Sebern F. Fisher, M.A.
All brain function—normal and pathological, intellectual and emotional—is bioelectric as well as biochemical. In fact, the brain communicates to itself and organizes its activity through its constant creation of brain waves of differing frequencies. The degree of our mental or emotional arousal largely depends on the frequency of our predominating brain waves. We know that large-amplitude, slow brain waves—known as delta waves—are associated with sleep. Theta waves are associated with a dreamy, sometimes hypnagogic, state. Alpha waves are usually associated with a relaxed meditative state of “open focus.” Narrowly focused states of attention, needed to perform tasks, are characterized by beta-frequency brain waves.
Although the brain’s electrical activity plays a major role in how an individual functions, until recently, surprisingly little attention has been paid to the electrical aspect of the brain. Instead, we’ve tended to view the brain solely as a biochemical organ, devoting billions of dollars to the development and promotion of psychotropic drugs.
At the same time, researchers and therapists have been teaching people to change their brains’ bioelectric activity—and hence their functioning—without chemical intervention. Today, this method, called neurofeedback, is being used by therapists around the world to address an increasing number of disorders, from ADD and AD/HD to bipolar illness, autism, and learning disability.
Neurofeedback is biofeedback to the brain—a form of operant conditioning that rewards the brain for activity at desired frequencies while discouraging activity at other frequencies. As a therapeutic intervention, neurofeedback training can reduce symptoms quickly, allowing the therapist and patient to better focus on broader psychological issues. Their attention need no longer be riveted to disruptions of emotional regulation, like rage, or the attempt to quell them, like excessive drinking. Emotional symptoms are seen and treated as indicators of firing disregulation in the brain.
Since integrating neurofeedback with psychotherapy seven years ago, I’ve used it in the treatment of more than a hundred people, some with diagnoses as severe as dissociative identity disorder, Asperger’s syndrome, borderline personality disorder, and post-traumatic stress disorder. The case that follows highlights its particular effectiveness in treating emotional overarousal.
The Unregulated Brain
Tony, a tall, husky, visibly distressed, 27-year-old man with severe dyslexia came to see me because a friend told him that I could “change his brain.” He paced my office as he described what it felt like to live with dyslexia. Since earliest childhood, classmates had teased him mercilessly. By eighth grade, he felt so humiliated, angry, and filled with self-hatred that his parents thought it best to send him to a boarding school specializing in learning disabilities. “If it hadn’t been for that school,” Tony said, “I’d be either dead or in jail.”
Being with others who were dyslexic, and with teachers who understood and empathized with his condition, made his life bearable. As with most dyslexics, reading was very difficult, and Tony got through school only with the help of tutors and special programs. He was accepted at a community college with a center for learning-disabled students, but he quit after the first semester, discouraged, bitter, and depressed because it was too hard. Since then, he’d worked sporadically as a manual laborer. He told me he dreamed of becoming a filmmaker, because he “thought better in pictures than in words,” but doubted that he ever could succeed in anything.
Tony attributed virtually every problem he had—his chronic depression and seething anger, his excessive drinking, his inability to find a good job, and his history of unstable relationships with women—to dyslexia, either directly or indirectly. He often flew into rages, breaking anything at hand. He couldn’t hold on to relationships or jobs, had panic attacks, couldn’t sleep, and chewed his nails. At the point he came to see me, he was drinking a case of beer a night to manage his agitation and despair.
Although I usually use psychotherapy in conjunction with neurofeedback, all Tony wanted was the neurofeedback. No talk therapy. I thought this would be a good case in which to test the effects of using neurofeedback exclusively.
Before beginning the training, I did a complete assessment of the problematic patterns in Tony’s brainwaves. I began with a symptom-focused questionnaire to systematically evaluate his arousal. Once I’d completed that assessment, I determined that, to control his temper, drink less, and even stop biting his nails—symptoms that indicate a high degree of arousal in the right hemisphere—Tony needed to learn to produce calming alpha waves on the right side of his brain, the hemisphere devoted to affect regulation. So, one treatment goal was to teach Tony to lower arousal in this hemisphere. Additionally, to address the dyslexia, which Tony considered to be the primary symptom, he needed to increase the arousal in the left hemisphere of his brain. Tony’s initial EEG assessment also revealed that he was producing an excess of delta and theta waves in both hemispheres, which interfered with the alertness required for such tasks as driving a car or reading an article. As a result, for Tony, concentrating on reading was like swimming across a lake against huge waves. Another treatment goal, then, was to train Tony’s brain to inhibit the production of excess slow waves and excess fast waves, both of which interfered with his ability to remain focused and relaxed, in addition to encouraging him to produce the frequencies that lowered arousal in the right hemisphere and raised arousal in the left.
