health. For example, stressors early in life can cause dysfunction in the brain-gut microbiota axis and therefore increase the likelihood of disease and alter cognitions, moods, and emotions (Cryan & Dinan, 2012; Rhee, Pothoulakis, & Mayer, 2009).

Behavior An individual’s behavior can influence and be influenced by their person

and environment. An individual who has been exposed to trauma in a devel­ opmentally sensitive period may present with a myriad of bidirectional mal­ adaptive behavioral responses, from aggression to juvenile delinquency. For an individual exposed to trauma, the reciprocally deterministic nature of behavior with environment and person can be better understood and influenced through an integrated lens. Maladaptive behaviors in adolescence, such as aggression and poor regulation, are mechanisms in reaction to a stimulus. Responding to stress involves internal systems such as the autonomic nervous system (Porges, 2009) and is often a learned behavior (Bandura, 1978). Autonomic dysregula- tion, or hypersensitivity, may explain higher rates of conduct problems such as aggression and delinquency (Beauchaine, Gatzke-Kopp, & Mead, 2007).

Environment An individual’s environment from prenatal inception to death includes

physical environment, attachment, and genetic expression. An individual who has been exposed to environmental trauma in a developmentally sen­ sitive period may present a number of social and physiological maladaptive responses. Long-standing research on bonding and attachment underlines the importance of environment for healthy, adaptive development. Insufficient early childhood attunement (Bowlby, 1980) and connection can lead to physio­ logical developmental delays as well as social maladaptation later in life. Siegel (2012) argued that attachment problems in adulthood may be due to the lack of secure attachment or bonding in developmentally sensitive periods, leading to problems in neurological integration.

Environmental context does not manifest solely in neurological expres­ sion but also in genetic expression. Epidemiologists estimate that genes can explain approximately 10% to 20% of adverse health conditions. The vast majority of diseases are caused by a combination of, or interaction between, genes and the environment. Epigenetics, or “the study of changes in gene func-

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tion that are ... heritable and that do not entail a change in DNA sequence” (Wu & Morris, 2001), is a growing consideration for mental health providers (Simon-Dack & Marmarosh, 2014).

Brain-Body Neural oscillations, or brainwaves, are one prominent way to understand

the communication pattern between brain and body. Brainwaves are theorized to have a self-regulatory function based on behavior and demands from the environment. Looking at the function of each type of brainwave shows us the opportunities for regulation within those patterns. For example, slow delta waves are prominent during sleep; theta waves have high amplitude during light sleep and meditation; alpha waves are associated with relaxed, detached awareness; and beta waves are linked to a heightened state of alertness and critical thinking (Swingle, 2008).

However, when brainwaves become dysregulated, they can become unhelpful (Hamlin, 2011). For instance, Clark, Barry, McCarthy, & Selikowitz (1998) found that excess delta and theta bandwidths were associated with hyperactivity and inattention. Individuals with more magnitude of beta waves are more likely to develop alcoholism (Rangaswamy et ah, 2002). Hamlin (2011) explained that these individuals seek alcohol, an external source of per­ ceived relaxation, because they are unable to internally diminish the amplitude of beta waves, which have an arousing effect. Likewise, adverse experiences may require high beta waves, which are adaptive for being alert; however, when these patterns persist, they can lead to behaviors that are maladaptive in other environments (Hamlin, 2011).

CLINICAL IMPLICATIONS

The model provides counselors a framework to take a reciprocally deter­ minant perspective of their clients’ presenting problems while being sensitive to the impact of ACEs (Felitti et ah, 1998) and aware of the role of neurobio- physiological processes as a response to interaction with the environment and underlying mechanisms for behavior (Siegel, 2012). Awareness of ACEs has grown in the counseling profession, and many counselors include an assess­ ment of ACEs upon intake and through the conceptualization process. The model then facilitates client conceptualizations with consideration for interac­ tions among ACEs, the person, their brain, and their environment. Counselors may use the model to make hypotheses about how these interactions impact development, mental health, behavior, physical health, and physiology.

