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The American Journal of Drug and Alcohol Abuse 31:455 – 469, 2005
Copyright ©Taylor & Francis Inc.
ISSN: 0095-2990 print / 1097 – 9891 online
DOI: 10.108 / ADA-200056807
EFFECTS OF AN EEG BIOFEEDBACK PROTOCOL ON
A MIXED SUBSTANCE ABUSING POPULATION
William C. Scott, BSW, CCDP
1
, David Kaiser, Ph.D.
2
, Siegfried Othmer, Ph.D.
3
, and
Stephen I. Sideroff, PhD
4
Abstract: This study examined whether an EEG biofeedback protocol could improve outcome
measures for a mixed substance abusing inpatient population. Method: One hundred and twenty-
one (121) volunteers undergoing an inpatient substance abuse program were randomly assigned to
the EEG biofeedback or control group. EEG biofeedback included training in Beta and SMR to
address attentional variables, followed by an alpha theta protocol. Subjects received a total of 40
to 50 biofeedback sessions. The control group received additional time in treatment equivalent to
experimental procedure time. The Test of Variables of Attention (TOVA), and MMPI, were
administered with both tester and subject blind as to group placement to obtain unbiased baseline
data. Treatment retention and abstinence rates as well as psychometric and cognitive measures
were compared. Results: Experimental subjects remained in treatment significantly longer than
the control group (p< 0.005). Of the experimental subjects completing the protocol, 77% were
abstinent at 12 months, compared to 44% for the controls. Experimental subjects demonstrated
significant improvement on the TOVA. (p< .005) after an average of 13 beta-SMR sessions.
Following alpha-theta training, significant differences were noted on 5 of the 10 MMPI-2 scales
at the p<.005 level. Conclusions. This protocol enhanced treatment retention, variables of
attention, and abstinence rates one year following treatment.
1
Neuropsychiatric Institute, University of California, Los Angeles, CA, USA and Restorative Technologies, Santa
Monica, CA USA
2
Department of Psychology, Rochester Institute of Technology, Rochester, New York, USA
3
EEG Spectrum International Inc., Encino, CA, USA
4
Department of Psychiatry and BioBehavioral Sciences, University of Califormia, USA and Moonview Sanctuary,
Santa Monica, CA USA
2
INTRODUCTION
Alcohol and drug abuse is an ongoing societal and treatment problem. (1,2)
While major
resources have been employed to study and treat addiction, there has been little significant
improvement in the success rate of treatment. Relapse rates remain high, typically over 70%.
(3,4,5) Gossop et al reported 60% of heroine addicts relapsed one year following addiction
treatment. (6)
Peniston and associates have demonstrated significantly higher abstinence rates with alcoholics
when they incorporated EEG biofeedback into the treatment protocol (7,8,9,10) Eighty percent of
subjects in these experiments were abstinent one-year post treatment.
EEG biofeedback training is an operant conditioning technique used to reinforce or inhibit
specific forms of EEG activity. In the alpha theta protocol employed by the Peniston studies, low
frequency EEG activity was reinforced. The alpha theta protocol was first demonstrated to be
effective with Post-Traumatic Stress Disorder. (11)
The efficacy of alpha-theta EEG biofeedback may lie in its ability to allow participants to better
tolerate stress, anxiety and anxiety-eliciting situations, which are particularly evident during the
initial phases of recovery. This protocol was shown to significantly lower 13 of the scales of the
Millon Clinical Multiaxial Inventory (MCMI), including anxiety, whereas traditional treatment
produced decreases in only two of these scales. (7) There have been however, questions raised in
the literature regarding the sample size, sample independence and methodology in the Peniston et
al studies. (12) Furthermore, there have been no controlled studies reported that extend these
findings to other substances of abuse.
