BRAIN CHANGE THERAPY: Clinical Interventions for Self-Transformation

Even in the context of a warm and supportive environment, therapeutic words may not be powerful enough to surmount the effects of deep wounding and ingrained dysfunction. When the verbal interventions of BCT are insufficient to address symptomatic emotions and to effect needed neurological and behavioral change, we may supplement them with one or more of the new devices utilizing recent brain research. The following case demonstrates the introduction of brain technology with a person for whom verbal interventions were unable to sufficiently address her issue.

Leslie, a high school junior and already a promising harpist, experienced intense anxiety before every performance, at times becoming so extreme that she would shake uncontrollably. As Carol gently probed to learn more of her family situation, Leslie mentioned that her mother had abandoned an early career as a concert oboist when she married. “She never says anything, but I know she’d love it if I wound up in a major symphony.” Regarding her performance anxiety, Leslie added, “Before each concert, all I can think of is that my mother will hear every mistake.”

Carol’s initial treatment plan included teaching Leslie to alter her state by slowing her breathing (inhaling to a count of 5 and exhaling to a count of 5) and by shifting her internal focus. In conversation with Carol, Leslie mentioned that as a child at her parents’ beach house she had been fond of lying right at the edge of the ocean and letting the tide wash back and forth over her. This led to the practice of imaginary “ocean swinging” as a means for Leslie to shift states.

Although Leslie’s preperformance anxiety improved somewhat, it became clear that neither talking therapy nor client education would be able to do more than mitigate the anxiety. Because hypnosis was difficult for Leslie—she began to feel as if she were falling when she relaxed—Carol suggested alpha–theta training to divert attention away from the body and refocus it on the visual and auditory feedback. This type of training both reinforces the calm state and distracts the client from thoughts potentially leading to tension.

Alpha–theta training allowed Leslie to access a more relaxed and comfortable state (a taste of what was possible) and to experience several scenarios: breathing in tranquility, imagined as the scent of a beautiful flower; imagining her mother’s face with her eyes closed and smiling as she feels the music; and looking for people in the audience who seem to be caught up in the music (at times when she was on stage but not playing). After approximately 15 sessions, Leslie reported that she had auditioned for a state-wide high school symphony—without any shaking. Beaming, she then said, “And I’m in!”

Using brain imaging to study the neural activity of Buddhist monks, yogis, and ordinary people, neuroscientists have developed a number of cutting-edge tools that can lead to a reduced stress threshold, better control of one’s thoughts, and an increased ability to hold a selected brain-mind state. These include biofeedback, neurofeedback, and photic stimulation with binaural beats. In addition, a variety of specialized computer games are now available that help people develop particular psychocognitive skills, such as achieving and holding particular brain states, perceiving positive expressions, maintaining focus and concentration, enhancing memory functions, and relaxing.

Sophisticated equipment is not necessarily required for sophisticated observation. Based on meticulously detailed observations, ancient Egyptian and Mayan astronomers were in possession of facts concerning the sun, planets, and other heavenly bodies that were only reconfirmed in the 20th century. Similarly, sophisticated exploration and training of human brain–mind capabilities has been going on for thousands of years, and only in the last 50 years has contemporary science begun to comprehend the abilities of those individuals long trained in various practices of meditation.

To facilitate state change, BCT makes use of simple meditation techniques such as slowing the breath and heart rate by focusing on a repetitive word or sound, breathing in to the count of 7 and out to the count of 7, and other methods that have proven to be powerful self-regulation strategies in dealing with stress-related issues. With training, the sympathetic nervous system can remain calm and the state of neural arousal remains low, even under potentially stressful experiences. Through meditation, individuals can develop the ability to reflect on their own feelings and behavior and overcome the tendency to react automatically to events. Self-awareness, mindfulness, or an attitude in line with what the great economist Adam Smith described as the “impartial spectator” helps a person observe events that would previously have engulfed him or her and led to reactive behavior (Rock & Schwartz, 2007b).

In studying happiness, Richard Davidson (2001) at the University of Wisconsin discovered that people had a happiness set point. That is, although external events might shift the level of happiness temporarily in one direction or another, people invariably returned to their default setting. As one would expect, people fell along a bell-shaped curve with respect to happiness; most were moderately happy most of the time. Changes in external circumstances would bump them in one direction or another, but they would return to the middle range. However, one person he measured was on the extreme end of the happiness scale. That was Matthieu Ricard, a Buddhist monk, who has been dubbed the “happiest person in the world” by popular media.