Underpinning the counseling profession are the principles of wellness, of a strengths-based focus, of the belief that intrinsic features of resilience are

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inherent in an individual, and of the internal capacity for change and self- healing (Rogers, 1951). Given these beliefs, many professional counselors have embraced the integration of mind-body work in clinical practice. Examples of mind-body-based interventions include mindfulness meditation (Kabat-Zinn, 1982), dance/movement therapy (Payne, 2003), and somatic experiential therapy (Levine, 1997), to name a few. More and more therapeutic modalities have been developed that incorporate mind-body interventions alongside traditional talk-therapy methods such as acceptance and commitment therapy (Hayes, Luoma, Bond, Masuda, & Lillis, 2006), coherence therapy (Ecker & Toomey, 2008), dialectical behavior therapy (Linehan, 1993), and eye move­ ment desensitization and reprocessing (Shapiro, 2001). Counselors practicing integrative therapeutic techniques are often looking for new evidence-based and neuroscience-informed interventions to support brain-body healing. As more counselors begin to understand the importance of including biological considerations in their assessment and treatment of clients, a model from which to conceptualize and treat clients is needed. Our model illustrates how biological considerations, such as brain activity, can complement the counsel­ ing perspective. Our model suggests a need for greater measurement of neuro- biophysiological concerns as a part of the presenting problems of our clients.

Neuro feedback A readily accessible and safe technology, NFB is an ideal methodology

integrating the current findings of neuroscience with the body’s ability for self-healing. A type of biofeedback, NFB uses electroencephalogram (EEG) and operant conditioning to guide clients toward optimal cognitive flexibility based on cortical electrical activity, also referred to as brainwaves (Swingle, 2008). In an NFB session, a clinician applies sensors on the client’s scalp. The sensors detect brainwaves and feed the signal to computer software, which quantifies and transforms the data into auditory and/or visual stimuli for the client to observe, completing one of many reciprocal loops of ongoing informa­ tion (Angelakis, Hatzis, Panourias, & Sakas, 2007).

The nature of NFB, however, has presented a unique challenge for researchers. Studies have found improved outcomes for a wide range of prob­ lems in research spanning more than four decades. However, few of these studies have convincingly attributed the results to the specific mechanism of feedback of a particular brainwave (Thibault & Raz, 2017). The double-blind randomized clinical trial design is the gold standard for minimizing most threats to internal validity, but the reciprocal nature of NFB presents numerous challenges for this design. Recent innovations are thought to have improved the science of NFB. For instance, live Z-Score NFB training allows the cli-

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nician to contrast the clients’ brain activity to a normative database, nesting an individual’s performance within a social and statistical context (Collura, 2017). However, a new model is needed for researchers to better understand the process of NFB. Although this article is practitioner oriented, a model that can be used by researchers and practitioners alike will improve the ability for these two professional activities to inform one another. In addition, research is needed to test and/or modify the reciprocally determinant brain-body model. Random control trial research is specifically needed to contextualize the model in order to further address current concerns about the efficacy and scope of the impact of NFB.

The reciprocal interaction among brainwaves, the computer software’s quantified analysis of the electroencephalogram data, the perception of the visual and auditory stimuli of NFB by the individual, and the normative data­ base is inherently consistent with the reciprocally determinant brain-body model. This model may provide a framework for counselors to integrate NFB into their practice and easily apply research guided by the same model.

Applying IS euro feedback If inclined, counselors may integrate NFB into their evidence-based prac­

tice. Extensive literature showing the effectiveness of NFB for a wide range of conditions dates back to the 1960s (Hammond, 2011). NFB has been success­ fully integrated into treatment for individuals who have been exposed to long­ term traumatic experiences during early development (Fisher, 2014). Recent studies have shown long-term benefits for individuals with attention-deficit/ hyperactivity disorder (ADHD) after treatment and at 6-month follow-up (Van Doren et ah, 2018) and with intractable epilepsy 10 years following treatment (Strehl, Birkle, Worz, & Kotchoubey, 2014). Recent meta-analyses and reviews have described NFB’s efficaciousness for PTSD (Panisch & Hai, 2018) and for criminal behavior associated with ADHD, schizophrenia, substance use, and psychopathy (Fielenbach, Donkers, Spreen, Visser, & Bogaerts, 2018). In addition, NFB can enhance performance for athletes (Xiang et ah, 2018) and visual artists (Shourie, Firoozabadi, & Badie, 2018) and can improve cognitive functioning (Reiner, Gruzelier, Bamidis, & Auer, 2018) and creativity (Agnoli, Zanon, Mastria, Avenanti, & Corazza, 2018) among healthy adults.

