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by Paul G. Swingle
Rutgers University Press, 2008
Review by Roy Sugarman, Ph.D. on Mar 24th 2009
Swingle bravely takes on a topic that has been fraught with controversy for some 40 years. He has practiced for 30 of those, drawing on the likes of Siegfried Othmer.
Still, Neurotherapy, the principal component of which is neurofeedback, is a form of operant conditioning that is designed to change the activity of the brain as represented by the signals that are measured at the scalp by the electrodes, but is widely unaccepted by the general medical community. Referred to as EEG biofeedback, the object is to change the brain activity.
One can debate the issue, but detractors have pointed out that there is simply isn't the data to present in support of neurofeedback in any condition, with some exceptions in the case of ADHD. So busy with the clients who beat down their doors, since so strong is the need for an alternative to psychostimulant or other noxious or even toxic treatment, that most consumers simply don't care whether it has evidence of efficacy or not. So there isn't really a convincing and robust evidence base.
Another reason for its failure to make it entirely as a mainstream intervention is the cost. The brain waves referred to are relatively stubborn, and take 30-40 sessions in many cases to change in any meaningful way. That is not a small investment. Standardized treatment protocols are also seldom clearly defined, so it's each to his own.
But more importantly, in the individual, who knows what brain pattern represents dysfunction, since Quantitative EEG's (Q's) are not diagnostic enough in the individual, to refer to any major condition such as ADHD. The neurofeedback community simply has not gone out there and got the data.
There is one spot on the horizon though, and that is a yet to be accepted for publication study by Arns and colleagues in Europe who have completed a meta-analysis in ADHD with 1196 subjects, and found good treatment effects in everything but hyperactivity.
Swingle is thus offering his experience and history, but mostly, he does it based on anecdotes rather than research: he is, after all, a clinician. The problem is, with a lack of clear data, the detractor will say that the claims of effectiveness are a mistaken evaluation of placebo responses.
So Swingle describes the process in clients with various conditions, starting off with a sensitive analysis of a child with ADHD. The process of neurofeedback is the same principle as with any biofeedback approach, namely to produce some kind of analogue of activity in the brain, usually visual. So the therapist can reward any particular wave generation or suppression by some activity on the screen that the client finds rewarding. The brain, faced with these images or procedures will automatically adjust itself, being rewarded by some movement or change on the screen when it inadvertently gets it right. The brain being what it is, it will then train to that frequency. Moving the goalposts at times increases the level of difficulty, and the brain has to increase the intensity, changing the threshold of the activity to a higher level.
As the first little boy learns to suppress the delta activity in his brain that is being regarded as linked to his disorder, he is rewarded with movement onscreen, or the increasing appetite of the Pac Man.
The process of QEEG is first established by placing electrodes in set locations in the brain. These will be labeled as F, P, C, T etc because they are frontal or central etc, and labeled further with positive or negative integers, depending on whether they are left or right, or Z for central ones. In more sophisticated programs, there will be these sites shown on maps as left, with colors related to deviation from the mean in Z scores if there is a large enough database to draw on. A skilled investigator will know if this is signal, or if it is EMG artifact for instance. Assumptions can be made that central signals might represent anterior cingulate functioning, or not. Essential to Swingle's process, is the effect on opening of the eyes after signal strength has been measured with the eyes closed. The extent to which signals disappear or are attenuated by opening the eyes is important information. So with eyes closed, the signals might include, very soon, a lot of Theta or other wavelength indicating the brain is going to sleep, but this should rapidly resolve away when the eyes are opened and the cortex is stimulated. The failure of this to happen, in the first boy described in the book indicates to Swingle that the signal should be trained away by the operant conditioning effect, or trained down, with other signals trained up in contrast.
Important for Swingle's approach, and commendable, is the appreciation that this is not a standalone treatment, but that given ADHD is a polymorphic illness, there is a need to intervene with other treatments that run alongside these conditions, and may include the need for family, individual, and addiction therapies for instance. Comorbid behavioral conditions are the norm, rather than the exception.
What Swingle is also keen on is the idea of signatures in various conditions. He refers to an artist signature in the young boy above, essentially an identification of alpha wave in creative and sporty individuals, and in an obsessive, pain filled woman, slow theta waves in the frontal areas appear to him to indicate that the results are consistent with the signature of fibromyalgia.
This would overall place Swingle in the wishful thinking basket of some critics of the methods, or in the Integrative Neuroscientist basket of those who are aware and have some evidence for the body brain continuum. Dick Gevirtz has spent the last 15 years showing similarly for heart rate variability and lately, resonant frequency training, both of which have penetrated the peak performance training in athletes, as measures of risk and recovery. What he clearly believes in is that disorders of both body and mind show up in abnormal EEG activity.
