Alpha/Theta Training of 19 Dine’ Alcohol Drinkers – Three year Outcome Study
Matthew J. Kelley, Ph.D.
June 8, 1998
In 1991, 16 men and 3 women chosen by nurses from among the resident population at RMCH-BHS in Gallup, New Mexico, were given two l hour sessions of alpha/theta neurofeedback (NF) training for five days a week. This regime was in addition to their “mainstream” 33 day treatment program (mean of 40 NF sessions). The Peniston protocol of temperature training and additional culture specific breathing techniques were also used. Electrode placement was at CZ, not O1, with linked ears. Unlike the Ss reported by Peniston and Kulkowsky, most of these Ss did not have deficient alpha before pretreatment. CZ was chosen for convenience, as a location more indicative of theta/alpha change and cross-overs, and to avoid chair-induced artifacts.
Three years after treatment 4 Ss are in sustained full remission; 12 are in partial remission (but experiencing no problems related to drinking) and 3 remain dependent drinkers. There was a significant increase in level of functioning as defined by Axis V of the DSM-IV. Subjective and objective reports regarding the NF experience were positive.
The author is the clinical director of the Na’nizhoozhi Center (NCI) in Gallup New Mexico, the country’s largest treatment center for Native Americans. As a specialist in Native American drinking dynamics he is developing an intense treatment protocol based on traditional Native American practices as psychophysiological techniques.
The author made a complete follow up study in 1994-95 three years after completion of the alpha/theta portion of treatment. The lengthy and detailed study is available in the Journal of Neurotherapy, Vol 2, Number 3, Fall 1997/Winter 1998.
It is generally held that treatment programs for Native Americans have lower levels of success than those in the dominant culture (Kivlahan, 1985). A thorough literature review of treatment outcome study challenges this conclusion. Follow-up protocols are available in the full paper. A considerable literature review on both Anglo and Native American drinking dynamics was also presented in an attempt to place these participants in their unique and challenging socio/economic/environmental context. The challenges of this study are many and can not be fully appreciated out of context.
Of the 28 potential participants selected by the nurses as needing special help, nine were not trained for various reasons such as scheduling difficulties. The nurses reported that they tended to select Ss who most needed the treatment, skewing the project toward lower success. In one instance, for example, a participant was chosen because of his excessive anger and threats to both staff and residents.
Most of the participants were dually diagnosed: other diagnoses included post traumatic stress disorder; head injury; diabetes, attention deficit disorder, major depression. The author remarked “none of my colleagues were optimistic about any of these clients” (Kelley, 1998).
Of the 19 contacted participants, 14 who met the DSM-IV criteria for alcohol dependence, and 5 of whom met the criteria for alcohol abuse. Fifteen were court-ordered into the treatment facility. 3 of the participants were women. Ages ranged from 20 to 56 years. Although intelligent, in most cases participants rated at the bottom of the economic and education scale.
PENISTON/KULKOWSKY PROTOCOL (PKP)
The PKP was markedly modified in that the entire program was delivered within a culturally congruent program of Dine’ spiritual belief. An intensive program of community information including exposure to the equipment and procedures of the treatment was initially taken. Dine’ (Navajo) terms, metaphors and religious images were used. For example, the treatment room was decorated to suggest a traditional healing environment with Dine’ music in the background. A great effort was made to compliment and utilize the strong local beliefs.
To stimulate and encourage the NF process, participants initially were taught diaphragmatic breathing, muscle relaxation, and temperature training on a J&J I330. The participants attended two, 1 hour training sessions five days each week in addition to their regular residential treatment schedule. Within 33 days of residential treatment, the 19 participants received an average of 40 sessions of NF.
EEG signals and vocal presentations were given through high quality enclosed headphones. The EEG was measured by a Lexicor 24. Tones were emitted for both alpha and theta. The threshold for tone was set at 66% of the participant’s highest resting baseline amplitude. The deeply resonant theta tone was emphasizes as the goal.
In each session the subject closed his eyes, then listened to a 10 minute induction by the author through the headphones regarding breathing patterns, sobriety, empowerment and self-healing before the tones became dominant (via a mixer). The therapist observed the amplitude of EEG during the induction. When alpha amplitude increased the therapist gradually turned the feedback signal up and slowly withdrew. During the changeover phase the therapist also gave additional instructions such as (a) “Increase the power of your healing tones by following the sounds deeper inside;” (b) “As you sink deeper into our personal power, the tones will increase; as the tones increase, they purify and cleanse your heart and mind.” An attempt was made to customize phrases to the preference of each subject.
At the end of 30 minute training the therapist debriefed the client for five minutes to help orient them back to the external environment. In this reorienting talk more images of sobriety and self empowerment were suggested. Finally 10-15 minutes were taken up with light discussion.
Episodes of abreaction did occur but without problems. The therapist did attempt to create a positive, pleasant, even sensuous, experience for the Ss such as making statements of protection and distance and safety. All abreactions were allowed to complete themselves with only positive comforting verbal imagery and reassurance from the therapist. The suggestion was frequently made that the client’s brain was simply reorganizing its experiences. No attempt was made to analyze the content of the abreaction except in a supportive way.
