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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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