Among the principal neurofeedback venues, the Winter Brain Conference has had perhaps the best shot over the years at attracting newcomers to the field with the diversity and vitality of its program. The pricing threshold was always too high to attract casual interest, however. This year, pricing was reduced along with the length of the conference, but the decline in attendance only continued. Hemmed in by proximity to the turn of the New Year and the early AAPB Conference in Monterey, the meeting failed to attract many of the usual speakers and attendees. We were also caught in Palm Springs’ brief winter, so even the jaccuzzis were not being frequented. With all of the conferences in California this year, perhaps this was the year for Winter Brain to move back East. Even the Biofeedback Society of California is combining its efforts with the AAPB and ISNR this year rather than staging a separate event.Whenever a meeting like this goes counter to the organic growth that is propelling the field forward, one is tempted to slide back into self-criticism. At times like these, I take solace in the fact that people such as Karl Pribram seem to thoroughly enjoy themselves at these affairs and feel like that they have finally found a congenial crowd. Pfurtscheller said the same of the Winterthur conference a couple of years ago.
There was in fact a panel discussion early in the conference on what it might take to move the field energetically forward. Bernie Brucker contributed from the audience, making the point that when we start presenting ourselves in a manner that does not offend the medical mind, we shall succeed. He cited his own work as a case in point. I could not resist challenging him on this because I see his own experience as a cautionary tale. For years I have been making mental comparisons between the growth in neurofeedback and the work of Bernie Brucker. Brucker had a huge headstart, first of all. His work was based on John Basmajian’s research going back to the sixties. He was already ensconced in a medical setting. He was working with intractable cases of spinal cord injury for which “medicine” has no remedy, and for which no fool would proffer a placebo model. The evidence for the selective progression from disorder to order in motor unit drive, in response to reinforcement, was there for anyone to inspect.
At the time the AAPB was meeting in Albuquerque a few years ago, I asked Brucker about the number of places in which his work was being replicated. He answered “six, with four of these outside of the U.S.” I asked him the same question on this occasion, and the answer came back “twelve.” This is what Brucker sees as a success, after lo these many years? Meanwhile, a good case can be made that the total neurofeedback market is not far away from $800M to $1B, most of it in self-pay services. (That’s about two percent of the whole alternative healthcare market of $50B.) Neurofeedback is now a substantial fraction of the Ritalin market. The number of practitioners must be close to 10,000 around the world. So who is it that should be lecturing whom?
The problem of course is that Brucker and his old-school colleagues are not likely to be pleased by such growth data. That would be like raving over kudzu in Mississippi. The flipside, however, is that if growth had been left to the tut-tutters and puckerlips in the field, neurofeedback would now look much like neuromuscular re-education, a wall-flower like almost everything else in biofeedback. There is no reason to think otherwise.
My own contribution to the discussion was to suggest that gaining visibility for our field should not be our first concern. Our field is not ready to be “discovered.” We still have to get past the major divisions in the field, as well as tend to some of our shortcomings in professional preparation, etc. We don’t have our house in order. Simply having more clinicians doing more of what is currently being done may not actually help our reputation as much as we would hope. The bar needs to be raised. Discovery of NF will happen soon enough, and we won’t be ready.
In his plenary talk, Val Brown wrestled with some of the same issues that have been entertaining us as well. He has clearly gone well beyond the operant conditioning model in motivating his own approach to neurofeedback, and we have had to do the same. Val talked about the Orienting Response (OR) and the Relaxation Response. Current understanding is that the OR is not merely responsive to novelty but more generally to significance. “When significance is high, the OR remains robust.” “The OR remains salient during NF because were always working with personally significant skills sets—specifically the emergent variability of the CNS activity.”
If that model holds, then that has implications for how neurofeedback should best be accomplished. “If the process doesn’t retain enough significance for the orienting response to remain cogent, then it isn’t very connected to the client, whatever it is doing.” The signature of a fading connection with what is going on of course is boredom.
As for the Relaxation Response (RR), this concept too needs to be elevated over its more pedestrian associations. After the person becomes assured that the NF environment does not hold a threat, he can settle in to the process. With an absence of environmental challenge to the brain, any pronounced volatility in EEG parameters may be deemed to be state-inappropriate—a signature of incipient excursion into dysfunction. An audio stream is interrupted to cue the brain to the event. The OR sets in and the brain is prompted back toward a more quiescent and controlled state. “All we need to do is to interrupt the process of recreating the prior trauma…” and bring the person back into the present. The movement back to the present moment brings about a decrease in negative affect, which feels positive. With a suitable inflation of the concept of trauma to include not only psychological but physical trauma, we cover the whole domain of brain-based disregulation.