Using the reciprocally determinant brain-body model, NFB can be con­ ceptualized as a microcosm of the reciprocal flow of information that occurs in clients’ environments. Brainwaves, or cortical electrical activity, are measured with quantitative EEG (Niedermeyer & Da Silva, 2004), which influences the visual or auditory stimuli, functioning as the environment, presented to the client. The client then perceives the stimuli and allows the self system, includ-

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ing beliefs and brain activity, to adapt to the ongoing environment. This cycle occurs in real time and is ongoing throughout an NFB session (Hammond, 2011).

CONSIDERATIONS FOR COUNSELORS

Adopting NFB into clinical practice requires careful consideration of a variety of questions, as Chapin (2016) comprehensively described. Counselors practicing in settings that focus on acute or short-term solution-focused interventions would not be ideal candidates for NFB. Counselors working in settings that provide longer-term therapy (20+ sessions) would be excellent candidates to integrate NFB into their practice. NFB therapy requires multiple and continuous sessions to activate sustained change in the brain.

Counselors must consider ethical and legal issues applicable to NFB. Counselors are obligated to “practice only within the boundaries of their com­ petence” (American Counseling Association [ACA], 2014, p. 8). In keeping with the ACA code of ethics, we recommend that interested counselors receive comprehensive training such as that designed by certification agencies like the Biofeedback Certification International Alliance or the International Society for Neurofeedback and Research. Certification involves didactic coursework, hours of hands-on practice, and supervision by a certified clinician. No laws currently require practitioners to be certified in NFB to provide the service; however, ACA (2014) ethical standards ask counselors to practice “in specialty areas new to them only after appropriate education, training, and supervised experience” (p. 8).

The American Mental Health Counselors Association (AMHCA, 2015) code of ethics states that counselors in practice should maintain confidential­ ity. Adequate NFB training involves case consultation after the basic training. Given that few experts in the field provide such consultation, this service is often done via videoconferencing. Therefore, counselors must take precautions to ensure they are in line with the AMHCA (2015) code of ethics when dis­ cussing their clients’ NFB data electronically. Clients should also be informed during the consent process if their personal identifying information will be shared for case consultation purposes. Mental health counselors must take precautions to protect, store, transfer, and dispose of client records including NFB session and assessment data in a confidential manner consistent with applicable laws and regulations (AMHCA, 2015).

During the informed consent process, mental health counselors must provide information to clients that describes any potential risks that could occur with NFB. NFB is a Class II device approved by the US Food and Drug Administration for relaxation. However, clients should be informed that

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relaxation does not always mean feeling better immediately. For instance, NFB could increase self-awareness of anxiety the client had previously denied. O ther possible side effects of NFB include headaches, changes in sleep patterns, or irritability, but these are usually temporary and reversible (Hammond, 2011). T he importance of informing clients of these risks is reinforced by the ACA (2014), which states “counselors explicitly explain to clients the nature of all sendees provided ... such as ... techniques, procedures, limitations, potential risks, and benefits of services” (p. 4). This is especially important given the lack of regulations on NFB and the am ount of information that is still unknown about brain activity.

Counselors must also consider the age and typical symptom presentation of the clients with whom they work. Although NFB has shown promising find­ ings with children with ADHD, few clinical studies have included children younger than 7 in their sample (Van Doren et al., 2018). This is due in large part to rapid cortical maturation in gray matter volume during the critical early years of child development (Sowell, Thompson, & Toga, 2004), and NFB may not be an effective treatment during this time period. Given this, counselors who work primarily with small children may choose to forgo incorporating NFB into their practice. Additionally, although NFB may be an effective treat­ m ent for some individuals presenting psychotic symptoms (McCarthy-Jones, 2012), counselors must be careful to assess the severity of the symptoms and the individual’s capacity to understand the treatment so as not to become triggered by the treatment procedure itself. Severely acute individuals suffering from active phase psychosis would not be appropriate candidates for NFB treatment. Counselors must also be mindful of a client’s mental health history so as not to trigger a psychotic episode in an individual prone to psychosis.