In addition to the psychological problems that substance abusers face in remaining abstinent, they
also experience co morbid conditions that affect cognitive and attentional deficits. These deficits
may be acquired from prolonged substance abuse (13,14,15,16,17), but the evidence also points to
deficits that predate the abusing behavior. (18) For example, in one study, approximately 35% of
treatment-seeking cocaine abusers met the DSM-IV criteria for childhood Attention Deficit
Hyperactivity Disorder. (19) Also, adult alcoholics report more residual-type Attention Deficit
3
Disorder than controls. (20) Low cognitive ability has also been shown to predict relapse after
treatment at an alcohol treatment facility. (21)
EEG biofeedback has also been used successfully to improve attentional, cognitive and
psychosocial functioning, including reductions in impulsivity (22,23,24)
These and other studies
have employed a protocol in which beta and SMR frequencies (15-18 Hz and 13-15 Hz
respectively) were operantly conditioned, while inhibiting theta frequencies, in remediating
attentional and cognitive deficits in children and adults with Attention Deficit Disorder.
(25,26,27,28) Given the relationship between cognitive/attentional impairment and addiction it
would strengthen a treatment model to address these deficits.
In the present study a beta/SMR EEG biofeedback training regimen was combined with an
alpha-theta protocol in the treatment of a mixed substance abusing population. One expected
objective was the enhanced ability of the subjects to focus on the treatment program, reduce
impulsivity and thereby increase program retention.
In order to extend the positive EEG biofeedback findings in the alcoholic population, an addict
population was selected that included patients addicted to the following primary drugs: heroin,
crack/cocaine, methamphetamine, as well as alcohol.
METHOD
Participants
One hundred and twenty-one volunteers from the Cri-Help, Inc. residential treatment program in
the Los Angeles area participated in this study. There were 49 females and 72 males. They were
19 to 53 years of age, with a mean age of 32.4. The primary drug of choice reported at admission
was 31% heroin, 28% crack cocaine, 26% methamphetamine, 6% alcohol, and 9% other
controlled substances. Ninety-four percent were multiple-drug users.
4
Subjects determined to have a diagnosed psychotic or personality disorder (based on DSM-IV
criteria), or a seizure disorder, were excluded. Subjects were randomly assigned to the EEG
biofeedback plus conventional treatment group (60 experimental subjects) or the conventional
treatment-only group (61 control subjects).
Subjects were provided informed consent before participating in this experiment, approved by the
UCLA Human Subjects Protection Committee.
Procedures
All subjects received treatment based on the Minnesota Model 12-step oriented program,
described by Stinchfield and Owen, supported by group, family, and individual counseling. (29)
In addition, the experimental group received 40-50 EEG biofeedback sessions. The control group
received additional treatment time equivalent to the biofeedback sessions.
Experimental subjects underwent two sessions of EEG biofeedback training (45 minutes per
session) five days a week for four to five weeks. EEG biofeedback was performed on a
Neurocybernetics 2- Channel EEG biofeedback system.
In Phase I, experimental subjects underwent 10 to 20 sessions of Beta-SMR EEG biofeedback in
which operant conditioning was used to augment either 15 to 18 Hz (Beta) or 12 to 15 Hz (SMR)
EEG activity. At the same time, training attenuated elevated activity in the 2 to 7 Hz (Theta) and
22 to 30 Hz (High beta) ranges. Active bipolar electrode placement was at C3-FPZ for Beta and at
C4-PZ for SMR, based on the International 10-20 system of electrode placement. (30)
The starting protocol consisted of Beta training 50% of the time and SMR training 50% of the
time. These percentages would be altered, based on changing symptomatology and TOVA results
(Test of Variables of Attention) (31) with inattentive or impulsive profiles resulting in increased
Beta or SMR training, respectively.
5
After 10 Beta-SMR EEG biofeedback sessions, participants were reassessed with the TOVA. If a
participant scored within the normal range (i.e., scores of 85 or above), he or she began alpha-
theta training. If the TOVA remained abnormal after the initial 10 Beta-SMR sessions, 5 or 10
additional Phase 1 treatments were administered. It took a median of 10 Beta-SMR sessions with
a mean of 13 sessions for the TOVA to normalize for the experimental subjects.
