| 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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