| EARLY
DEVELOPMENT OF ALPHA AND THETA BRAINWAVE TRAINING
Electroencephalographic
(EEG) biofeedback has been in use since the early
1970's for treatment of anxiety disorders and
a variety of psychosomatic disorders. Early work
conducted by researchers such as Kamiya and Kliterman
focused on alpha wave biofeedback (Kamyi &
Noles, 1970). Much of this initial research associated
changes in EEG state with different states of
consciousness (Basmajian, 1989). Researchers learned
that certain tasks, such as mental arithmetic,
reduce or suppress alpha wave production. Furthermore,
researchers found that these changes in brain
activity were positively correlated with changes
in electromyographic (EMG) activity and skin temperature.
This finding was significant in that it suggested
that brainwave activity could be operantly conditioned
in the same manner as EMG or temperature. Alpha
waves are smooth, high amplitude waves in frequency
range of 9-13 Hertz (Hz). Alpha wave biofeedback
was explored by some researchers, as a treatment
adjunct for alcohol abuse (Passini, Watson, and
Dehnel, 1977). There were two theoretical rationales:
first, investigators had reported that EEGs of
alcoholics were "deficient in alpha rhythms
and alcohol use induced more alpha wave activity
(Pollock, Volavka, Goodwin, et al., 1983). Clinicians
speculated that alcoholics might drink less if
they could be taught to produce more alpha waves
(Jones & Holmes, 1976). Secondly, many alcoholics
and other drug abusers reported using alcohol
or other drugs to relax. Thus, biofeedback training
was proposed as a way teach alcoholics an alternative
to using alcohol to relax. Alpha training did
not, however, appear to be of benefit to most
alcohol abusers because they were unable to learn
to increase their production of alpha waves.
Various types
of relaxation training and/or stress reduction
techniques have been used in the treatment of
alcoholism. These techniques include progressive
relaxation training (Klajner, Hartman, & Sobell,
1984), meditation (Wong, Brochin and Gendron,
1981), Hypnosis (Wadden & Penrod, 1981), and
alpha wave feedback training (Passini, Watson,
Dehnel, Herder & Watkins, 1977; Watson, Herder,
& Passini, 1978).
Several studies
have investigated the effects of alpha biofeedback
training in the treatment of alcoholism (Passini
et al., 1977; Watson et al.,1978). The theoretical
rationale for the use of relaxation procedures
has usually included two assumptions: (a) that
substance abuse is caused or exacerbated by stress
and anxiety, and (b) that relaxation training
is effective because it reduces anxiety and increases
an individual's sense of perceived control over
stressful situations (KIajaer et al., 1984). Results
indicate that alpha training reduces chronic anxiety
and does appear to have some long range therapeutic
effects on anxiety levels. However, even though
there has been some evidence of positive findings
attributable to the use of these relaxation techniques,
many of the studies involved poor methodology
and results are equivocal at best.
Interest in the
combination of alpha-theta training evolved from
investigation of sleep and creativity (Budzynski,
1973). One earlier study found that, as individuals
became drowsy, their brain waves commonly changed
from high-amplitude alpha to low-amplitude theta
(Vogel, Foulkes, & Trosman, 1966). During
the transition, some individuals experienced a
hypnogogic state in which they had vivid visual
imagery and auditory and visual hallucinations.
Investigators studying creative individuals noted
that when their subjects were in a state of "reverie,"
they produced increased amounts of 6-8.5 Hertz
(Hz) activity (Green, Green & Walters, 1970).
In an effort to facilitate production of the reverie
state and hypnogogic imagery, the investigators
developed an alpha-theta biofeedback system that
provided information to the subject about both
alpha and theta production. As memory for the
content of images in the hypnogogic state is often
poor, subjects were asked to verbalize the imagery.
The investigators thought that the production
of the alpha-theta twilight state "should
prove to be a powerful technique for the study
creativity enhancement in particular, and the
hypnagogic state, in general." They suggested
the possibility of using the alpha-theta state
for psychotherapy (Budzynski, 1973).
Alpha brainwaves
are smooth, high-voltage brainwaves in the frequency
range of 9-13 Hertz. Some research suggests that
alpha brainwaves are associated with a subjective
state of relaxed alertness or tranquillity (Brown,
1970; Stoyva and Kamiya, 1968) while other research
suggests that alpha brainwaves are not associated
with any particular subjective physiological state
(Walsh, 1973).
The theta rhythm
state is defined as a dominance for 4-7 Hertz
brainwaves. Transient elevation of theta occur
during Zen meditation (Kassamatsu & Hirai,
1969) or while entering the early stages of sleep
and are reported to be associated with vivid visualization,
imagery and dream-like states. The origin of theta
waves is predominately the hippocampus (Michel
et al., 1991), although theta activity can be
recorded throughout the cortex and cerebellum
(Green, Green & Walters, 1971).
