Clinical Application of ISF Neurofeedback in PTSD

I am a registered psychotherapist and occupational therapist who is board certified in neurofeedback. My clients tend to be military veterans who are highly hypervigilant or utterly burned out from years of hypervigilance. More than a few of my clients have been “sleeping” fully clothed in a recliner chair and waking up several times per night to walk the perimeter of their property since the mid-1990s. Some still wear flack jackets to mow the lawn, and others have self-isolated in their basements (lights off!) for over 10 years. As a group, they report feeling undervalued and forgotten by society. The summer 2021 news of the withdrawal from Afghanistan caused further injury, as many now view their contribution and trauma as being dismissed and worthless.

Prior to initiating therapy with our practice, many of my clients have been supported by wonderful psychologists, psychiatrists, social workers, occupational therapists, and psychotherapists for years – in some cases, for over 20 years. Their progress had either plateaued and or they continued to be extremely acute and/or had been deemed non-respondent to therapy. They were referred by Veterans Affairs Canada to our practice for the regulating effects of neurofeedback.

Using ISF neurofeedback for these clients allowed me to significantly boost their rehabilitation progress in a very nonthreatening manner. In many cases, (according to their pre-existing therapy team) the veteran was able to make more progress within one year than they were able to make during the previous several.

Under my philosophy, neurofeedback is used as a system regulator that better allows the client to engage in their therapy. It doesn’t replace therapy or medical support; rather, it allows a platform for better success.

Conceptualizing the Problem

Consider the use of relaxation strategies in practice. Those of you who have worked with clients presenting with high anxiety or PTSD know that teaching a client breathing techniques in clinic, and expecting them to be able to apply those techniques the next day while wandering through a busy grocery store is unrealistic. Learning to use and apply relaxation/calming strategies situationally can take months to years to learn...if ever!

Asking our clients to breathe, even in a safe environment, can be a challenge. To further explain, think about the most nervous you have even been. Now imagine you feel like that every day, all day. How much of your life would have to be spent doing breathing exercises to try to regulate your system? ....and would it work? Would the technique be strong enough?

For the most part, our clients are intellectually aware of the odds of being attacked in their home or community environment ... but the body doesn’t believe it. The body holds itself in a sustained activated state no matter what they tell themselves. And when it is highly activated, calmly and deliberately implementing a breathing exercise while in a (for example) crowded grocery store can be an insurmountable challenge. To further compound the issues, consider what they were doing when they were on patrol while deployed. They were controlling their breathing and visually and auditorily scanning their environments for threats. Now we send them to Costco and ask them to do the same thing. There are strong correlations that are difficult to overcome.

But what if there is a shortcut?

I believe that neurofeedback, primarily ISF, is a shortcut. Literature indicates that ISF regulates the autonomic nervous system. Using ISF, we can teach our clients to move from a 9/10 in hyperarousal, to a 3/10. At 9/10, the idea of “stop and breathe in for 5 seconds, now hold your breath for 7...,” or “name 5 things you can see...” is
unrealistic. Their systems are on high alert and all attention is outwardly focussed to ensure safety. At a 3, however, applying the breathing strategies they have been taught becomes achievable.

Using ISF training, we can gradually teach our clients how to 1) feel safe when less hyperaroused in a supportive clinic environment, and 2) help them do it while sitting in a chair and watching Duck Dynasty. (One of the favourite shows of the first group of veterans with whom I used ISF.)


We do need to be cautious and have appropriate training. In my early days, I had one client stop me mid-session when his self-rated arousal/relaxation dropped from 9/10 to a 3/10. Why? He didn’t feel that he could protect himself if he was that “relaxed.”

At our clinic, we also tend to avoid eyes closed training (and assessment) if the client is unable to do so. Asking a highly hypervigilant soldier to come into a new office, meet a new person, have electrodes stuck to their head, and then close their eyes is, perhaps, not the best way to establish a strong therapeutic relationship.

Why ISF?

Of all the different kinds of neurofeedback that I use, why ISF? A few reasons:

1. The in-session physiological response. Clients come in the door, train, and leave feeling better than when they came. When they walk out the door, they can experience life lived in a more regulated state. The brain and body learn from those moments. It’s more efficient. It requires less energy expenditure. Life is easier when your autonomic nervous system is more regulated.

2. Solid research is moving the field forward.

3. The hope that in-session physiological change instills in an individual, who generally feels that recovery is impossible, can change the course of rehabilitation; even aside from the neurophysiological changes we achieve with ISF training.

4. Most importantly, I watch, track and listen to my clients and their therapy teams. Many of my clients have tried everything from zscores to amplitude training, 1 channel to 19, sLORETA and beyond. When I ask them what makes them feel best, what had the biggest impact on their ability to engage in their lives, they almost invariably tell me it is ISF.

5. I have a delightful client who tells me ISF makes her “teeth relax.” It’s hard to argue with that kind of feedback! ISF is a solid tool that has made a significant difference in the lives of my clients.

Final Thoughts

Does rehabilitation have to be awful? What if it can be a pleasant experience? What if they like their therapist, they like the show they are watching, and enjoy the relaxing and regulating experience of a therapy session? What if neurofeedback is an easy-to-use tool that makes the rest of their therapy easier? What if they come in to session at a 9/10, leave at a 3/10, and are actually able to go to the store or play with their kids and be calm enough that they can breathe, apply relaxation strategies, and allow the brain and body to learn (via repeated successes) that they are not under threat?

That’s an intervention worth considering.

Sharie Woelke is a registered psychotherapist and occupational therapist based in Ottawa, Canada.

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