Another consideration for counselors contemplating NFB is cost (Chapin, 2016). NFB devices can cost anywhere from $3,000 to $50,000 or more, depending on the type of technology used. Counselors would also need NFB software and a subscription to training packages in addition to supplies such as sensors, ear clips, alcohol swabs, and syringes. In an effort to make NFB devices more accessible for practitioners, many NFB device distributors offer monthly rental or financing plans. Despite these options, the cost can be a barrier of entry for many practicing counselors.

DISCUSSION

Counselors have the capacity to utilize theory and research from other fields to affect positive change. The clinical application of counselor training with a focus on wellness opens the door for the counseling profession to inte­ grate theory and knowledge from the fields of cognitive psychology, neurology,

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and psychiatry. Our model draws from these professions and provides a deeper understanding of the part mental health plays in overall functioning and well-being. This new conceptualization offers a map to guide counselors to aim fora variety of possible treatment outcomes. These potential outcomes include improved sleep patterns; adaptive interpersonal relationships; increased emo­ tional regulation, resilience, self-control, attention, and executive functioning; and decreased digestive problems, substance dependence, anxiety, depression, and delinquent or aggressive behaviors. Moreover, the model highlights the need to incorporate more mind-body theories and interventions in counseling. Mind-body interventions can have positive effects in the domains of physio­ logical response, physical health, social and emotional health, mental health, and behavior (Jayawardene, Bebe, Lorhmann, & Torrabi, 2017). With the raised awareness of the impact of trauma (van der Kolk, 2015) and the need for evidence-based mind-body interventions, counselors have the opportunity to advocate for trauma-exposed individuals on an individual and societal level. Integrative therapies, such as NFB, when used from a counseling perspective, offer an accessible mind-body modality that works within a whole-person model of conceptualizing exposure to childhood trauma and ways to treat it (Fisher, 2014). Flowever, ethical issues, such as competence (ACA, 2014), must be considered before incorporating new specialty areas like NFB into counseling practice.

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REFERENCES

Adams, A. S., & Petersen, C. (2016). Precision medicine: Opportunities, possibilities, and challenges for patients and providers. Journal o f the American Informatics Association, 23, 787-790. https://doi.org/10.1093/jamia/ocv215

Agnoli, S., Zanon, M., Mastria, S., Avenanti, A., & Corazza, G. E. (2018). Enhancing creative cognition with a rapid right-parietal neurofeedback procedure. Neuropsychologia, 118, 99-106. https://doi.Org/10.1016/j.neuropsychologia.2018.02.015

Allbaugh, I,. ]., Mack, S. A., Culmone, 11. D., Hosey, A. M., Dunn, S. E., & Kaslow, N. J. (2018). Relational factors critical in the link between childhood emotional abuse and suicidal ideation. Psychological Services, 15, 298-304. https://doi.org/10.1037/ser0000214

American Counseling Association. (2014). AG'A code of ethics: As approved by the ACA Governing Council, 2014. Alexandria, VA: Author.

American Mental Health Counselors Association. (2015). AMHCA Code of Ethics: Revised October 2015. Retrieved from http://connections.amhca.org/HigherLogic/System/ DownloadDocumentFile.ashx?DocumentFileKey=d4el0fcb-2Bc-c701-aald-5d0f53b8bcl4

Angelakis, E., Hatzis, A., Panourias, I. G., & Sakas, D. E. (2007). Brain-computer interface: A reciprocal self-regulated neuromodulation. In D. E. Sakas, & B. A. Simpson, Operative neuromodulation (pp. 555-559). Vienna, Austria: Springer.

Bandura, A. (1978). The self system in reciprocal determinism. American Psychologist, 33, 344-358. https://doi.Org/10.1037/0003-066X.33.4.344

Beauchaine, T. P., Gatzke-Kopp, L., & Mead, H. K. (2007). Polyvagal theory and developmental psychopathology: Emotion dysregulation and conduct problems from preschool to adolescence. Biological Psychology, 74, 174-184. https://doi.Org/10.1016/j.biopsycho.2005.08.008

Bowlby, J. (1980). Attachment and loss: Loss, sadness and depression (Vol. 3). New York, NY: Basic Books.