In Phase II, subjects underwent 30 sessions of alpha-theta training. The frequency range for alpha
was 8 to 11 Hz and for theta it was 5 to 8 Hz. The initial sessions were used to train down alpha
levels that were above 12 µV (peak to peak), while augmenting theta, until there was "crossover".
This was defined as the point at which the alpha amplitude drops below the level of theta.
Subsequent to the first achievement of crossover, both alpha and theta frequencies were
augmented.
Before initial crossover was achieved, excess EEG activity in the range of 15-30 Hz was
inhibited. This was intended to reduce muscle tension and to quiet the mind. After crossover was
achieved, the 2 to 5 Hz frequency range was also inhibited. This was intended to discourage the
sleep transition during low-arousal states.
Each alpha-theta session began with the subject sitting in a chair with eyes closed. The active
electrode was placed at Pz with a left-ear reference (A1). The right earlobe was connected to
circuit ground. Two distinct tones were employed for alpha and theta reinforcement, with the
higher pitched sound used to index the higher-frequency alpha band.
At the start of each session, the technician spent 3 to 5 minutes reading a script of guided imagery
to the experimental subject that dealt with identified essential elements of maintaining abstinence.
These included ongoing regular attendance at 12-step meetings; weekly meetings with a sponsor,
expanding the individuals identified comfort zones, and mental exercises dealing with cue
extinction and relapse rejection.
After the guided imagery, it was made clear to the subject that the objective of the training did not
involve explicit rehearsal of the script during the EEG biofeedback. Subjects reporting previous
6
meditative practices were asked not to use them during the training, since meditation has been
observed to override alpha-theta reinforcement effects. Following the alpha-theta training, clients
were given the opportunity to process their experience.
When it appeared that sleep might be occurring during training, subjects were told prior to their
next session to move a limb if they heard the technician say either, "Right foot, left foot, right
hand, or left hand". At points where the subject’s delta activity (2 to 5Hz EEG) started to elevate,
as well as at their highest amplitudes, (indications of sleep onset) the limb commands were given
to determine responsiveness. The delta amplitude value at which the subject transitioned to non-
responsiveness was documented. Subsequently, during sessions where delta was elevating toward
non-responsiveness levels, the feedback sounds were inhibited in order to discourage the sleep
transition.
Measurements
Tests were administered prior to training, after Beta-SMR training (Phase 1) and after Alpha-theta
training (Phase 2) for experimental subjects and at commensurate points in time for the control
group (typically 1, 16 and 46 days into the research program). All subjects had acclimated to the
institutional setting for a minimum of seven days prior to testing. The initial testing was
accomplished with subjects and experimenters blind to group placement.
The Test of Variables of Attention (TOVA) was administered to assess attentional and cognitive
functions (31,32,33) The Minnesota Multiphasic Personality Inventory (MMPI-2) was
administered at the start of the study and again at 46 days.
Patient abstinence was determined by collateral contacts in addition to self-report. Follow-up
interviews for this purpose took place at three-month intervals over a 12-month period. Research
subjects gave permission to contact individuals who were intimately involved in their recovery.
These individuals were their 12-step sponsors, family members and those people referring the
subject into the program. Subjects who used substances beyond one, 4-week window were
7
considered to have fully relapsed. Those whose relapse duration was within a single 4-week
window were categorized as a brief relapse.
RESULTS
Days in Treatment
Length of stay in treatment averaged 135 days for experimental subjects and 97 days for controls.
This difference was significant (p< 0.005). Median length of stay was 142 days for experimental
and 88 days for control subjects. Figure 1 shows retention in the program over the first twelve
weeks of the program. As can be seen, at the end of this period, 46% of control subjects had
dropped out of treatment, compared to only 24% of those who received EEG biofeedback. A Chi-
square analysis demonstrated a significant difference in drop-out rate between experimental and
control groups over the 12 week period (X
2
(n=121) = 6.29, p< .05.) There was no significant
interaction between drug type used (stimulant versus sedating drugs) and days remaining in
treatment (F(1,118)=.004, ns).
