Automated EEG biofeedback proven effective in treatment for substance abuse

An automated EEG biofeedback system for reducing attention deficits in individuals with substance use disorders has been found to work just as well as a clinician-run system and to provide substantial benefit in a residential treatment setting, according to a joint study from researchers at the University of California, Los Angeles (UCLA) and the University of North Carolina Wilmington.

It is estimated that roughly one in four persons with substance use disorders has an attention issue as well. EEG biofeedback can be used to train people how to self-generate a state of effortless attention—a relaxed, alert focus that increases control over actions associated with addiction. That in turn can translate to an improved ability to make healthy decisions and a greater willingness to be in treatment, according to the authors of the study.

This technique also can provide an alternative to the drugs commonly used to treat attention-deficit disorder (ADD) and attention-deficit/hyperactivity disorder (ADHD), which have the potential to spark addiction or relapse in a population that tends be at greater risk for substance abuse or dependence.

“We wanted to see if a system that was programmed to make a lot of the decisions that a trained therapist would usually have to make would do as well as a therapist-controlled system, with the difference being that a therapist uses judgment to adjust the protocols versus the machine using algorithms,” says study lead author Julian Keith, PhD, professor of psychology, University of North Carolina Wilmington. “They are based on the same kind of decision-making principles the therapist should be using, but it’s possible to actually program them into the machine.”

The study involved 95 participants randomly assigned to one of three groups who either received 15 sessions of BrainPaint automated EEG biofeedback, 15 sessions of Neurocybernetics—a clinician-run system—operated by a therapist with almost two decades experience, or 15 therapy sessions without biofeedback.

In addition to both neurofeedback groups significantly improving results on the Test of Variables of Attention (TOVA), an outcome measure used to diagnose ADD/ADHD, the BrainPaint group stayed 65 days or 71% longer in treatment than the control group. Longer stays in treatment are considered one of the most important determinants of long-term sobriety.

“What was impressive in the study is we showed that neurofeedback did in fact produce large measurable changes in as few as 15 sessions of neurofeedback treatment,” Keith says. The sessions took place in a span of a week and a half. 

Addressing attention issues

According to Keith, substance use disorder patients will see better results from treatment if they can first address their attention issues prior to beginning to absorb what they’re trying to learn from treatment.

“Changing behavior generally will require neuroplasticity, and it’s going to require the ability to attend to what it is that’s supposed to be the focus of learning during that time,” he says.

According to David Sack, MD, CEO of Elements Behavioral Health, the company's Promises Malibu facility has had an EEG biofeedback program for four years, and Elements has now integrated neurofeedback at 11 of its treatment centers nationally.

“We have extensive experience with EEG biofeedback in a clinical population with substance abuse and co-occurring disorders,” Sack says.

There are two broad protocols that are typically used with EEG biofeedback. The first is an Alpha-Theta protocol geared toward arousal symptoms to use for patients with anxiety, depression and insomnia. The second is a Theta-Beta or SMR protocol for patients with co-occurring ADHD.

According to Sack, most Promises patients go through the Alpha-Theta protocol after coming off opioids or alcohol where they are excessively aroused, in a reactive emotional state, and being treated for anxiety symptoms or post-acute withdrawal symptoms.   

Detox treatment

Sack says EEG biofeedback can be particularly helpful during the detox stage when patients are experiencing various levels of discomfort, because it helps decrease withdrawal symptoms.

“Even when you manage [detox] optimally with medicine, it’s very hard for someone to be completely asymptomatic,” he says. “[EEG biofeedback] reduces their muscle spasms, they sleep a little better and they feel like they have some control over their symptoms.”

EEG biofeedback is started for patients as soon as they’re safe to get up and out of bed, Sack says, adding that very few people decline to participate because they experience so much benefit from the first few sessions that they want to continue. Additionally, he says, clients who are not able to participate in group therapy or individual psychotherapy are often very willing to participate in EEG biofeedback.