Centers for Disease Control and Prevention. (2018). About the CDC-Kaiser ACE study. Retrieved from https://www.cdc.gov/violenceprevention/acestudy/about.html

Chapin, T. J. (2016). Developing a specialty in neurofeedback: Decision points, journal o f Mental Health Counseling, 38, 155-169. https://doi.Org/10.17744/mehc.38.2.06

Clarke, A. R., Barr)', R. J.. McCarthy, R., & Selikowitz, M. (1998). EEC analysis in attention- deficit/hyperactivity disorder: A comparative study of two subtypes. Psychiatry Research, 81, 19-29. https://doi.org/10.1016/S0165-1781(98)00072-9

Cole, M. (1978). Alexander Romanovich Luria: 1902-1977. American Journal o f Psychology, 91, 349-352. Retrieved from https://www.press.uillinois.edu/journals/ajp.html

Collura, T. F. (2017). Quantitative EEC and live Z-score neurofeedback—current clinical and scientific context. Biofeedback, 45, 25-29. https://doi.org/10.5298/1081-5937-45.L07

Cryan, J. F., & Dinan, T. G. (2012). Mind-altering microorganisms: The impact of the gut microbiota on brain and behavior. Nature Reviews Neuroscience, 13, 701-712. https://doi.org/10.1038/nrn3346

Decety, ]., & Jackson, P. L. (2004). The functional architecture of human empathy. Behavioral and Cognitive Neuroscience Reviews, 3, 71-100. https://doi.org/10.1177/1534582304267187

Ecker, B., & Toonrey, B. (2008). Depotentiation of symptom-producing implicit memory in coherence therapy, journal of Constructivist Psychology, 21, 87-150. https://doi.org/10.1080/10720530701853685

Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129-136. https://doi.org/10.1126/science.847460

Felitti, V. J., Anda, R. F., Nordernberg, D., Williamson, D. F., Spiltz, A. M., Edwards, V., ... Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the causes of death in adults. American Journal o f Preventive Medicine, 14, 245-258. https://doi.org/10.1016/S0749-3797(98)00017-8

256 0 Jo u rn a l o f M e n ta l H e a lth C o u n s e lin g

F o s t e r in g I n t r i n s i c R e s ilie n c e

Fielenbach, S., Donkers, F. C. L., Spreen, M., Visser, H. A., & Bogaerts, S. (2018). Neurofeedback training for psychiatric disorders associated with criminal offending: A review. Frontiers in Psychiatry, 8, 1-12. https://doi.org/10.3389/fpsyt.2017.00313

Fisher, S. F. (2014). Neurofeedback in the treatment o f developmental trauma: Calming the fear driven brain. New York, NY: Norton.

Giaconia, R. M., Reinherz, H. Z., Silverman, A. B., Pakiz, B., Frost, A. K., & Cohen, E. (1995). Traumas and posttraumatic stress disorder in a community population of older adolescents. journal o f the American Academy o f Child and Adolescent Psychiatry, 34, 1369-1380. https://doi.org/10.1097/00004583-199510000-00023

Gonqalves, O. F., & Perrone-McGovern, K. M. (2014). A neuroscience agenda for counseling psychology research, Journal o f Counseling Psychology, 61, 507-512. https://doi.org/10.1037/cou0000026

Grawe, K. (1997). Research-informed psychotherapy. Psychotherapy Research, 7, 1-19. https://doi.org/10.1080/10503309712331331843

Ham lin, E. (2011). Lecture on the electroencephalogram (EEC): Source and measurement. Personal collection of E. Hamlin, Institute of Applied Neuroscience, Asheville, NC.

H am m ond, C. (2011). W hat is neurofeedback? An update, journal ofNeurotherapy, 15, 305-336 https://d0i.0rg/l 0.1080/10874208.2011.623090

I layes, S. C., Luoma, J. 13., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and com m itm ent therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44, 1-25. https://doi.0rg/l 0.1016/j.brat.2005.06.006

Ivey, A., & Zalaquett, C. P. (2011). Neuroscience and counseling: Central issues for social justice leaders. Journal for Social Action in Counseling and Psychology, 3, 201-115. Retrieved from http://web.b.ebscohost.com.ezproxy.memphis.edu/ehost/pdfviewer/ pdfviewer?vid=3&sid=03d3d312-b8cb-4a3f-a869-d49dfeffb0d7%40pdc-v-sessmgr03

Jayawardene, W., Bebe, R., Lorhmann, D., & Torrabi, M. (2017). Use of treatm ent and counseling services and m ind-body techniques by students with emotional and behavioral difficulties. Journal o f School Health, 87, 133-141. https://doi.Org/10.l 111/josh. 12475

Kabat-Zinn, ]. (1982). An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General Hospital Psychiatry, 4, 33-47. https://doi.org/10.1016/0163-8343(82)90026-3

Levine, P. (1997). Waking the tiger: Health trauma. Berkeley, CA: North Atlantic Books. Linehan, M. M. (1993). Cognitive behavioral therapy oj borderline personality disorder (Vol. 51).