Putting on the Brakes, Stepping on the Accelerator
We were ready to begin Tony’s neurofeedback training. As I do with all clients, I explained that the video game he was about to play was linked directly to his EEG, and that its beeps and displays would encourage and reward his brain for the production of the brain waves that would, over time, change his experience. He sat in a comfortable chair in front of a computer screen, and I applied sensors to his head to detect his brain’s electrical activity. The EEG signal was displayed across the top of my computer screen. It showed his brain activity in three bandwidths: the band I wanted to encourage, or the “reward band,” and the two bandwidths I wanted to discourage, or “inhibit bands.”
Tony’s screen had a video game with three spaceships set to respond to his brain waves. The middle space ship represented the frequency that I wanted him to increase. The other two represented the very slow and very fast frequencies that I wanted him to decrease. Whenever Tony’s brain generated the optimal brain-wave pattern, the middle spaceship would pull ahead, and he’d score points in the video game. It was a simple video game, but without a joystick: Tony had to control the game solely with his brain.
Most clients, including Tony, have difficulty believing that “trying” to make the spaceships move doesn’t work. But they don’t know, at first, how not to try. Tony asked several times how to do it, and I couldn’t tell him, any more than I could tell him how to ride a bike. I just assured him that his brain would learn what it had to learn. When he tried to make the space ship move, it stayed in its dock. When he relaxed, the space ship flew out into space. Every time his brain “happened on” the correct frequencies, the center space ship would move ahead, while the other two would fall behind. Tony’s brain gradually began to learn, automatically and without conscious volition, to use this instantaneous feedback as a road map of which way to go. Unlike drug therapies, neurofeedback is a process of learning—the brain learns to regulate itself.
We trained two or three times a week, with 20 minutes of checking in and reassessment and 30 minutes of neurofeedback training each time. I used the quality of his sleep, the amount he was drinking, his appetite, his mood, and the frequency and intensity of his aggressive outbursts for my ongoing assessment of his progress. Changes in these markers indicated shifts in brain function. If the shifts were positive, I’d continue to train left and right hemispheres as I’d been doing. If the shifts were negative and he seemed worse in any of these areas, I’d reassess the training and change the brain-wave frequency of the reward band as needed.
By the fourth session, Tony reported that he was sleeping better, that he felt less angry, and that he’d started taking photographs again. He was also drinking less. But he still felt restless and dissatisfied with himself.
At session seven, he reported that he was bored with TV, that he was no longer sleeping during the day, and that he was feeling calmer and more organized. He could focus better and reported living “a more ordered life.” Tony was, it seemed, beginning to live in a more coherent brain. Neurofeedback training helped him feel increasingly calm and, as that happened, he became less fearful. It was also clear that Tony was beginning to trust me.
As with talk therapy, there are occasionally bumps in the road with neurofeedback. I had to be away for a month, and while I was gone, Tony’s father had a stroke. Tony also quit his new job in a rage and went out drinking several times with friends. The bright spot was that he found that soon after the initial binge, he didn’t want to drink at all. “I just don’t like it anymore.”
The stress of his father’s illness, coupled with the absence of training, accounted for the lapses in his ability to regulate his temper. All brains, particularly early in training, can default to older, familiar patterns of firing. Tony, however, was discouraged by his failures. I asked that he withhold his judgment while we continued to train.
Over the next several sessions, Tony spoke to me with increasing openness about his two most important relationships, his father and his girlfriend. He was still reporting problems with anger and depression, but he began to have more insight into these problems. He talked about his anger at his father, who was now recovering, and his feelings about his deceased mother. Talking like this was new to him, but he hardly seemed to notice. Almost inadvertently, he’d started to engage in talk therapy as well as neurofeedback. This isn’t uncommon with people who come in only for neurofeedback—the training enhances clients’ ability to relate.
At the twelfth session, Tony told me, “You might be interested. I read an entire book, for the first time.”
“What did you read?”
“A book about Vietnam. I’ve always been interested in Vietnam,” he said nonchalantly.
I couldn’t believe that the first book Tony would read, after never voluntarily reading more than a paragraph, was historical nonfiction! The brain’s electrical “short-circuits” had repatterned themselves and the printed page became accessible. The training was working. It was organizing him cognitively and quieting him emotionally.