Promises Malibu has a designated EEG biofeedback technician on staff who has been trained to provide the treatment and to supervise and monitor the procedure. The activity takes place in a designated room.   

Clinical benefits

Sack says EEG biofeedback has helped patients complete treatment with less adjunctive medicine for symptoms of anxiety and insomnia, and has given them the ability to respond to stress better.

He says that although it seems as if EEG biofeedback is promoting higher completion rates, the organization cannot specifically attribute that to the EEG biofeedback.

“We don’t have systematic data that would show that that’s the case, but certainly the clinical impression is that completion rates are improved by it, that the reliance on symptom-triggered medication seems to go down, and that people have a very positive view on the treatment in terms of their own subjective impression that they feel that it helps them,” he says.

How the Biofeedback Procedure Works

The automated system used in the study, designed by BrainPaint, emits sounds that are generated with particular EEG frequencies that change as the cognitive state of the patient changes, Keith says.

“When you’re in a state of focused concentration and really relaxing, the sounds are quite different than when you’re agitated, mind-wandering or fidgety, and so they’ll notice that and that’s intriguing,” he says.

It also features an interface with a number of items for the patient to watch on the computer screen, including a game-like element that has accruing points and a bar that goes up and down as the patient tries to stay in the desired target zone. This allows the patient to have a sense of feedback and see that his/her brain activity correlates to what’s happening on the screen, Keith says.

“[The patient] intuitively starts learning that there are particular patterns that arise when your brain is producing particular patterns of activity. If you’re not maintaining the target activity that the system is trying to train you to do, it will disappear momentarily and that alerts you that you haven’t been playing the game—you’re not participating,” he says. “It’s almost like trying to keep a really interesting looking candle lit with your brain.”

Straining or forcing concentration is not sustainable, Keith says, and a patient must learn to relax in the moment and let what’s happening happen while they’re noticing it, not judging it, and not consciously trying to make it different. Once that happens, the computer will give the patient positive feedback.

“It trains a concentrated skill that’s very much like what meditation trains, but sometimes it’s hard for people to meditate because they feel like they’re not getting any feedback—they don’t know if they’re doing it right,” he says. “This gives the patient instantaneous feedback.”

Facility Implementation

The automated system makes EEG biofeedback far more accessible to just about any facility, Keith says.

“Any intelligent technician or staff [member] at a treatment facility who’s willing to sit down and take a little bit of training—just a few days of learning the system—can operate it with a high level of proficiency,” he says. “Most of the complexity of operating the system has been managed through some clever programming, so there are no obstacles for integrating this into practices.”

Once a patient gets used to the system after two or three sessions, a supervising staff member can leave him alone while the computer is administering the session, but initial supervision is imperative.

“You need to have a clinician in the room with them for the first few sessions, at least, to just help them relax and provide encouragement and to make sure that if they need to interrupt the training, they can hit a pause button and disconnect; if they need to go to the bathroom, that’s fine; if a sensor comes loose, they’re there to take care of that,” he says. “You want to make sure that they’re still taken care of, but they don’t have to have an expensive technician do this.”   

Although it’s rare for a patient to have a negative reaction and ask to end participation, Keith says many patients in treatment have abandonment fears on top of the anxiety issues being addressed with the EEG biofeedback, and it’s important to be sensitive to that.   

Sack says automated EEG biofeedback would greatly benefit facilities that are trying to develop alternative treatment strategies that don’t rely as extensively on stimulant medicines, particularly with young adult ADD patients.

“EEG biofeedback can play a very useful role in the co-occurring population that has both the substance abuse and ADD problems,” he says. 

There are still some significant questions that have not been answered, with one being the intervention's long-term effects. Another big question, Sack says, is how widely applicable the treatment is.

“The data is not that clear,” he says. “The number of treatment sessions to get a sustained benefit is high because the full benefit seems to require many more sessions than many people will typically get while they’re in the treatment program… but we’ve certainly seen positive results."