In the late 1980's,
the advances in digital processing technology
gave clinicians and researchers biofeedback equipment
that significantly improved the quality of EEG
neurofeedback signal compared with that previously
available using analog filters. The availability
of high-speed desktop computers opened new possibilities
for neurofeedback training and research. New neurofeedback
equipment incorporated high-speed analog-to-digital
converters and computers for data logging and
the creation of data displays using fast-fourier
transforms. In addition, some neurofeedback equipment
could now automate data logging and session statistics.
It was during
the late 1980s and early 1990's that Peniston
and Kulkosky developed an innovative therapeutic
EEG alpha-theta neurofeedback protocol (Peniston
& Kulkosky, 1989, 1995) for the treatment
of alcoholism and prevention of its relapse. The
Peniston/Kulkosky brainwave neurofeedback therapeutic
protocol combined systematic desensitization,
temperature biofeedback, guided imagery, constructed
visualizations, rhythmic breathing, and autogenic
training incorporating alpha-theta (3-7 Hz) brainwave
neurofeedback therapy (Blankenship, 1996; Peniston
& Kulkosky, 1989, 1990, 1991, 1992; Saxby
& Peniston, 1995). These investigations prompted
a reexamination of EEG neurofeedback as a treatment
modality for alcohol abuse. Successful outcome
results included a) increased alpha and theta
brainwave production; b) normalized personality
measures; c) prevention of increases in beta-endorphin
levels; and d) prolonged prevention of relapse.
These findings were shown to be significant for
experimental subjects who were compared with traditionally
treated alcoholic subjects and non-alcoholic control
subjects. Subjects in several studies were chronic
alcoholic male veterans, some of whom also suffered
from combat-related posttraumatic stress disorder.
For many subjects, pharmacological treatment was
not generally beneficial. Data suggested that
alpha-theta brainwave neurofeedback training appeared
to have potential for decreasing alcohol craving
and relapse prevention.
EXPERIMENTAL
DATA
Consider the following
experiment that examined the Peniston/Kulkosky
EEG alpha-theta neurofeedback protocol with a
sample of chronic alcoholics. There were three
interventions utilized with this group of subjects
including: (a) alcoholic alpha-theta brainwave
neurofeedback therapy (PKBWNT), (b) traditional
psychotherapy, and (c) non-alcoholic control group.
Subjects were age matched and evaluated for alcoholic
history, number of prior hospitalizations, IQ,
and socioeconomic status. Before and after treatment
subjects were given the Beck Depression Inventory
(BDI), the Millon Clinical Multiaxial Inventory
(MCMI), and the Sixteen Personality Factor Questionnaire
(I6PF). Subjects were also tested for EEG characteristics
and serum radioimmunoactive beta-endorphin levels.
This investigation showed enhanced percentages
of alpha and theta waves in the EEGs of the PKBWNT
group after treatment compared to pretreatment
status. The control group showed no such increase.
Alcoholic subjects receiving PKBWNT also showed
a gradual increase in alpha and theta brain rhythms
as the thirty experimental sessions progressed.
The increase in alpha and theta activity were
desirable outcomes of this study. The theta increase
may have made the visualization experiences (which
were part of the training and discussed at the
end of each training session) easier to access
and more effectively integrated and processed.
It was concluded that alpha training may promote
a more relaxed state and lead to better perceived
control of stress; this may, subsequently, decrease
the occurrences of stress-related drinking or
stress-related craving in the recovery phase.
The PKBWNT group had shown sharp reductions in
self-assessed depression (BDI) and sustained abstinence
with significantly less relapse episodes (2/10)
than the traditional therapy group (8/10) in a
36-month follow-up study. The traditional therapy
group showed a significant elevation in serum
beta-endorphin levels at the end of treatment
compared to their own pretreatment levels as well
as the repeated measurement levels of the non-alcoholic
control group. (The beta-endorphins are stress-related
hormones and are elevated during the experience
of physical or emotional stress. Successful treatment
would stabilize beta-endorphin levels, so that
stress-related increases would be less likely
to occur.) Since elevations in serum beta-endorphin
levels are associated with stress, their elevation
in the traditional therapy group may indicate
that this group is experiencing the stress associated
with abstinence and fear of relapse. It is interesting
that the PKBWNT group did not show an increase
in this stress hormone after treatment, but instead
showed a stabilization (Peniston & Kulkosky,
1989). On the MCMI and l6PF, prior to treatment,
both groups of alcoholics showed significantly
higher scores (in the pathological ranges) than
non-alcoholics on most of the clinical scales
and characteristic scales. Administration of PKBWNT
was accompanied by significant decreases in all
of the MCMI clinical scales (i.e., within normal
limits) and normalization on the 16 PF characteristic
scales. Alcoholics receiving traditional therapy
showed significant decreases only in two MCMI
scales (avoidant and psychotic thinking) and an
increase on one MCMI scale (compulsive), and showed
only a significant increase on the l6PF in concrete
thinking (Peniston & Kulkosky, 1990). Evidence
corroborating some of the findings from the aforementioned
experiment come from the work of Fahrion (Fahrion
et al., 1992).