Tony trained for 10 additional sessions. By the end, he was reading every day and we were talking at every session. He was holding down a steady job on a road crew and making plans for his future. He no longer suffered panic attacks, had stopped drinking, and had ended the relationship with his girlfriend, which he realized was destructive. He was sleeping well and rarely had explosive outbursts. He felt that neurofeedback had been more helpful to him than anything else he’d done, and that he’d accomplished most of what he’d sought to achieve. Most important perhaps, he felt good about himself.
I ran into Tony a year and a half later. He’d opened his own retail business. He was working at another job part time to support his fledgling endeavor, but would soon be making enough money to devote himself entirely to his new enterprise. I asked him, with equal parts curiosity and trepidation, if he was still reading. “Oh yeah.” he said, “that stuff you do must work.” He was reading a book on management, and he read fiction for pleasure. An inveterate channel surfer before neurofeedback, he no longer watched TV. The brain regulation that he’d learned in less than 12 hours of actual training time had held for 18 months without any further intervention, without any further training, with little psychotherapy, and with no medication.
Tony’s case demonstrates that biofeedback directly to the brain can help organize brain function, both cognitively and emotionally. It can do so predictably and efficiently, and it can do so even for the large part of the population in need of help who, like Tony, have no interest in psychotherapy. Through reducing overarousal, boosting underarousal, and organizing the brain to function closer to its optimal capacity, neurofeedback enhances clients’ ability to relate and, in many cases, makes therapy with them not only possible, but more deeply rewarding.
By Margaret Wehrenberg
In this case, neurofeedback made change possible, where mentoring, tutoring, and talking had been unable to solve Tony’s presenting problem. Sebern Fisher shows the importance of both respecting a client’s initial request (“fix my brain”) and, when necessary, being willing to go beyond traditional treatment methods. Neurofeedback is one in a growing number of bioelectrical and neurophysical methods that psychotherapists are bringing into their work, especially in cases involving conditions like attention deficit disorder, trauma, learning disorders, impulsivity, and anger control. These methods include techniques that use metronome pacing, neurophysical movement, and colored light to change brain function. They represent a new clinical armamentarium designed to correct underlying problems in brain function, rather than just provide strategies to manage the underlying condition. Methods like neurofeedback hold tremendous promise in cases where standard treatments have proven ineffective, but therapists must be sure to balance the hope of a new way to help against possible risks, as Fisher appears to have done in this case. My biggest concern isn’t with what takes place in this case, but with what’s left out. After forging a highly effective therapeutic bond with Tony, I was disappointed that Fisher didn’t use that relationship to more emphatically argue the case for further treatment to Tony. While it’s tempting to see a change in brain function as sufficient, with a client like Tony, who has so many developmental gaps and relationship issues, the necessary therapeutic learning can’t occur as fast as his brain function can change, nor until it changes. It’s up to the therapist to provide clients with a broader vision of what therapy can provide, along with encouragement to continue on a fuller course of treatment. Even if brain-pattern change can be made quickly, it’s important to emphasize that short-term shifts aren’t enough to change lifelong relationship patterns. For example, once a client shows progress in controlling his impulsivity, I’d then highlight the need to learn to read the emotions of others—something his poor impulse control previously blocked from developing properly. I’d directly state that developing empathy requires time and practice, and use therapy as a place to learn and evaluate new skills for self-control and interpersonal relationships. While in this case, neurofeedback dramatically opened up possibilities for Tony to move on in his life, I’d be much more convinced of a long-term positive outcome if treatment had altered more than the brain-wave pattern and given more attention to the relationship, career, and self-management skills he’d missed.
I couldn’t agree with Margaret Wehrenberg more. My preferred practice is to interweave neurofeedback and psychotherapy. I find that neurofeedback enhances the capacity for relatedness, and the relationship, in turn, helps the client better recognize and incorporate their brain-wave changes. I typically introduce neurofeedback to clients who come to me for therapy and psychotherapy to those who come for neurofeedback. Even clients who seek brain-wave training because of disappointing results with therapy often change their attitude as the neurofeedback training proceeds.
While Tony only wanted to “fix his brain” when he first came to see me, the neurofeedback training fostered a strong relationship between us. As our work together continued, we moved more and more into what I considered a therapy relationship. Although Tony never thought of our sessions in this way, we not only talked about his dyslexia but also the relationship and life skills Wehrenberg mentions. For him, the issue of ending treatment was pragmatic: while he could finally read and felt better, he was out of money. I agree that he’d have benefited from more therapy.