Richard Davidson wondered why Ricard was so happy and determined to study his brain with an fMRI. Davidson discovered that he could remain quite calm under experiences other people would typically find very stressful. Ricard’s amygdala, which is the part of the brain that senses danger or anger, was quiet, as was the right prefrontal cortex. When there is significant activity in the amygdala, a person experiences anxiety or fear. Davidson posed the question: Was Ricard an anomaly or could other people experience the same calm neurological activity with meditation? That led Davidson to study other monks and, in them, he discovered a similar calm state.

Davidson then wondered if regular people in high-stress jobs could learn to change their brain activity with meditation. He worked with Jon Kabat-Zinn to design a program using Vipassana meditation (which emphasizes the observation of one’s thoughts, sensations, and emotions without reactivity) for highly stressed employees at a chemical plant. The employees followed the program for 6 weeks and began to show neurological changes similar to those of the monks (Goleman, 2003).

Ricard suggested that it would be useful to study monks meditating on the themes of devotion and fearlessness. He described the meditation of fearlessness as “bringing to mind a fearless certainty, a deep confidence that nothing can unsettle—decisive and firm, without hesitating, where you’re not adverse to anything. You enter into a state where you feel that, no matter what happens, ‘I have nothing to gain, nothing to lose’” (Goleman, 2003, p. 6). Through this meditation, advanced practitioners achieve what Ricard called the “open state”. He characterized it as “open, vast, and aware, with no intentional mental activity. The mind is not focused on anything, yet totally present—not in a focused way, just very open and undistracted. Thoughts may start to arise weakly, but they don’t chain into longer thoughts—they just fade away” (p. 6). When an experiment was done to see if he could suppress the startle reflex, he was able to do so by being in the open state when a gun was fired next to his head.

Another study investigated the possible correlation between therapists who meditate and the therapeutic outcomes of their clients (Alvarez de Lorenzana, 2008). The study found that when a therapist has a quiet mind, he or she can notice more accurately what is happening, rather than overlaying a theory onto the client or reacting to what the client brings into the therapy session. As the therapist models better self-care, the client may replicate that behavior at home. Both of these factors contributed to improved outcomes.

If it is appropriate in terms of the therapeutic goals and a client is interested, Bill may teach a person how to meditate on compassion. This practice engenders a sense of connection and a feeling of safety while also promoting positive attachment and mental stability. One way of meditating on compassion, found in traditions of Tibetan Buddhism and mindfulness, is to sit quietly with closed eyes and direct a feeling of compassion first toward people whom you love, then toward neutral strangers, and finally toward people whom you do not like. The meditation is usually found to be calming and tends to reduce a person’s judgmental attitudes. (Davidson & Lutz, 2008). Later, Bill might introduce meditating on a role model, such as a saint. If a person feels more comfortable using a style of meditation from his or her own tradition, Bill will teach that. For example, with a person who is at home in the Eastern Orthodox Christian tradition, Bill might encourage him or her to meditate on the Jesus prayer.

Along with meditation, it is also important to teach clients how to accept the impermanence of life and the inevitability of change. Some clients become depressed about being depressed. We suggest that depression or anxiety is not a static state and that it changes throughout the day. Learning to recognize more pleasant states as they occur is uplifting and encouraging for clients.

Bill worked with an attorney who had suffered for years from a debilitating obsessive–compulsive disorder. Bill encouraged him to meditate. As the client began to do so several times per week, his obsessive-compulsive symptoms were reduced in frequency and intensity. What he learned through meditation was not only to calm the brain but to allow thoughts to come and go without giving them any meaning. His state of tension reduced dramatically. When a person performs a compulsive act in order to reduce tension, the relief is only temporary. Using meditation, the obsessive thoughts driving the compulsion abate. We often explain to clients that thoughts are only electrical activity that often signify nothing unless a client gives them meaning. The more the attorney was able to observe his obsessive thoughts without giving them meaning, the less frequently they occurred. Through this practice he also became more insightful and self-aware.

Biofeedback encompasses a variety of techniques for training the autonomic nervous system (part of the peripheral nervous system) by feeding back information regarding a client’s physiological condition. For example, by watching a computer display showing a person’s moment-to-moment skin temperature or heart rate, a client can learn to influence physiological processes that were previously unconscious, such as heart rate variability and skin temperature.