In the closing five sessions Ss were given brief meditative and self hypnosis training with instructions to practice these skills at home. Each participant was given at least one customized self-hypnotic audio tapes. The Ss were also encouraged to practice at home, to attend AA, traditional Native American practices, sweat lodge, the Native American Church, and or a church of their choosing.
Individual participants were interviewed using a simplified DSM-IV Multiaxial Assessment (APA, 1994) and a customized, culturally appropriate hybrid form of six outcome assessment tools (Cahalan et al, 1976; NIAAA, 1976; Selzer, 1971; Skoloda et al, 1975; Sobell et al, 1979; Mclellan et al, 1980). These field interviews were difficult and time consuming due to the rural distances and environment. Eight participants were interviewed in face-to-face meetings with the author; 5 were interviewed by telephone by the author; and the status of 6 participants were verified by interviews with relatives, friends and counselors. The author also interviewed aftercare specialists, police officer, neighbors, postal workers, andmarket workers a further attempt to corroborate behavior. He also read client files, reviewed crisis center databases, and other written records. The author graded his level of confidence of information on his Ss as 9 excellent; 8 good; and 2 fair. On an average, 8 hours of investigation were expended on each S. As an example of the difficulty of doing outcome studies, the author recorded 2,700 miles of travel during these interviews.
Originally, 14 of the 19 were alcohol dependent and 5 were alcohol abusers.
Three years later four were in sustained full remission (DSM-IV)and have had no binge drinking. Twelve participants are in sustained partial remission (DSM-IV). These 12 have had several binges (slips) in the three years but did not drink regularly, and did not get into any significant difficulty because of drinking (or otherwise). One of these 12 was arrested and remained in jail for two of the three years but was sober for the year after release. Three of the 19 remain alcohol dependent (DSM-IV). These continued to have significant problems associated with bouts of excessive drinking. One of these 3 is in prison for parole violation on a DUI conviction; and another was recently released from imprisonment for parole violation again after a DUI.
The author also assessed these 19 participants using a customize clinical scale: 2 still have serious problems with alcohol dependence; 1 is a chronic abuser but not dependent (he doesn’t have the physical characterstics of dependence, but still gets into difficulty due to drinking); 11 occasionally drank alcohol but avoided problems (of these 11, nine infrequently binged); 1 man is a daily social drinker who has experienced no drinking problems (nor any other); 1 man drinks lightly once a week with no problems. Four of the participants have had little or no alcohol drinking at all.
GLOBAL ASSESSMENT OF FUNCTIONING
Only one client had no change in his life after the training. Two who are still rated as dependant on alcohol had slight improvements (both are still in prison). Sixteen clients achieved marked to major improvement in their lives after training.
All of the participants still have lives limited by poverty in job, money, and housing. Four of 11 of the 19 who reported significant family problems at the start of the program did report improvement of these problems. Four of the 13 who reported no available housing in the beginning did find housing.
18 of the participants were given the Beck Depression Scale and rated valid forms. This scale changed from a mean of 25 (s.d.9) to a mean of 4 (s.d. 4.6). Six of the 19 entered post training Beck scores of zero (0).
Only one client practiced a significant aftercare program (including two episodes of in-patient care). This client stated that although he was active in AA, traditional practices, Native American Church, and had an occasional vision quest he continued to drink episodically. He attributed his drinking episodes to depression and to being confused about his sexuality. He also reported post traumatic stress disorder symptoms due to extensive childhood sexual abuse.
Of the 12 participants who were directly interviewed by the author, nine considered that their neurofeedback experience had some sort of spiritual impact. None of the participants reported that they continued to use the suggested daily home practices (meditation, breathing exercises, hand warming, etc); however, many commented that listening to their individualized audio tapes was useful. Several, however, reported that they did remember to breathe properly during times of stress. Most also alluded to knowing now how to remain relaxed. Six of the participants asked for new audio tapes.
It should be remarked that the nursing and other professional staff who were associated with this study all agreed that the behavioral and emotional changes in the subjects were marked, real, and positive.
Nineteen Dine’ (16 male, 3 female) drinkers were selected by nurses from an in-patient facility in Gallup, New Mexico.
The assumption is made that this selection method was biased toward less likely clients, ie, those whose drinking was more severe and who produced more problem behavior, and which was complicated by more dual diagnoses. Four years before the follow up study 14 of the 19 were alcohol dependent and 5 were alcohol abusers.
The Peniston protocol was modified by: (1) more sessions; (2) longer sessions; (3) more introductory sessions (with more imagery including Native American imagery; (4)breath training including a capnometer; (5)a system of headphone given induction at the beginning of each session; (6) training sensor placement at CZ rather the O2; (7) utilization of Native American spiritual context.
Three years after training, four of the Dine’ now drink rarely if at all and are in sustained full remission; 12 are in sustained partial remission (DSM-IV); three of the subjects remain in dependent drinkers. Clinical workers, the author, and objective testing indicate marked to major improvement in emotional and behavioral variables in the lives of the 19 program participants.