When we ran into each other recently, Tony said he wanted to come back to see me. My hunch is he will, and when he does, I think he’ll want both therapy and neurofeedback.
Sebern Fisher, M.A., practices psychodynamic therapy and neurofeedback in Northampton, Massachusetts. As clinical director of a residential treatment center for severely disturbed adolescents, she was the first therapist in the United States to implement Dialectical Behavior Therapy as milieu treatment. She’s a part owner of EEG Spectrum International, a company that provides training in the clinical use of neurofeedback. Address: 34 Elizabeth Street, Northampton, MA 01060. E-mails to the author may be sent to email@example.com.
Margaret Wehrenberg, Psy.D., has been in private practice as an addictions counselor and psychologist for more than 20 years. Address: 4513 Lincoln Ave (Rte 53), Suite 110, Lisle, IL 60532. E-mails to the author may be sent to firstname.lastname@example.org.
Posted with permission from Psychotherapy Networker.
AN INTRODUCTION TO NEUROFEEDBACK
© 2003, D. Corydon Hammond, Ph.D., ABEN, QEEG-D
Professor & Psychologist, Physical Medicine & Rehabilitation
University of Utah School of Medicine
In the late 1960's and 1970's we learned that it was possible to recondition and retrain brainwave patterns. Some of this work began with the training of alpha brainwave activity for relaxation, while other work originating at UCLA focused on uncontrolled epilepsy. This training is called EEG biofeedback or neurofeedback. Before discussing this in more detail, let me provide you with some preliminary information about brainwaves. Brainwaves occur at various frequencies. Some are fast and some are quite slow. The classic names of these EEG bands are delta, theta, alpha, and beta. They are measured in cycles per second or hertz (Hz).
Beta brainwaves are small, faster brainwaves (above 13 Hz) associated with a state of mental, intellectual activity and outwardly focused concentration. This is basically a “bright-eyed, bushy-tailed” state of alertness. Alpha brainwaves (8-12 Hz.) are slower and larger. They are associated with a state of relaxation and basically represent the brain shifting into an idling gear, relaxed and a bit disengaged, waiting to respond when needed. If we merely close our eyes and begin picturing something peaceful, in less than half a minute there begins to be an increase in alpha brainwaves. These brainwaves are especially large in the back third of the head. Theta (4-8 Hz) brainwaves represent a day dreamy, spacey state of mind that is associated with mental inefficiency. At very slow levels, theta brainwave activity is a very relaxed state, representing the twilight zone between waking and sleep. Delta brainwaves (0-3.5 Hz) are the slowest, highest amplitude brainwaves, and are what we experience when we are asleep. In general, different levels of awareness are associated with dominant brainwave states.
Each of us, however, always has some degree of each of these brainwave bands present in different parts of our brain. Delta brainwaves will also occur, for instance, when areas of the brain go “off line” to take up nourishment. If we are becoming drowsy, there are more delta and slow theta brainwaves creeping in, and if we are inattentive to external things and our mind is wandering, there is more theta present. If we are exceptionally anxious and tense, an excessively high frequency of beta brainwaves is often present. Persons with ADD, ADHD, learning disabilities, head injuries, stroke, Tourette’s syndrome, epilepsy, and often chronic fatigue syndrome and fibromyalgia tend to have excessive slow waves (usually theta and sometimes excess alpha) present. When an excessive amount of slow waves are present in the executive (frontal) parts of the brain, it becomes difficult to control attention, behavior, and/or emotions. Such persons generally have problems with concentration, memory, controlling their impulses and moods, or with hyperactivity. They can’t focus very well and exhibit diminished intellectual efficiency.
What is Neurofeedback Training?
Neurofeedback training is brainwave biofeedback. During typical training, a couple of electrodes are placed on the scalp and one or two are usually put on the ear lobe. Then, high-tech electronic equipment provides you with real-time, instantaneous audio and visual feedback about your brainwave activity. The electrodes measure the electrical patterns coming from the brain--much like a physician listens to your heart from the surface of your skin. No electrical current is put into your brain. Your brainwave patterns are relayed to the computer and recorded.
