Is there an Anti-Neurofeedback Conspiracy?
Karen F. Trocki, PhD
Scientist, Alcohol Research Group, Public Health Institute, Emeryville, CA, USA
Address correspondence to Karen Trocki, Alcohol Research Group,
Public Health Institute, 6475 Christie Avenue, Suite 400, Emeryville,
CA 95608. E-mail: ktrocki@arg.org
This work draws on material organized under a pilot grant to Dr.
Trocki (P50 AA05595 National Alcohol Research Center). I acknowledge
the contributions of numerous people who agreed to be interviewed
or offered suggestions: Tom Allen, Shannon Burkett, Bob
Dickson, Mike Gismondi, Cory Hammond, Siegfried Othmer, Carolyn
Robertson, Don Theodore, David Trudeau and Marty Wuttke.
As we all well know, addictions are very difficult to treat and
relapse rates are very high. Furthermore the individuals with
the best outcomes are likely to be white, of high socioeconomic
status (SES) better educated, addicted to a single drug, or in a socially
stable living situation. However over the past two decades
a new kind of adjunct therapy for addictions has emerged that
is ideally suited for delivery within treatment settings by midlevel
licensed professionals such as nurses, socialworkers, counselors,
or physical therapists. This is a treatment approach that
has shown strong, positive results in long term follow-ups but
the spread has been glacially slow. Given the strong positive
findings it almost seems as though there is a sort of a conspiracy
keeping this treatment from being used.
Neurofeedback (also known as Neurotherapy, EEG biofeedback
or brainwave training) has been found to be highly effective
in maintaining remission status in some of the most intractable
populations when used in combination with typical treatment
approaches (Trudeau, 2005). Neurofeedback is a form of biofeedback
where a therapist trains a person to increase or decrease
certain brainwave frequencies using electroencephalographic
measures taken from electrodes attached to specific sites on the
scalp. It has been used for substance abuse, attention deficit disorder
(ADD), seizure disorders, traumatic brain injuries (TBI),
and many other conditions marked by EEG abnormalities. The
main professional organization for neurofeedback, the International
Society for Neuronal Regulation, keeps an up-to-date bibliography
of published studies on their web site (www.isnr.org).
Most commonly, neurofeedback is administered by using a
combination of hardware, software, and computer connections.
Information is transmitted from the electrode sites to an encoder
device, which in turn transmits it to the computer to give the person
feedback (a sound and/or a visual signal) indicating whether
they are accomplishing the goals of the task. For instance, for
the standard Peniston/Kulkosky protocol (more about this later)
an electrode might be placed at a specific occipital lobe site
(O1 using the 10-20 system) and the individual is trained to
increase alpha and theta brainwaves to induce a profound relaxation
effect that occurs when the theta amplitude crosses over
(or becomes higher) than the alpha amplitude. There are protocols
other than alpha-theta and many different neurofeedback
devices. These devices use a range of different feedback techniques
such as photic stimulation (light feedback), electromagnetic
stimulation, or the measure of blood oxygenation (HEG);
but their intent is the same: to modify and restore healthy brain
functioning. However, since none of these other techniques have
any published studies on substance dependent or abusing populations,
they will not be addressed here.
One of the first published studies of substance abuse treatment
and neurofeedback was presented in 1989 in the journal,
Alcoholism: Clinical and Experimental Research (Peniston &
Kulkosky, 1989). This was a study done at a Veteran’s Administration
hospital in Colorado after Peniston had been trained in
neurofeedback and biofeedback at the Menninger Institute. The
study included 30 men, 20 of them severe alcoholics who had
a minimum of four prior admissions for treatment and an average
of more than 20 years of dependence. Ten men constituted
a non-alcoholic control. Details of the specific protocol can be
found in the article.
In the short-term follow-up immediately at the end of the
training it was found that the experimental group could significantly
increase alpha and theta relative to the control groups and
was significantly lower on depression scores as measured by
the Beck Depression Inventory (Peniston & Kulkosky, 1989).
A separate analysis of the same data (Peniston & Kulkosky,
1990) for the experimental and control groups showed significant
positive changes on the Millon Clinical Multiaxial Inventory
(MCMI) and the Sixteen Personality Factor questionnaire
(16PF). In a follow-up done 13 months later it was found that
eight of the ten men in the experimental group were still in remission
compared to only two in the control group. The results
were so startling that the investigators as well as a staff member
of the Menninger Institute personally validated the outcomes by
speaking with the subjects and their family members. Follow-ups
have been periodically conducted with the experimental group
and remission rates continue to be high.
Since that time there have been a number of other published
studies and still more presented at conferences. Saxby
and Peniston (1995) did an alpha-theta intervention with 14 alcoholics
(both men and women with an average of 17 years
alcohol dependence combined with depressive symptoms). At
the 21-month follow-up point, 13 of these 14 individuals remained
in remission according to self-report and the report of
collaterals. Kelley (1997) treated a group of 19 Navaho Indians
with a program based on alpha-theta which incorporated culturally
specific aspects such as a “singer” medicine man/therapist
who provided encouragement, blessings, purification and other
guidance. Three years later the follow-up found 21% in full
remission and 63% in partial remission (e.g., had experienced
some infrequent, problem-free relapses and a few who had gone
to normal drinking with no binges).