(Figure 1 goes here: Effect of the EEG biofeedback protocol on patient retention for control
(n=61) and experimental (n=60) subjects.)
Abstinence Rate
Figure 2 presents the data for the 103 subjects who had reached their 12-month post-study status.
This includes 55 experimental and 48 control subjects. Of these subjects, there were 7
experimental and 17 control subjects who dropped out of treatment prior to completing the study
(the initial 45 days), while there were four control subjects and one experimental subject who
could not be contacted at the 12-month interval.
Of the remaining experimental subjects who completed the study and were assessed at 12 months,
36 of 47 or 77% were abstinent. This included 8 subjects who had one brief relapse period of less
than 30 days during the year. Of the control subjects who completed the study, there were 12 of
8
27 subjects, or 44% who were abstinent. This included one subject who had one brief relapse
period of less than 30 days. A Chi square analysis demonstrated a significant difference between
one year abstinence rates of the experimental group versus the control group, X
2
2(74)=7.78
p<0.01. There was no significant interaction between drug type used (stimulant versus
depressant) and abstinence rate, F(1,113)=.844, p>.05.
(Figure 2 goes here. Twelve month follow-up abstinence data for experimental (n=55) and control
(n=48) groups.)
MMPI-2 Data
Figure 3 presents pre and post training MMPI data, including the ten clinical scales and three
validity scales, for the experimental and control groups. Subjects with Lie scores greater than 70
on either pre- or post-training tests were excluded from analysis (n=3, 2 experimental and 1
control). A univariate mixed-design analysis of variance (ANOVA) was used to evaluate the
effects of the experimental protocol compared to controls on the 10 clinical scales.
As shown in Figure 3, the experimental group’s changes exhibited significant improvement
compared with the changes in the control subjects, (p< 0.005) on the Hs (Hypochondriasis), D
(Depression), Hy (Conversion Hysteria), Sc (Schizophrenia) and Si (Social Introversion) scales.
The experimental group also improved on the Pt (Psychasthenia) scale, although the difference
between groups on this scale was not significant, p>.05. Both groups improved on the Pd
(Psychopathic Deviate) scale, p<. 05.
(Figure 3 goes here. Change in 10 MMPI clinical scales and three validity scales for the
experimental group (n=50) and the control group (n=33). (+, p<.05; *, p<.005) )
9
TOVA
Mean TOVA standard scores are presented for both groups in Figure 4 (61 experimental, 45
controls). There was no significant difference between groups in initial baseline TOVA scores
(F(1,303)=1.333, p>.05). A univariate, mixed-design ANOVA was used to compare the two
groups on four dependent measures of the TOVA: inattention (percent omission), impulsivity
(percent commission), response time, and response variability. Low scores were truncated at four
standard deviations below normal.
As can be seen in Figure 4, the experimental group exhibited significant improvement in
impulsivity and variability measures in response to Beta-SMR training (p< .005) whereas no
comparable change was found for the control group, (p> 0.05). Experimental subjects also
demonstrated significant improvement in inattention; however the score only marginally differed
from that of the control group (p<.05). TOVA scores were not further enhanced by either the
Alpha-Theta training nor 30 additional days of treatment.
(Figure 4 goes here. TOVA standard scores for experimental and control groups for pre-training,
post-beta/SMR, and post-alpha-theta assessments. (+, p<.05; *, p<.005) )
DISCUSSION
The results of this study support the efficacy of EEG biofeedback training in an in-patient drug
treatment program. Success was determined by length of time in treatment, or treatment retention,
as well as by abstinence rates one year after termination of treatment. Results were further
supported by positive changes in attentional variables, and positive changes on the MMPI 2.
These findings extend the previous research findings employing alpha-theta EEG biofeedback
with an alcoholic population, to other substances of abuse.