Ordinarily, we cannot influence our brainwave patterns because we lack awareness of them. However, when you can see your brainwaves on a computer screen a few thousandths of a second after they occur, it gives you the ability to influence and change them. The mechanism of action is operant conditioning. We are literally reconditioning and retraining the brain. At first, the changes are short-lived, but the changes gradually become more enduring. With continuing feedback, coaching, and practice, we can usually retrain healthier brainwave patterns in most people. It is a little like exercising or doing physical therapy with the brain, enhancing cognitive flexibility and control. Thus, whether the problem stems from ADD/ADHD, a learning disability, a stroke, head injury, deficits following neurosurgery, uncontrolled epilepsy, cognitive dysfunction associated with aging, depression, anxiety, obsessive-compulsive disorder, or other brain-related conditions, neurofeedback training offers additional opportunities for rehabilitation through directly retraining the brain. The exciting thing is that even when a problem is biological in nature, we now have another treatment alternative than just medication. Neurofeedback is also being used increasingly to facilitate peak performance in “normal” individuals and athletes.
Frank H. Duffy, M.D., a Professor and Pediatric Neurologist at Harvard Medical School, stated in an editorial in the January 2000 issue of the journal Clinical Electroencephalography that scholarly literature now suggests that neurofeedback “should play a major therapeutic 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” (p. v). “It is a field to be taken seriously by all” (p. vii).
Assessment Prior to Neurofeedback Training
Prior to doing neurofeedback training, clinicians usually want to ask questions about the symptom history of the patient. In some cases they may do neuropsychological or psychological testing. Competent clinicians will also examine brainwave patterns. Some practitioners may do this by placing one or two electrodes on the scalp and measuring brainwave patterns in a few limited areas. Other clinicians perform more comprehensive testing called a quantitative electroencephalogram (QEEG) or brain map where 19 or more electrodes are placed on the scalp.
A QEEG is an assessment tool to objectively and scientifically evaluate a person’s brainwave function. The procedure may take about 1½ hours. It generally consists of placing a snug cap on the head which contains small electrodes to measure the electrical patterns coming from the brain. This is done while the patient is resting quietly with his or her eyes closed, and sometimes also with eyes open or during a task such as reading. Afterwards, we then go through a tedious and lengthy procedure to remove any artifacts that occurred when the eyes moved or blinked, when patients moved slightly in the chair, or tightened their jaw or forehead a little bit. The brainwave data we gathered is then compared to a sophisticated normative database of how the brain should be functioning at the same age. Over a thousand statistical analyses are then performed. This assessment procedure allows us to then determine in a highly scientific, objective manner whether and how a patient’s brainwave patterns are significantly different from normal.
Beginning during the 1970's and 1980's there began to be a great deal of experimentation with QEEG. The American Medical EEG Association Ad Hoc Committee on QEEG has stated that QEEG “is of clinical value now and developments suggest it will be of even greater use in the future.” QEEG has scientifically documented ability to aid in the evaluation of conditions such as mild traumatic brain injury, ADD/ADHD, learning disabilities, depression, obsessive-compulsive disorder, anxiety and panic disorder, and a variety of other conditions (including autism, schizophrenia, stroke, epilepsy, and dementia). QEEG has even been able to predict outcomes from treating conditions such as ADD/ADHD, alcoholism, and drug abuse. The American Psychological Association has also endorsed QEEG as being within the scope of practice of psychologists who are appropriately trained, and ISNR has similarly endorsed its use by legitimate health care professionals who are appropriately trained.
The EEG and QEEG evaluations assist us in knowing if there are abnormalities in brain function that EEG neurofeedback might be helpful in treating, and it allows us to know how we can individualize neurofeedback to the unique problems of each patient. For example, scientific research has identified a minimum of three major subtypes of ADD/ADHD, none of which can be diagnosed from observing the person’s behavior, and each of which requires a different treatment protocol.
Once the assessment is complete and treatment goals have been established, we usually place two electrodes on the scalp and one or more on the earlobes during neurotherapy training sessions. The trainee then watches a display on the computer screen and listens to audio tones, sometimes while doing a task such as reading. These training sessions are designed to teach the person to slowly change and retrain their brainwave pattern. With continuing feedback, coaching, and practice, the healthier brainwave patterns are maintained. Some persons may need to learn to increase the speed or size of brainwaves in some parts of the brain. Other individuals need training to decrease the speed of brainwaves in certain areas of the brain. In a sense, it is like exercising or doing physical therapy with the brain, enhancing cognitive flexibility and control. Neurofeedback training usually requires at least 25, and most commonly 40-50 sessions of about 40 minutes in length.