Taub et al. (1994) did a study with three different intervention
arms compared to a regular treatment group. The added interventions
included transcendental meditation, EMG (muscle)
biofeedback, and “neurotherapy.” The first two groups had the
best outcomes at the one year point. However, what Taub called
“neurotherapy” was really a form of cranial electrostimulation
(CES) and not neurofeedback.
Recently two larger studies were done within residential treatment
programs with populations of severe poly-drug users, most
of whom were minorities and/or homeless. Scott et al. (2005)
conducted a study on a polydrug population in long-term residential
treatment at Cri-Help in Los Angeles. The investigators
used a modified version of the Peniston/Kulkosky protocol that
included a preliminary series of SMR (sensory motor rhythm
13-15 Hz) and beta training (15-18 Hz) instead of temperature
training. These sessions were included because many people
with substance abuse are comorbid forADDand these frequency
ranges tend to have lower amplitude than they should. They used
the Test of Variables of Attention (TOVA; Greenberg, 1992) to
assess whether attention parameters had normalized (it took an
average of 13 sessions) and this was then followed by 30 alphatheta
sessions. The follow-up found that77%of the experimental
group were in remission a year later compared to only 44% of
the controls. A non-published follow-up at three years showed
that the rates of remission had been sustained whereas the control
group had more relapses. Burkett and colleagues (Burkett,
2006; Burkett, Cummins, Dickson, & Skolnick, 2005) used a
similar training protocol for a crack/cocaine abusing population,
the majority of whom were homeless and unemployed on
treatment entry. At the 12-month point following treatment 49%
were in complete remission and an additional 30% had used cocaine
fewer than four times. Ninety-two percent had maintained
a regular residence (compared to 40% at entry) and 91% were
employed (compared to 17% prior to entry). There was no control
group.
In addition to reviewing published studies for this article,
personal interviews were done with numerous neurofeedback
practitioners who have worked with substance abusers. For instance
the head of the Texas Commision on Alcohol and Drug
Abuse was dismayed at the cost of traditional treatment services
that still resulted in high relapse rates. He became interested
in neurofeedback and funded several programs that were successful
but only one of them has been published (Burkett et al.,
2005). Most individual clinicians with private pay patients or
those in private institutions report successes equal to the published
reports, particularly when the therapy is an adjunct to a
formal treatment program or AA/NA.
There have been some negative findings or failures to replicate
but none of them published. For instance Grapp et al. (1998)
found that depression rates decreased in a PTSD sample but
other outcomes were no where near as dramatic as Peniston’s.
Graap also critiqued Peniston’s published reports as having reporting
flaws to which Peniston replied (Graap&Freides, 1998;
Peniston, 1998). The most notable failure was presented by
Fahrion (2002) about a study where alpha-theta training was
used with a large population of prisoners. The two-year followup
of over 500 showed only small differences between the experimental
and control groups. However the Fahrion protocol
differed substantially from the original Peniston/Kulkosky one
because it was done in groups of up to ten participants plugged
into the same, somewhat primitive, instrument. Subgroup analysis
revealed that the stimulant user group was particularly resistant
to change.
In addition, the published studies have weaknesses relative
to NIH-funded research. Notably, most of the studies have problems
with follow-up since the treatment entities have self-funded
the research and have tried to track highly mobile and dysfunctional
populations with inadequate resources (from my personal
experience follow-up for a difficult population usually costs
about $500 per case per interview point). In particular it is hard
to track controls and early drop-outs since they are more likely
to have higher severity levels. Thus the success rates often are
based on the clients the researchers are able to find. This creates
problems when the researchers attempt to get their work published
in prestigious and high impact journals. Still, the success
rates are remarkable and would stand against other treatment
approaches even if one were to factor in the lost-to-follow-up
groups.
Thus published studies, conference presentations, and
anecdotal reports have shown neurofeedback to be efficacious
for substance abuse as well as co-occurance of depression,
ADD, changes in personality profile, and the maintenance
of a stable lifestyle. Yet the approach is not widely used nor
has NIH or foundation funding been available to examine the
mechanisms that might explain, further validate, and refine this
therapeutic approach. There are only a few dozen treatment
programs, at most, in the country that include neurofeedback
among their services.
The contrast between the strong efficacy of neurofeedback
and the lack of adoption of the technique has led some people
in the field to think that medical associations or pharmaceutical
companies are trying to deliberately undermine it. The techniques
do not fall neatly into either the medical or behavioral
realm and thus both sides reject it. The cost of the therapy is also
front-loaded so that it appears that counseling or pharmaceutical
approaches are cheaper although medical visits, prescription
co-pays, side-effects, and failure to have any impact can become
a costly alternative when a person continues to have symptoms
or a disrupted life for decades.