New York, NY: Guilford Press. MeCarlhy-Jones, S. (2012). Taking back the brain: C ould neurofeedback training be effective

for relieving distressing auditory verbal hallucinations in patients with schizophrenia? Schizophrenia Bulletin, 38, 678-682. https://doi.org/10.1093/schbul/sbs006

National Institute of Mental Health. (2015). N IM H strategic plan for research. Retrieved from https://www.nimh.nih.gov/about/strategic-planningreports/nimh_ strategicplanforresearch_508compliant_corrected_final_149979.pdf

Navalta, C. P., M cGee., L., & Underwood, j. (2018). Adverse childhood experiences, brain development, and m ental health: A call for neurocounseling. Journal o f M ental Health Counseling, 40, 266-278. https://doi.Org/10.17744/mehc.40.3.07

Niedermeyer, E., & da Silva, F. L. (2004). Electroencephalography: Basic principles, clinical applications, and related fields. Philadelphia, PA: Lippincott Williams & Wilkins.

Panisch, L. S., & Hai, A. H. (2018). T he effectiveness of using neurofeedback in the treatment of post-traumatic stress disorder: A systematic review. Trauma, Violence, and Abuse, 1-10. https://doi.org/10.1177/1524838018781103

Payne, 11. (2003). Dance movement therapy: Theory and practice. New York, NY: Routledge. Porges, S. W. (2009). T he polyvagal theory: New insights into adaptive reactions of the automatic

nervous system. Cleveland Clinic Journal o f Medicine, 76, S86-S90. https://doi.org/10.3949/ccjm.76.s2.17

Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, and self-regulation. New York, NY: Norton.

$ Journal o f Mental H ealth Counseling 257

Rangaswamy, M., Porjesz, B., Chorlian, D. B., Wang, K., Jones, K. A., Bauer, L. 0 . , . . . Begleiter, H. (2002). Beta power in the EEG of alcoholics. Biological Psychiatry, 52, 851-842. https://doi.org/10.1016/S0006-3223(02)01362-8

Reiner, M., Gruzelier, J., Bamidis, P. D., & Auer, T. (2018). The science of neurofeedback: Learnability and effects. Neuroscience, 378, 1-10. https://doi.Org/10.1016/j.neuroscience.2018.04.024

Rhee, S. H., Pothoulakis, C., & Mayer, E. A. (2009). Principles and clinical implications of the brain-gut-enteric microbiota axis. Nature Reviews: Gastroenterology and Hepatology, 6, 306— 314. https://doi.org/10.1038/nrgastro.2009.35

Rockett, J. L., Murrie, D. C., & Boccaccini, M. T. (2007). Diagnostic labeling in juvenile justice settings: Do psychopathology and conduct disorder findings influence clinicians? Psychological Services, 4, 107-122. https://doi.Org/10.1037/1541-1559.4.2.107

Rogers, C. (1951). Client-centered therapy: Its current practice, implications, and theory. Oxford, United Kingdom: Houghton Mifflin.

Russell-Chapin, L. A. (2016). Integrating neurocounseling into the counseling profession: An introduction. Journal of Mental Health Counseling, 38, 93-102. https://doi.Org/10.17744/mehc.38.2.01

Schilling, E. A., Aseltine, R. H., & Gore, S. (2007). Adverse childhood experiences and mental health in young adults: A longitudinal survey. BMC Public Health, 7, 30-40. https://doi.org/10.1186/1471-2458-7-30

Schwartz, E., & Perry, B. (1994). The post-traumatic response in children and adolescents. Psychiatric Clinics o f North America, 17, 311-326. https://doi.org/10.1016/SO193-95 3X( 18)30117-5

Shapiro, F. (2001). Eye movement desensitization and reprocessing (EMDR): Basic principles, protocols, and procedures. New York, NY: Guilford Press.