ADD/ADHD & Learning Disabilities: Since the late 1970's, neurofeedback has been researched, refined, and tested with ADD/ADHD and learning disabilities. Clinical work with Attention-Deficit/Hyperactivity Disorder and learning disorders by Dr. Lubar and his colleagues at the University of Tennessee and others has demonstrated that it is possible to retrain the brain. This neurofeedback research is quite strong in demonstrating its effectiveness in treating ADD/ADHD. Whereas the average stimulation medication study follow-up is only three weeks long and the longest medication study is only 14 months long with ADD/ADHD, Dr. Lubar (1995) has published 10 year follow-ups on cases and found that in about 80% of patients neurofeedback can substantially improve the symptoms of ADD and ADHD, and these changes are maintained. Rossiter and LaVaque (1995) found that 20 sessions of neurofeedback produced comparable improvements in attention and concentration to taking Ritalin, and Fuchs et al. (2003) likewise demonstrated that neurofeedback produced comparable improvements to ritalin. In a one year follow-up, control group study, Monastra et al. (2002) found that neurofeedback produced superior improvements to ritalin, without needing to remain on drugs. Neurofeedback training for ADD/ADHD is commonly found to be associated with decreased impulsiveness/hyperactivity, increased mood stability, improved sleep patterns, increased attention span and concentration, improved academic performance, increased retention and memory, and increased IQ scores (often averaging 10 IQ points in published studies).
Epilepsy, Brain Injuries & Stroke. Uncontrolled epileptic seizures have also been effectively treated using neurofeedback. Research in this area began in the early 1970's, and is very extensive and rigorous, including blinded, placebo-controlled, cross-over studies (reviewed in Sterman, 2000). Neurofeedback has been found to be helpful with all kinds of epilepsy, including grand mal, complex partial, and petit mal (absence) seizures. Although the larger proportion of seizure patients are adequately controlled by medication, most of the individuals who have been treated with neurofeedback in research studies are among the most severe epilepsy patients, where anticonvulsant drug therapy was unable to control their seizures. However, even in this most severe group of patients, research found that neurofeedback training on average produces a 70% reduction in seizures. In these severe cases of medically intractable epilepsy, neurofeedback has been able to facilitate greater control of seizures in 82% of patients, often reducing the level of medication required, which can be very positive given the long-term negative effects of some medications. Many patients, however, will need to remain on some level of medication following neurofeedback. Training often requires 50 sessions or more. Treatment outcome studies of closed and open head brain injuries are also now beginning to be seen, as well as with stroke, but better research still needs to be done in these latter areas.
Alcoholism & Drug Abuse. EEG investigations of alcoholics (and the children of alcoholics) have documented that even after prolonged periods of abstinence, they have lower levels of alpha and theta waves and an excess of fast beta brainwaves in their EEG's. This means that alcoholics and the children of alcoholics tend to be hard-wired differently from other people, and in a way that makes it difficult for them to relax. However, following the use of alcohol, the levels of alpha and theta brainwaves increase. Thus, individuals with a biological predisposition to develop alcoholism (and their children) are particularly vulnerable to the effects of alcohol. Without realizing it, alcoholics seem to be trying to self-medicate and treat their own brain pathology. The relaxing mental state that occurs following alcohol use is highly reinforcing to them because of the manner in which their brain is functioning. Several research studies now show that the best predictor of relapse is how excessive the beta brainwave activity is in alcoholics and cocaine addicts (Bauer, 1993, 2001; Prichep et al., 1996; Winterer, 1998).
Recently, EEG biofeedback training to teach alcoholics how to achieve stress reduction and profoundly relaxed states through increasing alpha and theta brainwaves and reducing fast beta brainwaves have demonstrated promising potential as an adjunct to alcoholism treatment. Peniston and Kulkosky (1989) used such training with chronic alcoholics compared to a nonalcoholic control group and a traditional alcoholism treatment control group. Alcoholics receiving 30 sessions of brainwave training demonstrated significant increases in percentages of their EEG record in alpha and theta rhythms, and increased alpha rhythm amplitudes. The brainwave treatment group also demonstrated sharp reductions in depression compared to controls. Alcoholics in standard (traditional) treatment showed a significant elevation in serum beta-endorphin levels (an index of stress and a stimulant of caloric [e.g., ethanol] intake), while those with brainwave training added to their treatment did not demonstrate an increase in beta-endorphin levels. On four-year follow-ups (Peniston & Kulkosky, 1990), only 20% of the traditionally treated group of alcoholics remained sober, compared with 80% of the experimental group who received neurofeedback training. Furthermore, the experimental group showed improvement in psychological adjustment on 13 scales of the Millon Clinical Multiaxial Inventory compared to traditionally treated alcoholics who improved on only two scales and became worse on one scale. On 16-PF personality inventory, the neurofeedback training group demonstrated improvement on 7 scales, compared to only one scale among the traditional treatment group. Thus, neurofeedback training appears to hold encouraging promise as an adjunctive module in the treatment of alcoholism, and in remediating damage done through drug abuse.