One barrier to acceptance is the difficulty in explaining exactly
what it is that neurofeedback does and how it works. This
is particularly true for alpha-theta training, which is typically
explained in terms of the relief from life-long traumas in a very
psychodynamic paradigm. People talk about attaining higher
states of consciousness, or having spiritual awakenings and deep
personal insights. It is hard to wrap one’s mind around the fact
that there may be a connection between electrical activity in the
brain and states of consciousness. In addition, the alpha-theta
protocol is actually a mixed bag of techniques including not
only neurofeedback but hand temperature training, relaxation,
counseling, visualization, relapse prevention, refusal skills, hypnotic
suggestion, and considerable one-on-one attention from a
therapist. Although there have been attempts to explain what
happens to cognition, brainwaves, and the soul, the why and
how of the approach are still subject to speculation. The original
alpha-theta approach has evolved over time and researchers in
some of the published work have substantially modified parts of
the original protocol. For instance the Houston study (Burkett,
2006; Burkett et al., 2005) found overall positive results but few
changes on personality profiles; however they had discarded
the temperature training since they did not have the necessary
equipment.
Another notable barrier to acceptance has been the high-tech
nature of the therapy. Instead of counseling, group therapy, or
pharmaceutical interventions this therapy requires a fairly sophisticated
level of technological savvy. The therapist needs to
have high-level computer skills as well as education in how
to attach electrodes, measure impedance levels, and interpret
whether the client understands what to do. Ideally the therapist
is not just a technician but also should have high level counseling
skills since a strong therapeutic alliance may be key. Technical
skills and a warm counseling manner are not always present
in the same person. It takes a motivated and enthusiastic counselor/
clinician to learn this approach. Given that many people
do not know how to use the record function on their VCRs, the
need for technological know-how could be a significant drawback.
However, while neurofeedback has not reached the point
of being completely turnkey, there has been considerable improvement
since the 1980s when buggy software and primitive
instruments were the norm.
Another barrier has been the cost and intensive one-on-one
nature of the therapy. A substance abuse treatment program has
to take into account the cost of equipment and training a practitioner
but also the cost of doing 25 to 50 individual sessions
for each client. The added cost of this therapy could range from
$2,500 to $10,000 depending on the qualifications of the therapist
and whether it is done by a private practitioner or a salaried
clinician in a treatment program. On the other hand, the costbenefit
ratio is high particularly in cases where the there have
been multiple relapses and the person has become a significant
burden to society because of incarceration or health problems
that fall on the tax-paying public. Cri-Help in Los Angeles continues
to have a neurofeedback program but the intake and program
counselors have become adept at picking and choosing
clients who might most benefit from this technique since it is a
limited resource.
Further research (preferably funded through NIH or other
sources) could determine how many sessions are needed as
well as how best to individualize treatment and thus reduce
costs. Increasingly clinicians use quantitative electroencelphagraph
(QEEG) brain maps when beginning to work with clients.
This can reveal comorbid disorders such as traumatic head injuries,
attention deficit disorder, and mood disorders. Systematic
research involving designs that include or exclude certain elements
would help to determine how each aspect contributes to
the whole and thus allow some parts to be discarded or selectively
used. In addition, the proliferation of personal computers
has led to the development of home training machines which
might be used by individuals for interim sessions but under the
general care and direction of a practitioner.
There has been a lack of NIH funding in this field, but discussions
with leaders and practitioners suggests that this may be due
more to inexperience in how one constructs a grant application.
Most neurofeedback therapists are clinicians and do not have
university resources to help them when establishing a research
program. While some grants are working their way through the
system with positive encouragement from NIH project monitors
and peer reviewers, other have been submitted, gotten positive
peer reviews but then the project lost momentum or people
moved on to something else. The NIH grant submission process
is difficult, but most reviewers applaud innovation especially
when it has a potential for high impact.
Siegfried Othmer (personal communication, September
2006) suggests that a reason for the lack of widespread
acceptance is premature discovery. He thinks that if neurofeedback
had been discovered last year it might have gotten more
acceptance in light of emerging research on the brain. Instead,
it is a technique that has been around for nearly 30 years. It has
been occasionally trashed by researchers in related fields (Kline,
Brann, & Loney, 2002) most often with the complaint that there
have been too few controlled studies with random assignment
to groups. Techniques such as Eye Movement Desensitization
and Reprocessing (Levin, Lazrove, & van der Kolk, 1999) and
“journaling,” (Pennebaker, 2003; Pennebaker&Graybeal, 2001;
Pennebaker & Seagal, 1999) have had an easier time being accepted,
perhaps because they are simple techniques.
Neurofeedback for substance abuse is a promising approach
with potential for treating difficult and resistant addicts who
have gone through the revolving door of treatment many times.
Beyond that, it has the potential for helping us learn about fundamental
mind/body interactions and connections and even understand
some of the mysteries connecting traumatic life events
and substance abuse.
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