Using biofeedback, we teach clients to moderate the fight–flight–freeze response. When the thalamus perceives a threat, the endocrine and sympathetic nervous systems activate and concomitant physiological changes occur, which may include increased breathing, increased blood pressure, muscle tension, decreased skin temperature, and the elevation of slow or rapid brain frequencies. The adrenal glands begin pumping out adrenaline, epinephrine, and norepinephrine, which can impair immune function, digestion, and tissue repair (Demos, 2005).

Among the types of biofeedback are feedback of skin temperature, galvanic skin response (GSR), and muscle biofeedback. GSR measures changes in skin conductivity. Under threat, the sweat glands on the hands tend to produce saline perspiration; moisture increases electrical conductivity. Temperature biofeedback can be used to teach a client how to regulate finger temperature. Under threat, blood tends to pool in the center of the body, and the extremities become cold. Clients experiencing anxiety frequently have cold hands. By learning to increase the blood flow to his or her hands, the client not only interrupts the physiological pattern (constriction of blood flow to the extremities), but also quiets the internal feedback loop from the extremities back to the brain, instead of reinforcing it. Temperature training is also used for headaches, Raynaud’s disease (decreased blood flow, especially to the hands and/or feet), and hypertension. Muscle biofeedback can be useful when patients are unconsciously tensing muscles and creating problems, as in temporal mandibular joint (TMJ) problems.

Whether clients are learning to relax specific muscles, regulate their heart rate variability, or alter the temperature of a finger, in most cases, the primary state change is from anxiety to calmness. Having achieved this shift in the office, the client can remember the physiological sensations of calmness, generalize the learning to other situations, and replicate the sensations. In family therapy, this is especially helpful for parents to learn, both to help calm them about their children and to encourage them, as role models, to exhibit calmness.

With continued practice, feedback that is given for the alteration of certain physiological functions can be generalized to the resolution or mastery of life issues. Using biofeedback, one young woman who entered therapy to deal with severe test anxiety learned how to raise her finger temperature. We explained to her that memory and learning are state dependent and suggested that, when taking an exam, in order to retrieve the information she had learned, she needed to return to the calm state she was normally in while studying. Having learned to control the temperature in her finger, she was able to envision mastering other, more encompassing physiological states, such as calmness even in a situation that had previously been highly stressful. By the end of the semester, she was capable of maintaining a calm state during her final exams, a significant shift from her original feeling that her brain “froze” due to anxiety.

Some clients, after having addressed the symptoms that brought them into therapy, terminate fairly soon; fixing the symptom seems adequate. But often, those clients will return later to deal with an underlying or related issue. Or, having experienced change and becoming curious about what further improvement might be possible, they will continue until they find themselves experiencing states of thriving for longer periods of time. For example, as one client’s freeway driving phobia abated, he realized that he also wanted to overcome his fear of flying. So he continued in therapy and began to clear up many related problems; eventually he started to practice developing states of happiness during his sessions and then outside the office.

A subset of biofeedback is neurofeedback, also known as EEG biofeedback, which specifically trains the CNS. This is done using scalp electrodes (some instruments use a cap rather than individual electrodes; some are now wireless) and computer software that monitors brain waves and turns on a light, plays a sound, or runs a game as long as the client’s brain continues to function within set parameters. Although the technology has existed for over 30 years, research is only now suggesting that this approach is a powerful alternative to medical avenues for eliminating anxiety, depression, attention disorders, sleep disorders, immune problems, and epileptic seizures (Othmer, 2009).

Dysfunctional neural patterns may be genetic, learned, acquired suddenly during trauma, or developed gradually under long periods of stress. Regardless of their origin, the purpose of neurofeedback is to effect rapid electrical and (as a corollary) chemical changes to an individual’s brain in order to alter or extinguish the dysfunctional patterns and stabilize new ones. Changes in affect, attitude, and behavior occur through the stimulation of some frequencies and the suppression of others, a process that engenders brain stability with new neural configurations.

Most psychotherapeutic approaches work from the premise “Talk about it and you will feel better”; neurofeedback operates from the assumption “Feel better and you will talk about it.” Because of this difference, neurofeedback is often able to help those for whom other mental health interventions have not been successful. When used in conjunction with learning how to change states outside the office setting, a person can experience more frequent and consistent states of thriving.