The present study employed a Beta-SMR protocol prior to the alpha-theta procedure previously
used in addiction studies. (7,8,9,10) Beta-SMR training had previously been shown to be effective
in remediating attentional and cognitive deficits. Results of baseline performance testing using the
10
TOVA did not demonstrate that this population had significantly below average attentional
indices. However, testing following the Beta-SMR protocol showed that this procedure improved
these test measures for the experimental subjects, particularly impulsivity and variability. This
result may partly account for the improved treatment retention of this group.
It has been shown that time in treatment is one of the best predictors of remaining abstinent. (34)
In the present study, the experimental subjects averaged 136 days in treatment. This compared to
98 days for the control population. In addition, treating therapists reported that they noticed
experimental subjects appearing more cooperative and more attentive as EEG biofeedback
progressed. This subjective observation should be a focus in future studies with a more
systematic observation of subjects’ behavior.
There were eight experimental subjects who used briefly (less than 30 days) but were abstinent at
the 12-month follow-up, and there was one subject from the control group who had this
experience. It has been noted in the previous alpha-theta treatment studies that patients report
dysphoria when they used a substance following the EEG biofeedback protocol. (8) Some of the
experimental subjects in this study had similar experiences. This may indicate that a more
fundamental neurophysiological change had taken place as a result of the treatment. Peniston and
Kulkosky for example, noted that experimental subjects receiving EEG biofeedback did not show
increased circulating beta-endorphin levels, an index of stress, which was found in the control
group. (7)
It can be noted that once the EEG biofeedback was concluded, at week five, the subsequent
attrition rates became indistinguishable between the two groups. It may be useful in future studies
to extend the length of the biofeedback training to see if it has further impact on experimental
results.
One of the more striking findings of the present study and similar to the Peniston results, is the
positive change noted in the MMPI. The experimental subjects showed significant improvement
in five of the clinical scales: Hypochondriasis, Depression, Hysteria, Schizophrenia and Social
Introversion. These changes indicate a lowered level of general distress or discomfort. More
11
specifically there may be a reduced sense of alienation and depression, as well as defensiveness.
These are vital factors in recovery.
The present study did not demonstrate differential effectiveness of the EEG biofeedback protocol
for sedative or stimulant drug abusers. This should be a focus of future research in which larger
numbers of subjects are employed. Both groups of subjects appeared to benefit from this
protocol. If the lack of dependency on drug type is confirmed, the case can be made that
alpha/theta training addresses core issues in addiction rather than drug-specific aspects of
dependency.
In the present study one-year abstinence was determined by collateral contacts in addition to self-
report. These individuals were reliable sources who were intimately connected to the recovery
process, including their 12-step sponsors, family members and those people referring the subject
into the program. Future research results should be supported by incorporating urine testing as a
further corroboration of abstinence.
Since EEG-based reinforcement was such a prominent constituent of the experimental program,
the question arises as to whether the benefits of training could also be documented through
observable EEG changes. The present study was not designed to analyze the appropriate artifact
free data. Future research should incorporate methodology to record and analyze the appropriate
quantitative EEG data.
It is important to place the results of this study in the context of the long-standing difficulty in
achieving successful abstinence with the drug-abusing population. EEG biofeedback appears to
promote and support positive change in the level of neurophysiological and psychosocial
functioning in the addict, as well as enhancing treatment retention. It therefore constitutes a
promising approach that now requires additional study for further validation as well as to
elucidate operative mechanisms to optimize the procedures, and to facilitate integration into
standard treatment programs.
12
CONCLUSION
The present study supports the efficacy of an EEG biofeedback protocol as adjunctive therapy in
an in-patient drug treatment program. This protocol appears to be beneficial for both sedative as
well as stimulant substances of abuse. Success was determined by length of time in treatment as
well as by abstinence one year after termination of treatment. Supportive data were provided
through attentional/cognitive and psychological assessments. These findings extend the research
employing alpha-theta EEG biofeedback with an alcoholic population to other drugs of abuse.