Posttraumatic Stress Disorder. Peniston and Kulkosky (1991) added thirty 30-minute sessions of alpha/theta EEG biofeedback training to the traditional VA hospital treatment provided to a group of PTSD Vietnam combat veterans, and compared them at 30 month follow-up with a contrast group who only received traditional treatment. On follow-up, all 14 traditional treatment patients had relapsed and been rehospitalized, while only 3 of 15 neurofeedback training patients had relapsed. While all 14 patients treated with neurofeedback had decreased their medication requirements by follow-up, among traditionally treated patients, only one patient decreased medication needs, two reported no change, and 10 required more psychiatric medications. On the MMPI, neurofeedback training patients improved significantly on all 10 clinical scales--dramatically on many of them--while there were no significant improvements on any scales in the traditional treatment group.
Other Clinical Applications of Neurofeedback Training. Neurofeedback has good research support for its effectiveness in treating anxiety (Moore, 2000). It is also being used to work with other clinical problems such as depression (Baehr, Rosenfeld & Baehr, 2001; Hammond, 2001), chronic fatigue syndrome (Hammond, 2001), fibromyalgia (Donaldson et al., 1998; Meuller et al., 2001), sleep disorders, Tourette’s, obsessive-compulsive disorder (Hammond, 2003), autism (Jarusiuwicz, 2002), Parkinson’s tremors (Thompson & Thompson, 2002), and essential tremor. Neurofeedback is being utilized in peak performance training, for instance in enhancing musical (Egner & Gruzelier, 2003), with athletes, business executives, for cognitive enhancement in normal college students (Rasey, Lubar, McIntyre, Zoffuto & Abbott, 1996), for memory enhancement in normal individuals (Vernon et al., 2003), and for “brain brightening” to counter effects of normal aging. However, these areas of application do not yet have strong research validation.
Although there are many health care practitioners who are convinced of the effectiveness and value of this cutting-edge technology (and an estimated 2,000 clinicians are using neurofeedback), you should be aware that some insurance company personnel (whose job is to save their company money), and even some professionals (many of whom may not be aware of the latest published research), may regard all EEG neurofeedback as experimental. Even for well validated biofeedback treatments, some insurance companies insist on defining all biofeedback as experimental and, thus, may not reimburse for these services.
Training Side Effects & Home Training
Only rarely have significant side effects from neurofeedback training been noted. However, occasionally someone may feel tired, spacey, anxious, experience a headache, have difficulty falling asleep, or feel agitated or irritable. Many of these feelings pass within a short time after a training session. If you make your therapist aware of such feelings, they can alter training protocols and usually quickly eliminate such mild adverse effects. It has come to our attention, however, that some individuals are now renting and leasing home training equipment. It is our strong recommendation that training with equipment at home should only be done under the regular consultation and supervision of a legitimately trained and licensed professional, preferably following closely supervised training in the office for a period of time. Otherwise, more serious negative effects could possibly occur with unsupervised self-training. It is important to remember that the impressive success documented in research is based on work with qualified professionals, following careful assessment, and with training sessions that are supervised by the therapist rather than with unsupervised sessions taking place in an office or at home.
You may identify individuals who are doing neurofeedback training by consulting the web site listed below for the International Society for Neuronal Regulation (ISNR) and looking at the membership directory. Below you will find a few references to the literature I have cited, and a few web sites that provide further useful information. ISNR has listed on our web site a comprehensive bibliography that I have compiled of scientific publications on neurofeedback.
Baehr, E., Rosenfeld, J. P., & Baehr, R. (2001). Clinical use of an alpha asymmetry neurofeedback protocol in the treatment of mood disorders: Follow-up study one to five years post therapy. Journal of Neurotherapy, 4(4), 11-18.
Bauer, L. O. (1993). Motoric signs of CNS dysfunction associated with alcohol and cocaine withdrawal. Psychiatry Research, 47, 69-77.
Bauer, L. O. (2001). Predicting relapse to alcohol and drug abuse via quantitative electroencephalography. Neuropsychopharmacology, 25(3), 332-240.
Donaldson, C. C. S., Sella, G. E., & Mueller, H. H. (1998). Fibromyalgia: A retrospective study of 252 consecutive referrals. Canadian Journal of Clinical Medicine, 5(6), 116-127.