For example, beta training of the sensorimotor rhythm (SMR) between 12 and 15 Hz is a physiological intervention that strengthens sensorimotor activation in the cortex and inhibits patterns that may slow brain functioning. In the treatment of attention-deficit/hyperactivity disorder (ADHD), research has shown significant efficacy using beta training, as recorded near the sensorimotor cortex. More recently, neurofeedback has been expanded to include “deep states” or alpha–theta training in the treatment of anxiety, alcoholism, and other addictions. We have also found this useful for weight loss, anxiety reduction, and resolving traumatic memories.

Additionally, neurofeedback is a powerful tool for deeply exploring one’s true self. For example, over time, a mind obsessively fretting and imagining “the worst” becomes conditioned, and then locked, into inflexible styles of thinking and chronic anxiety. These attentional or emotional states are narrow, habitual, and lead eventually to physical and mental stress and burnout (Fehmi & Robbins, 2007). Correlated with these habituated attentional styles and behavioral pathologies are particular EEG signatures. Once these signatures are recognized and the individual learns to change them through gradual reinforcement of more appropriate brain waves, a more flexible emotional state and range of satisfying behaviors can occur.

Most clients can benefit from brain training (although it is generally contraindicated for those who fall along the continuum of autistic disorders and may not be able to sit comfortably in front of a computer monitor with electrical leads on their heads). At times, neurofeedback can promote a dramatic turnaround in a client’s life.

Rachel spent much of her time depressed and in tears. Beneath her depression was a smoldering anger directed at her husband, whom she was only steps away from divorcing. His primary fault, she reported, was that he spent too much time in the garage making golf clubs. Based on a QEEG evaluation, Bill worked with her using SMR training. After the first session, she noticed very little change. However, following the second session, Rachel was not as weepy the rest of the week. During the week after her third session, her mood lifted dramatically, and she was able to observe that her tears had nothing to do with her husband. In fact, during her next session, she began to recount all the good things her husband had done. After about 40 sessions of neurofeedback, Rachel’s mood was consistently happy and she was again in love with her husband.

In tandem with a client’s internist or neurologist, we can do brain training to ameliorate many medical issues. Strongly implicated in Rachel’s distress were the hormonal imbalances related to menopause. The brain is involved not only in regulating hormone levels, but with a sudden shift in hormone levels will display a corresponding shift in brain waves. For example, a hot flash is reflected in an EEG, with the amplitudes becoming quite high during its course. We cannot stop the natural process of menopause itself, but we can significantly mitigate some of its symptoms. Hot flashes and night sweats have been reported to cease for weeks with a few sessions using Cygnet Neurofeedback Software (discussed later in this chapter). In another case, using SMR training, we treated a young girl with epileptic seizures to the extent that her seizures stopped.

By working to change brain wave patterns, neurofeedback can also assist clients in breaking through defenses, changing belief patterns, loosening inflexible perceptions, and allowing them to make better use of the therapeutic interaction. Neurofeedback can facilitate changes in many domains, including the quality of attention, motivation, affect, attitudes, behavior, and understanding of the client. Additionally, many clients report benefits such as less mental chatter, greater mood stabilization, less concern with “trying to achieve,” and more focus on developing an improved quality of life.

One of the speculations coming out of neurofeedback research is that emotional and behavioral dysfunctions reflect brain disorganization in the domains of timing and frequency. Neurofeedback technology actually has the capacity to restructure brain functioning (which involves these two key elements of timing and frequency) through attention training. Farmer (2002) noted: “We are beginning to understand that brain rhythms, their synchronization and desynchronization, form an important and possibly fundamental part of the orchestration of perception, motor action, and conscious experience, and that disruption of oscillation and/or temporal synchronization may be a fundamental mechanism of neurological disease” (p. 1176). Based on this understanding, neurofeedback is also being used to help athletes and artists achieve peak performance. And more good news: Its use can contribute to optimal aging (Budzynski, Budzynski, & Tang, 2006).