EEG alpha-theta
brainwave neurofeedback therapy (Peniston/Kulkosky
protocol) had also been employed in a clinical
study using twenty male Vietnam combat veterans
with a dual diagnosis of posttraumatic stress
disorder and alcohol abuse. A goal of that study
was to determine the efficacy of brainwave training
in developing brain region synchronization and
altering amplitudes of intrasubject brainwaves.
It was discovered that during sessions in which
patients reported abreactive imagery, the PKBWNT
sessions displayed a statistically reliable interaction
seen as a "cross-over" pattern in which
theta waves gradually increased and the alpha
waves decreased. This pattern identifies a state
of consciousness which is believed to optimize
the surfacing of abreactive images. A follow-up
study revealed that only three of the twenty experimental
patients had relapsed to alcohol by twenty-six
months after PKBWNT (Peniston et al., 1995).
In addition to
the aforementioned clinical studies, the Peniston/Kulkosky
protocol was employed in private group practice
in the treatment of fourteen depressed alcoholic
outpatients (8 males and 6 females) (Peniston
& Saxby, 1995). After training, subjects showed
significant improvement on BDI scores. At 21 months
after PKBWNT training, only one subject was observed
to relapse. Other clinical studies using the alpha-theta
brainwave neurofeedback therapy (Bodenhamer-Davis
& deBeus, 1995; Blankenship, 1996; Peniston
& Kulkosky, 1990; Peniston et al., 1993; Saxby
& Peniston, 1995; Sealy et al., 1991; Sullivan,
1993; White, 1993, 1995) provide promising evidence
for the effectiveness of the alpha-theta brainwave
therapeutic protocol in: a) changing EEG scores
and self-assessed depression; b) stabilizing serum
beta-endorphin levels and; c) producing long-term
prevention of alcohol relapse. PKBWNT also produced
significant personality changes, reductions in
the need for psychotropic medications, some relapse
prevention of PTSD symptoms, and in some studies,
optimized the surfacing of abreactive images in
Vietnam theater combat veterans. The recent ten
year follow-up clinical evaluation of the original
Peniston/Kulkosky alpha-theta brainwave neurofeedback
(Peniston & Kulkosky, 1989) clinical study
confirmed the long-term effectiveness of this
therapeutic intervention. Such a success rate
of a treatment modality has never before been
achieved.
The Peniston/Kulkosky
EEG alpha-theta neurofeedback protocol (Peniston
& Kulkosky, 1989,1995) is being used by many
practitioners to treat alcohol and other psychoactive
substance disorders. Some alcohol treatment programs
using the Peniston/Kulkosky EEG alpha-theta neurofeedback
protocol as a primary treatment modality for alcohol
addiction have demonstrated that intensive neurofeedback-based
treatment has exerted a positive influence on
a number of factors which contribute to alcohol
intake including stress levels, depressive personality
traits, beta endorphin output, resting levels
of alpha and theta brainwaves, and prolonged abstinence
(Boeving, 1993, 1994; Blankenship, 1996; Day &
Cook, 1997; Dyers, 1992; Fahrion, 1995; Finkelberg
et al., 1993; Peniston & Kulkosky, 1989, 1990,
1991; Peniston, 1993; Rodenhamer-Davis et al.,
1995; Saxby & Peniston, 1995; Sealy, Bernstein
& Magid, 1991; Shubina et al., 1997; Sullivan,
1993; White, 1995; Wultke, 1992). Data supporting
the efficacy of the Peniston/Kulkosky method are
of particular interest for the treatment of substance
abuse because successful outcome is being discovered
with patients who are difficult to treat in traditional
alcohol treatment programs including patients
with postttraumatic stress disorder (Peniston
and Kulkosky, 1991) and chronic alcoholic problems
(Peniston and Kulkosky, 1989, 1990; Saxby &
Peniston, 1995).
If the EEG alpha-theta
neurofeedback training protocol can increase the
retention of patients in alcohol treatment programs
and decrease the relapse rates of alcoholism,
then this form of behavioral treatment would be
a significant new therapeutic intervention for
clinicians. Traditional interventions for alcohol
dependency have often resulted in high attrition
rates and release rates (Alford, 1980; Emrick
& Hanson, 1983; Marlatt, 1983; McLachlan &
Stein, 1982; Miller & Hester, 1980; Moos &
Finney, 1982, 1983;Vaillant, 1983).