Egner, T., & Gruzelier, J. H. (2002). Ecological validity of neurofeedback: Modulation of slow wave EEG enhances musical performance. NeuroReport, 14(9), 1121-1224.
Fuchs, T. Birbaumer,N., Lutzenberger, W., Gruzelier, J. H., & Kaiser, J. (2003). Neurofeedback Treatment for attention deficit/hyperactivity disorder in children: A comparison with methylphenidate. Applied Psychophysiology & Biofeedback, 28, 1-12.
Hammond, D. C. (2001). Neurofeedback treatment of depression with the Roshi. Journal of Neurotherapy, 4(2), 45-56.
Hammond, D. C. (2001). Treatment of chronic fatigue with neurofeedback and self-hypnosis. NeuroRehabilitation, 16, 295-300.
Hammond, D. C. (2003). QEEG-guided neurofeedback in the treatment of obsessive compulsive disorder. Journal of Neurotherapy, 7(2), 25-52.
Jarusiewicz, B. (2002). Efficacy of neurofeedback for children in the autistic spectrum: A pilot study. Journal of Neurotherapy, 6(4), 39-49.
Lubar, J. F. (1995). Neurofeedback for the management of attention-deficit/hyperactivity disorders. Chapter in M. S. Schwartz (Ed.), Biofeedback: A Practitioner's Guide. New York, Guilford, 493-522.
Mueller, H. H., Donaldson, C. C. S., Nelson, D. V., & Layman, M. (2001). Treatment of fibromyalgia incorporating EEG-driven stimulation: A clinical outcomes study. Journal of Clinical Psychology, 57(7), 933-952.
Monastra, V. J., Monastra, D. M., & George, S. (2002). The effects of stimulant therapy, EEG biofeedback, and parenting style on the primary symptoms of attention-deficit/hyperactivity disorder. Applied Psychophysiology & Biofeedback, 27(4), 231-249.
Moore, N. C. (2000). A review of EEG biofeedback treatment of anxiety disorders. Clinical Electroencephalography, 31(1), 1-6.
Peniston, E. G., & Kulkosky, P. J. (1989). Alpha-theta brainwave training and beta-endorphin levels in alcoholics. Alcohol: Clinical & Experimental Research, 13(2), 271-279.
Peniston, E. G., & Kulkosky, P. J. (1991). Alcoholic personality and alpha-theta brainwave training. Medical Psychotherapy, 2, 37-55.
Peniston, E. G., & Kulkosky, P. J. (1991). Alpha-theta brainwave neuro-feedback therapy for Vietnam veterans with combat-related post-traumatic stress disorder. Medical Psychotherapy, 4, 47-60.
Prichep, L., Alper, K., Kowalik, S. C., & Rosenthal, M. S. (1996). Neurometric qEEG studies of crack cocaine dependence and treatment outcome. Journal of Addictive Diseases, 15(4), 39-53.
Rasey, H. W., Lubar, J. E., McIntyre, A., Zoffuto, A. C., & Abbott, P. L. (1996). EEG biofeedback for the enhancement of attentional processing in normal college students. Journal of Neurotherapy, 1(3), 15-21.
Rossiter, T. R., & La Vaque, T. J. (1995). A comparison of EEG biofeedback and psychostimulants in treating attention deficit/hyperactivity disorders. Journal of Neurotherapy, 1, 48-59.
Sterman, M. B. (2000). Basic concepts and clinical findings in the treatment of seizure disorders with EEG operant conditioning. Clinical Electroencephalography, 31(1), 45-55.
Thompson, M., & Thompson, L. (2002). Biofeedback for movement disorders (dystonia with Parkinson’s disease): Theory and preliminary results. Journal of Neurotherapy, 6(4), 51-70.
Vernon, D., Egner, T., Cooper, N., Compton, T., Neilands, C., Sheri, A., & Gruzelier, J. (2003). The effect of training distinct neurofeedback protocols on aspects of cognitive performance. International Journal of Psychophysiology, 47, 75-85.
For more information about neurofeedback, I recommend the following web sites which I have found to have good educational content.
1. The International Society for Neuronal Regulation: http://www.isnr.org
2. Association for Applied Psychophysiology & Biofeedback: http://www.aapb.org
3. Dr. Joel Lubar, University of Tennessee: http://www.eegfeedback.org
4. Neuropathways EEG: http://www.neuropathways.com/index.html.
5. Applied Neuroscience qEEG: http://www.appliedneuroscience.com