BCT makes use of recently developed equipment that combines light (photic) and sound (aural) stimulation. However, the therapeutic use of flickering light dates at least back to the early 20th century. Pierre Janet, a pioneering French psychotherapist, noted that when he had patients gaze at the light of a kerosene lantern, filtered through the spindles of a turning wheel, their symptoms of depression, tension, and hysteria were reduced (Pieron, 1982). In the 1920s and 1930s, Dr. Harry Spitler, a physician and optometrist, experimented with flashing colored light into the eyes to correct visual problems. In the 1940s, Dr. Gray Walker, a British physician, discovered that the brain’s dominant frequency tends to become entrained by a flickering light.

More recently, flashing colored light has been shown to affect or “drive” the brain in specific ways. Komatsu (1987) found that there is a relationship between the color of the flickering lights and the evoked brain wave response. In a study of college students, flashing red light drove the 17–18 Hz band of brain waves, whereas green increased 15 Hz waves, and blue stimulated 10–13 Hz waves. Similar results were found with the Lumatron, a device that beams light directly to the brain through the eyes. Red light stimulated brain waves above 15 Hz, yellow drove 13 Hz, and green drove 10.5 Hz; blue light increased 9 Hz, and indigo/violet drove the theta and delta frequencies (Breiling, 1996). Amber light (between red and yellow) stimulated activation at 14 Hz and was found to be “warmer” and more pleasant than red (Austin, 1991). EEGs show that the brain also responds to steady colored light. Researchers found that the alpha amplitude is suppressed when subjects are exposed to red light as opposed to blue and concluded that red light tends to increase vigilance (Ali, 1972).

Frequency-specific flickering lights can also entrain brain waves. A light flickering at 8–12 Hz can induce an alpha state. Shealy (1990) reported that 88 of 92 patients with chronic pain experienced both pain relief and relaxation after 30-minute sessions during which the 10 Hz rhythm was stimulated. Budzynski (1999; Budzynski & Sherlin, 2002) and Fahrion (1995) reported that using 3–7 Hz in photic stimulation resulted in an extremely calm feeling that lasted 3–4 days after the session. In addition, migraine headaches have successfully been treated by Anderson (1989), who used red light-emitting diodes (LEDs) to stimulate the optic nerve with frequencies between 0.5 and 50 Hz.

EEG-driven stimulation is a type of neurofeedback that involves monitoring and analyzing EEG signals read through surface electrodes on the scalp and then using the EEG itself to guide low-intensity light stimulation. The EEG signals influence the stimulation, which in turn changes the EEG pattern. For example, the flashing lights are set either to lead or lag the dominant brain wave by some fixed amount—say, 5 Hz— meaning that the lights always flash 5 Hz faster (or slower) than the dominant brain frequency. This stimulation tends to prod the dominant frequency into a slightly higher or lower range.

Patrick (1996) reported on the effectiveness of using photic stimulation in just 15 sessions for attention problems. When the light stimulation is presented, there is a slight brain response in the EEG, where there is an event-related potential (ERP). This ERP is an indication of brain response to the stimulation. The research suggests that repetitive stimulation tends to improve attention and reduce pain (Kikuchi, 2002) as the EEG begins to respond at the same frequency as the stimulation (Trudeau, 1999).

Like light, rhythmic sound can also be used to entrain brain waves. For example, Tibetan Buddhist chanting entrains the brain in theta rhythm, in which people may experience rejuvenation, “flashes” of intuition, or suddenly grasp an understanding of relationships or ideas.

Binaural beat frequencies, first discovered in 1839 by the Prussian physicist and meteorologist Heinrich Wilhelm Dove, have been used for years to alter consciousness. Binaural beats are auditory brainstem responses that occur in the superior olivary nucleus of each hemisphere. They result from the brain’s integration of two auditory impulses, originating in opposite ears and differing just slightly in frequency. The human ability to “hear” binaural beats appears to be the result of evolutionary adaptation and is one mechanism used by the brain in audio direction finding.

The beat frequency is usually “carried” by another frequency of less than 1,000 Hz. For example, a 10 Hz alpha wave beat is caused by a difference of 10 Hz between two “pure” frequencies, one resonating at 400 Hz and another at 410 Hz. When auditory signals are presented to the brain with slight phase differences, the brain can detect the difference, although the listener does not consciously hear it.