Although psychopharmacological
treatments for alcohol dependence are being investigated
by many individual researchers and by NIDA's Medications
Development Division, at present no psychopharmacological
agents have been established as safe and effective
for treatment of alcohol dependence.
This is an additional
reason for making the development of effective
treatments for alcohol dependence a high priority.
Alcohol abuse is associated with cirrhosis (e.g.,
liver), fetal alcohol syndrome, several alcohol-related
illnesses, and various types of accidents (e.g.,
motor vehicle). New treatment strategies that
would attract alcohol users to treatment and keep
them in treatment would be of immense value in
reducing alcohol-related morbidity and mortality
among the American population in the United States.
The PKBWNT represents
cutting edge methodology which has moved from
the preoccupation with the voluntary muscular
and autonomic nervous system to the central nervous
system, and in particular to alpha-theta brainwave
neurofeedback. It has been indicated that the
self-induced reverie state (i.e., theta state
of consciousness) which the PKBWNT protocol produces,
makes it possible for patients to regain some
control of their behaviors and improve the outcomes
of treatments for several disorders including:
(1) alcoholism; (2) depression; (3) combat-related
PTSD syndrome and; (4) bulimia nervosa. My associate,
Paul Kulkosky and I have found that combining
temperature biofeedback, guided-imagery, constructed
visualization, autogenic training and systematic
desensitization with alpha-theta brainwave neurofeedback
and booster sessions contributed to sustained
prevention of relapse in alcoholics and posttraumatic
stress disorder.
THE CRISIS
IN MENTAL HEALTH CARE
The conflict between
productivity/cost efficiency and quality of care
will intensify in the future. At the level of
individual practitioners, managed care in healthcare
will require seeing more patients, for shorter
treatment sessions, over shorter time-frames.
As always, the goal of maintaining and improving
outcomes, is paramount. The emphases on preventive
health care and on outpatient treatment will resemble
the broader healthcare environment. Skills in
assessment, particularly in areas of neuropsychology
and in behavioral medicine will be preferred.
Skills in briefer cognitive-based therapies will
be desirable. Most mental health care plans will
explicitly call for a reduction of bed days of
care. This may result in an increase in the need
for community-based clinics for acute and longer-term
mental health/substance abuse treatment, PTSD
treatment programs and behavioral medicine programs.
These clinics can serve as alternatives to treatment
in private, government, or psychiatric hospitals.
It is suggested
that neurofeedback therapy can become the future
alternative choice of treatment for subgroups
of addicts who are alienated by the religious
overtones of traditional 12-step recovery programs.
Moreover, such an intervention may prove to be
more useful for treating depression, posttraumatic
stress disorder, learning disabilities, attention
deficit disorder (ADD), eating disorders and psychosomatic
health problems. The PKBWNT has been scientifically
proven, for some disorders, to be a more efficient
therapeutic intervention (when compared to traditional
psychotherapy), and is more cost-effective over
the long-term. PKBWNT attempts to address causes
rather than symptoms of disorders. Neurofeedback
therapy works by assisting one's own mind-body
connection to heal itself as opposed to relying
on the use of medication.
Insurance company
guidelines, however, tend to devalue psychotherapy,
particularly long-term therapy, by limiting the
number of sessions that a person can utilize in
a year and by dictating which professional will
provide the therapy. This means that patients
may end up paying money out of pocket for therapeutic
treatment (that they may truly need) or go without
treatment altogether. Manage care companies may
also suggest psychotropic medications to patients
for several reasons (e.g., to minimize the costs
of therapy).
PKBWNT protocol
is a unique treatment because the frequency, cost,
and length of therapy is effective and well-controlled.
The future of PKBWNT holds even greater promise
for the refinement of our present knowledge about
alpha-theta brainwave training. Moreover, it may
facilitate treatment and research with cognitive
and emotional dysfunction and in the areas of
behavioral medicine.
The neurofeedback
therapeutic modality requires intensive training
in the Peniston/Kulkosky alpha-theta brainwave
neurofeedback therapeutic protocol. This consists
of a period of continuous supervision with a variety
of clients and close monitoring by a properly
trained licensed Psychologist or Psychiatrist.
Other therapists can use the technique with regular
supervision and only under the direction of the
aforementioned licensed professionals. Therapists
who are not properly trained and supervised in
the PKBWNT protocol in the mental health specialties,
run the risk of their clients experiencing and
suffering from some debilitating side effects
including: depression (result of too much theta
feedback); experiences of depersonalization; tunnel
vision and other experiences reflecting immediate
dissociative responses to trauma; alteration of
time; disorientation; confusion; altered pain
perception.
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