It is at this point that our respective journeys part ways. Whereas this model is quite sufficient to explain the process of neurofeedback in NeuroCarePro, it remains event-focused. The OR is a discrete response to a discrete event. For Sterman it was the singular SMR-burst in the cat that elicited the reward, and for Val it is the excursion in EEG variability beyond ambient values. The interruption of the audio stream itself contains no useful information except for its precise timing correlation with a brain event. The information is minimally prescriptive; in fact it is entirely non-prescriptive with respect to what the brain might do to get the audio stream going again. In this regard, Val’s description holds for all inhibit-based neurofeedback.
We have something more to explain, which is how the brain relates to our ongoing reward signal. For this aspect of our training, we have to jettison the OR only because it is modeled as a phasic response to a discrete occurrence, whereas we have to explain our ongoing attentiveness to a continuous process. We will, however, pursue the concept of significance because clearly that must be in play to bind the brain into continuing engagement with the evolving signal on the screen. In what way does the brain attach significance to what is occurring?
The clinician versed in neurofeedback will over time acquire a profound respect for the significance of the signal we are providing, but we will find it difficult to give substance to that understanding. Now the client is not anywhere near even that level of understanding when neurofeedback is first experienced, and yet the process may succeed immediately. We would suggest that significance attaches to the mere fact that a correlation exists between what is displayed on the screen and what goes on in the cerebrum. That correlation is sufficient to facilitate the process of neurofeedback both in cats and in humans. One does not need to raise the discussion to any other level.
Val has decided over time to refrain from presenting a continuous reward signal to the client. One reason: “I want to leave no footprints.” Another: “The more you intervene specifically the more likely it is that you are going to get a specific effect that you don’t like…” He prefers the more fault-tolerant process of inhibit-based training. It is difficult to argue with a position that is partially values-driven. Having discovered the power of reward-based training, however, we would not give it up. But with regard to the issue of what we call “negative effects,” it is quite clear that in any neurofeedback process that involves “prescriptive” training, the clinician has to be in the loop to respond to contingencies and respond actively to what occurs.
The result of watching both the general (population) and the specific (individual) response to protocol-based training over the years has been the increasing refinement and individualization of training parameters. And the parameter space has enlarged to a degree that no one would have thought likely at the outset. The personalization of training parameters has led to a significant strengthening of training effects, thus further heightening the importance of fine-tuning. The training induces state shifts that in a compromised brain are accompanied by a variety of responses, some welcome and some not. These guide the process of optimization.
Another useful classification of neurofeedback approaches is on the issue of “transient” versus “steady-state” training. And in that categorization, both NeuroCarePro and LENS would be bed-fellows. In NCP the EEG transients are merely detected; in LENS they are deliberately introduced. With respect to active clinician involvement, however, the LENS falls in the same class as our kind of reward-based training. Both LENS and NCP could usefully be complemented with continuous reward-based training. In the case of NCP that could be done with either the ROSHI or the Nexus without violating the design philosophy of leaving no footprints. In the case of LENS, the natural complement is our own reward-based training. Some practitioners are already doing this. Lillian Marcus comes to mind.
Val’s final point was that in neurofeedback we are not performing a disorderectomy. This is true not only for his kind of training paradigm but for others as well. The classic notion that we are targeting specific flaws associated with specific disorders is still being promoted. But this is increasingly to be seen as little more than a marketing ploy, a necessary over-simplification analogous to pushing psychopharmacology as a fix for a chemical deficiency. There is still sufficient validity to the notion to keep it alive (as in specific learning disabilities), but the bulk of what we do addresses itself to more fundamental, broad classes of disregulation. Jay Gunkelman presented the EEG phenotype model at this conference, and it speaks to the same theme. The EEG phenotypes index classical failure modes that are addressed in feedback; they do not index the canonical disorders.
Jay also spoke to a new theme that is emerging in the field subsequent to Juri Kropotov presenting on the subject at the ISNR. It is the use of simple DC voltages applied directly to the scalp for localized activation. Work in this area has been ongoing at the Institute of the Human Brain in Saint Petersburg since the seventies, and it is being researched currently in connection with stroke rehabilitation and speech disorders. Karl Pribram told me that he had discussions with Kropotov on the subject in that earlier timeframe, and that his own group published on that topic as far back as the sixties. This area of investigation is not new. One also surmises that the whole field of neurophysiology was so small back then that everybody knew everybody else personally. (In his own talk, Pribram recalled his interactions with Lashley and with Skinner….)