The take however, from many, is that each person has a genetically inherited EEG, and that the between-group studies that would be needed to produce such signatures, convey nothing about the individual. What is dysfunctional in one may suite others.
So for instance, as pointed out by Barkely over the years, ADHD boys may make very good stand up comedians (Robyn Williams?), door to door salesman, rock musicians, ER specialists and so on. What if we trained them down from their delta/theta highs? What of the sportsmen and women in peak performance groups, does training theta/beta help or hinder?
Thus page 29 has “possible” brainwave effects listed. Delta is associated with mental fog and pain, in excess, or poor sleep if there is too much present. Theta in the same vein might represent a lack of focus in the one side, or a failure to relax on the other side of the equation.
These considerations thus permeate the chapters, as case study reports such as those on traumatic brain injury dominate. The brain injured patient referred to as Vincent receives 50 treatments, goes on to hold down a job, and reunite with his estranged wife: but we are not told what wavelengths were measured, or what was trained up/down. So where is the science base for this intervention, in this case?
He takes up the case of brain signatures in chapter three, citing five brain regions as the major elements in these signatures. This means combining, say the occiput, with theta and beta disturbances, looking for ratios say of theta/beta in the order of theta being twice beta in terms of amplitude. Less would mean the brain cannot easily self soothe. This agitation could lead to addiction, or there could be excess alpha over the frontal areas for instance if one is considering this ratio in anxiety. Likewise, alpha here should change by an order of 50% in its amplitude when the eyes open-eyes closed is manipulated.
The discussion is very interesting and informative, but little evidence is offered for the direct effects and nature of the training here, or of the science behind what signature means what, but it does help one understand neurofeedback and the significance of the presence and character of various wavelengths as measures of particular activities and roles in the cortex.
Swingle further describes the adjunctive therapies that must attend neurofeedback treatment, as well as the controversies over diagnosis that are common to modern psychiatry discussions. He adds to this debate with a typology of ADHD, namely such presentations as the High Frontal Alpha version and one with Occipital Theta 'deficiency' for instance. When he does cite references, it will be for instance on how hard it is to treat some addictions for instance, not on how ADHD related excitement seeking is attenuated by neurofeedback, how this works, and who has shown that in a satisfactory set of data.
Swingle however ventures to describe the broad reach of neurofeedback therapy, including multiple conditions for which it is indicated, but again, he would be hard pressed to show the literature that this is indeed the case, with the possible exception of ADHD, and I would guess epilepsy, for which, if my memory serves me correctly, neurofeedback was invented originally. Several types of brainwave patterns may all distinguish or at least fingerprint ADHD, and he mentions these in other conditions, such as the spectrum of Autism, as befits another polymorphic syndrome. In any event, treatment here is guided by the brain activity found on QEEG, and so Swingle successfully ameliorates some of the symptoms associated with these conditions, and others, including bipolar disorders and traumatic brain injury. There is a difference between normalizing and optimizing brain function, as he points out.
Newer techniques such as LORETA are proving promising, and Swingle looks to the future.
The future however is not looking promising, as every man and his highly trained dog enter the poorly regulated field of neurotherapy, with its awful lack of really impressive data, and its absolute mountain of anecdotal evidence that there is no reasonable doubt that in practice it really works.
From a science point of view, lack of real data, compelling data, makes its practitioners pretty close to charlatans by definition, as such a poorly researched field should not be allowed to influence so many lives. Many practitioners go bankrupt each year, despite some hefty advertizing of their cures for ADHD, a very lucrative market.
What is true however, is that EEG-based neurotherapy, and biofeedback as a whole, works. No data. But it works. There are countless ideas about what to do when and whenever, but no rigorous data to show the way. And now rTMS is entering the field as well, just to complicate matters.
However, the field has to urgently watch Martijn Arns and his collaborators and colleagues in Europe, Schutter, Ulrich, van den Bergh, Gunkelman, who will hopefully publish soon their meta-analytic and other studies which will now include rTMS treatments. The field is on the move, and Swingle might soon have all the evidence he needs for his claims, in ADHD at least.
A wonderful primer for the would-be practitioner, and Swingle writes nicely, very readably, and is a good teacher, and I am sure, a good healer.
As the emerging literature and consequent uptake of Resonant Frequency Heart Rate Variability has shown as an intervention supported by real data, so the field of Neurotherapy will rise and experience its increasing promise in the field of behavioral interventions, that work.
© 2009 Roy Sugarman
Roy Sugarman PhD, Director: Behavioural Solutions, Brain Resource Limited, Ultimo, Australia