13
CONTRIBUTORS
1
Please address correspondence to: Stephen Sideroff, Ph.D. Department of Psychiatry and
Biobehavioral Sciences, UCLA, 1245 16
th
Street, Suite 210, Santa Monica, CA, 90404.
2
William Scott, BSW, CCDP, Restorative Technologies, Santa Monica, CA.
3
David Kaiser, Ph.D., Department of Psychology, University of Rochester, Rochester, New York.
4
Siegfried Othmer, Ph.D., The EEG Institute, Woodland Hills, CA
ACKNOWLEDGEMENTS
We wish to thank Marcus Sola (CRI-Help, Chairman of the Board) Jack
Bernstein (CRI-Help, CEO) and Marlene Nadel (CRI-Help, Clinical Supervisor) for their
participation and willingness to add an innovative approach to their existing treatment model.
Thanks also to the CRI-Help board of directors for providing funding for this project. We also
thank EEG Spectrum International for their donation of a Neurocybernetics EEG biofeedback
system. We wish to thank Don Theodore, MA, MFT, and Leslie Ruddock, BA (Research
Technicians) who administered all EEG biofeedback protocols and coordinated subject sessions
with the traditional treatment team. We wish to thank Susan Othmer who shared her knowledge
of beta / SMR protocols; and case consultation. Thanks also to Meredith Sagan for her
consultation and critical review of the manuscript. National Computer Systems (NCS
Assessments) donated administrations of a self-scoring computerized version of the MMPI-2.
Universal Attention Disorders, Inc. contributed administrations of the Test of Variables of
Attention (TOVA)
Key Words: EEG, Biofeedback, EEG biofeedback, Addiction Treatment, Chemical Dependency,
Alpha-Theta, TOVA, MMPI
14
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17
Research Flow Chart
Subjects meet exclusion criteria
no research involvement
15 working days elapse
control subjects are ready
for final testing phase
Subjects participate in more
groups and traditional treatment
activities while exp subjects undergo
EEG biofeedback sessions
Testing period 2 (5 working days later)
TOVA and Neurocog
Continue traditional Tx
Control group
Final testing is administered
TOVA, Neurocognitive test battery
and MMPI-2
Subjects complete 30
alpha-theta sessions
TOVA is above average
subjects are ready to begin
alpha theta sessions
twice daily for 15 working days
TOVA remains abnormal
begin alpha-theta training regardless
subjects complete 30 alpha-theta sessions
TOVA remains below average
up to 10 additional EEG biofeedback
sessions are administered with TOVA
retesting after 5 subsequent sessions
Testing period 2
TOVA and Neurocog
Continue traditional Tx plus EEG biofeedback
2 sessions per day over next 5 working days
Experimental group
Random placement
With subjects and test administrator
blind as to group assignment,
baseline testing occurs
Subjects agree to research involvement
and sign consent forms and releases
Subjects disagree to
research involvement and
are excused from participation
Weekly, P.I. meets with
potential research subjects
to explain research project
Subjects meet criteria
for research candidacy
Subjects enter treatment facility
Intake department screens for inclusion/exclusion criteria
18
Figure 1. Effect of the EEG biofeedback protocol on patient retention for control (n=61) and
experimental (n=60) subjects.
19
Twelve-Month Abstinence Data
0
5
10
15
20
25
30
35
40
No Contact Aborted
Study
Relapse Abstinent
number of subjects
EXPL n=55
CTRL n=48
Figure 2. Twelve month follow-up abstinence data for experimental (n=55) and control (n=48)
groups.
20
Figure 3. Change in 10 MMPI clinical scales and three validity scales for the experimental group
(n=50) and the controls (n=33). (+ p<.05, * p<.005)
21
Figure 4. TOVA standard scores for experimental and control groups for pre-training, post-SMR,
and post-Alpha-Theta assessments. (+ p<.05, * p<.005)