The role DC stimulation may play for us is as a simple probe of where neurofeedback training should usefully be done. In mere minutes the state of activation of a particular brain region can be altered, and we can discern at once whether we’re being productive at that location. Hershel Toomim is using the nIR HEG in that fashion, and here we have a simple probe that is accessible to anyone without great expense or complexity. In the normal brain the measurable effects of such an activation procedure fade over time, but in an under-perfused or under-activated brain the benefits may be lasting. The technique could also serve as a priming procedure to set the stage for more effective neurofeedback to follow, something that we might also expect for HEG training and hyperbaric oxygen exposure just preceding a neurofeedback session.
Chuck Davis showed his new and improved personal ROSHI at the conference. I found it smoother and much more tolerable in its effect. I followed this trial up with a trip on Schultz’s wobbling bed. I ended up in a blissed-out state—but now I don’t know just where to give credit.
Ron Minson was a new presenter at the conference, with his auditory training program, the Dynamic Listening System, that evolved out of his personal training with Tomatis in France. Minson was yet another mainstream professional, a psychiatrist in this case, who was wrenched out of his conventional life by a crisis in his family. His adopted daughter had increasing difficulties functioning in life, with dyslexia, speech and language deficits, and poor memory function. She became delinquent and a high school dropout. She was seriously depressed between grade school and HS. When the daughter dropped into another major depression at age 19, Minson sought out Tomatis for his work with dyslexia.
Alas, it was the depression that lifted first. Problems with dyslexia, with memory, and with spelling took longer to resolve. This was quite a challenge to Minson’s worldview as a psychiatrist: “She got better without analyzing her childhood to the nth degree!” This was 1989.
Minson took up the work after training with Tomatis, and then developed his own technology. He also became interested in neurofeedback in the early nineties, attending our training course and offering neurofeedback in his office. But his primary interest remained with the auditory training. By now, hundreds have been taken off stimulants and antidepressants with this training in his office in Denver. He helps a lot of ADD kids whose primary issue is problems in processing speed.
The story overlaps remarkably with that of neurofeedback. But there are gaps. The training is not good for Alzheimer’s, Bipolar Disorder, and tinnitus, where neurofeedback does have something to offer (a lot in the case of Bipolar Disorder). On the other hand, EEG neurofeedback is not the end of the story for auditory processing deficits. So we tend to think that the two techniques, neurofeedback and auditory training, are natural complements. The techniques are complementary in yet another way: the auditory training can be done at home under clinical supervision.
Auditory training also tends to support the emerging model of EEG neurofeedback as a general brain challenge in the timing and frequency domains. Both techniques can be seen as non-specific challenges to brain functional organization. The EEG training has an obvious bias to the lower frequencies, and the auditory processing training to the higher. It may be that auditory processing plays a key role in maintaining brain function for all of us in the normal course of events, provided of course that the system is on-line in the first place. If so, then hearing failure in the elderly could be a contributing factor to their cognitive decline.
When one hundred blind and one hundred deaf children were tracked through their normal school experience, it was found that the blind children generally maintained themselves at grade level. The deaf children, however, ended up two years behind. Minson has developed a series of listening tests to discern problems in auditory processing, and the interpretation of such tests constitutes the major portion of his professional training program in the technology. Neurofeedback clinicians may help their effectiveness immensely by adding this modality to their offerings. And it would allow them to extend their reach even to those who cannot afford neurofeedback.
Stephen and Robin Larsen presented on their work with animals using LENS. This work is a nice demonstration of efficacy where a placebo effect is not expected. Blindness is also easier to arrange for. In one case of working with a horse that had an abuse history, the trainer said: “The horse has never listened to me before and now it’s listening to me. What has happened?” He did not know about the procedure that had been used on the horse. The procedure amounted to a two-second stimulation. Immediately after the treatment, the horse acted like it had smoked a joint. In a case of longer-term training with an abused dog that the Larsens had taken into their home, progress paralleled that achieved at their office with a Russian child diagnosed with Reactive Attachment Disorder. The Larsens also showed data in which the heart rate variability waveforms of a boy and his dog were obviously correlated. This could point to one mechanism for the positive impact on health that has been demonstrated for having pets in the home.
The big news at the Winter Brain Conference with respect to traditional EEG neurofeedback was Sue Othmer’s presentation on low-frequency training. We now find ourselves training productively in the spectral range of slow cortical potentials, and this new thrust is applicable to at least half of our clinical population. This topic is taken up separately in our newsletter.