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Home > Relieve > Addictions
Summary of Addicitons Research

A solid telling of the studies that have been done supporting neurofeedback as 80% effective for all kinds of drug and alcohol addictions.

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.

REFERENCES

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Abstracts International: Section B: The Sciences and Engineering,

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Burkett, V. S., Cummins, J. M., Dickson, R. M., & Skolnick, M. (2005). An

open clinical trial utilizing real-time EEG operant conditioning as an adjunctive

therapy in the treatment of crack cocaine dependence. Journal of

Neurotherapy, 9(2), 27–47.

Fahrion, S. L. (2002, February 26). Group biobehaviroal treatment of addiction.

Paper presented at the The 4th Meeting of the Neurobiology of Criminal and

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