Eugene O. Peniston, Ed.D., A.B.M.P.P., B.C.E.T.S.,
F.A.A.E.T.S.
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
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