Shevlin, M., McElroy, E., & Murphy, J. (2015). Loneliness mediates the relationship between childhood trauma and adult psychopathology: Evidence from the adult psychiatric morbidity survey. Social Psychiatiy and Psychiatric Epidemiology, 59, 591-601. https://doi.org/10.1007/s00127-014-0951-8

Shourie, N., Firoozabadi, M., & Badie, K. (2018). Neurofeedback training protocols based on spectral EEG feature subset and channel selection for performance enhancement of novice visual artists. Biomedical Signal Processing and Control, 43, 117-129. https://doi.Org/10.1016/j.bspc.2018.02.017

Siegel, D. J. (2012). The developing mind: How relationships and the brain interact to shape who we are (2"" ed.). New York, NY: Guilford Press.

Simon-Dack, S. L., & Marmarosh, C. L. (2014). Neurosciences and adult health behaviors: Recent findings and implications for counseling psychology. Journal of Counseling Psychology, 61, 528-533. https://doi.org/10.1037/cou0000020

Sowell, E. R., Thompson, P. M., & Toga, A. W. (2004). Mapping changes in the human cortex throughout the span of life. The Neuroscientist, 10, 372-392. https://doi.org/10.1177/1073858404263960

Strehl, U., Birkle, S. M., Worz, S., & Kotchoubey, B. (2014). Sustained reduction of seizures in patients with intractable epilepsy after self-regulation training of slow cortical potentials 10 years after. Frontiers in Human Neuroscience, 8, 1-7. https://doi.org/10.3389/fnhum.2014.00604

Swingle, P. G. (2008). Biofeedback for the brain: How neurotherapy effectively treats depression, ADHD, autism, and more. Piscataway, NJ: Rutgers University Press.

Thibault, R. T., & Raz, A. (2017). The psychology of neurofeedback: Clinical intervention even if applied placebo. American Psychologist, 72, 679-688. https://doi.org/10.1037/amp0000118

Thompson, E. J., Richards, M., & Gaysina, D. (2017). Cumulative effect of adverse childhood experiences on affective symptom trajectories in adulthood: Evidence from a British birth cohort. Journal of Epidemiology and Community Health, 71 (Suppl. 1), A60. https://doi.org/10,1136/jech-2017-SS.YlAbstracls. 122

Tronson, N. C., & Taylor, J. R. (2007). Molecular mechanisms of memory reconsolidation, Nature Reviews Neuroscience, 8, 262-275. https://doi.org/10.1038/nrn2090

258 0 Jo u rn a l o f M e n ta l H e a lth C o u n se lin g

F o s t e r i n g I n t r i n s i c R e s i l i e n c e

van der Kolk, B. A. (1994). T he body keeps the score: Memory and the evolving psychobiology of posttraunratic stress. Harvard Review o f Psychiatry, 1, 253-265. https://d0 i.0 rg/l 0.3109/10673229409017088

van der Kolk, B. (2005). Developmental trauma disorder. Psychiatric Annals, 35, 401-408. https://doi.org/10.3928/00485713-20050501-06

van der Kolk, B. (2015). The body keeps the score: Brain, mind, and body in the healing o f trauma. New York, NY: Penguin Group.

Van Doren, J., Arns, M., Heinrich, H., Vollebregt, M. A., Strehl, U., & Loo, S. K. (2018). Sustained effects of neurofeedback in ADHD: A systematic review and meta-analysis. European C hild and Adolescent Psychiatry, 28(3), 1-13. https://doi.org/10.1007/s00787-018-1121-4

W11, C., & Morris, J. R. (2001). Genes, genetics, and epigenetics: A correspondence. Science, 10, 1 103-1105. https://doi.Org/10.1126/science.296.5532.l 103

Xiang, M., Hou, X., Liao, B., Liao, J., & Hu, M. (2018). T he effect of neurofeedback training for sport performance in athletes: A meta-analysis. Psychology o f Sport and Exercise, 36, 114-122. https://doi.Org/10.1016/j.psychsport.2018.02.004

Zettler, H. R., Wolff, K., Baglivio, M., Craig, J. M., & Epps, N. (2017). T he racial and gender differences in the impact of adverse childhood experiences on juvenile residential placement. Youth Violence and Juvenile Justice, 16, 319-337. https://doi.org/10.! 177/1541204017698213

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