Resonant entrainment of oscillating systems is well understood within the physical sciences. If a tuning fork that produces a frequency of, say, 800 Hz is struck (causing it to vibrate or oscillate) and then brought into the vicinity of another 800 Hz tuning fork, the second tuning fork will begin to oscillate. In this case, the first tuning fork has entrained the second. Entrainment can also occur in biosystems, including the entrainment of electromagnetic brain waves. Neural entrainment is defined as any instance in which an EEG reflects the brain wave frequency duplicating that of a stimulus, be it audio, visual, or tactile (Siever, 2004). Binaural beats can be used to entrain specific neural rhythms through the frequency-following response (FFR; Moushegian, 1978)—that is, the tendency for cortical potentials, as evidenced through brain waves recorded by EEG, to entrain to the frequency of an external stimulus. Based on this, it has been shown that a specific binaural beat frequency can be used to entrain the cortical rhythm to that frequency. Binaural beats can be readily perceived at frequencies below 30 Hz, which are characteristic of the EEG spectrum (Oster, 1973).

Binaural beats have also been found to synchronize the two hemispheres of the brain because both ears send neural signals to the olivary nuclei (sound-processing center) in both hemispheres of the brain. Therefore, when a binaural beat is perceived, there are actually two identical beats perceived, one in each of the two hemispheres. In this way, the binaural beats promote hemispheric synchronization similar to that observed in meditative and hypnogogic states of consciousness. Binaural beats have been used to enhance the learning process, promote relaxation, improve memory (Kennerly, 1994), stimulate creativity, and assist the onset of sleep (Hiew, 1995).

Any given frequency of stimulation that can be reflected in brain wave activity and is observable on an EEG or QEEG can be “driven” (meaning, the brain can be induced to entrain to that frequency) using flickering light, sound waves, or a combination of the two. The combination of photic and aural stimulation, now formally called audiovisual stimulation (AVS) or audiovisual entrainment (AVE), is the basis for the functionality of many neurofeedback devices used in BCT.

The use of AVS has been shown to effectively relax people who exhibit high sympathetic activation and/or traumatic states of mind by bringing a return to homeostasis. Siever (2000) suggests that AVS achieves its effects through several mechanisms simultaneously, including dissociation, an increase in neurotransmitters, possible increase in dendritic growth, altered cerebral blood flow, and normalized EEG activity. Particularly if the flickering occurs in the alpha–theta band, an individual is likely to go into a state of hypnosis. Subsequent research has shown that using photic and aural stimulation to effect brain entrainment, and thereby engender various states of consciousness, may have potential not only for a therapeutic goal of relaxation but also for healing certain mental and physical conditions (Siever, 2004).

Many AVS devices make therapeutic use of two physiological facts. One is that light is processed contralaterally: Light entering the right visual field of both eyes is transmitted as neural stimulation to the left side of the brain, and light entering the left visual field of both eyes is transmitted as neural stimulation to the right side of the brain. Signals move from rods and cones in the ganglion cells to the optic nerve and then to the brain. The network of nerves called the optic chiasm sends images from the left visual fields of both eyes to the right lateral geniculate and then to the cortex, and vice versa. The second fact is that the human brain naturally switches hemispheric dominance, on average, every few seconds. The tenor of the left hemisphere is more upbeat and expansive, more focused at the macro level; the tenor of the right hemisphere is more downbeat and contained, more involved with the details. Recent studies suggest a correlation between slower-than-average switching rates and bipolar disorder. One hypothesis is that, in bipolar swings, the brain tends to get “stuck” or linger in one state over the other (Pettigrew & Miller, 1998).

Harold Russell (1997a, 1997b) conducted a study using photic and aural stimulation with boys who had learning disabilities, ages 8–12. The pulsed light was varied every 2 minutes between 10 and 18 Hz. Aural stimulation at the same frequency accompanied the pulsed lights. The researchers reported significant increases in the boys’ intelligence, as measured by the Raven IQ test, and increases in their ability to sustain attention and inhibit impulsive behaviors, as measured by the teacher-completed Attention Deficit Disorders Evaluation Scale. Russell (1997a) patented hardware and software for further work and conducted several studies with their equipment. All of the studies found an increase in intelligence measures and an improvement in behavior. Using the EEG, earlier studies had found hypoperfusion (lack of blood flow) and an associated increase in the theta band (4–8 Hz) at certain brain locations in individuals with attention-deficit disorder (ADD) as well as in elderly people (Alexander & Schneider, 1996; Celsis, 1997). Russell reported that auditory and photic stimulation, used repetitively, induced changes in EEG frequency, increases in glucose and oxygen metabolism, an increase in cerebral blood flow, and changes in brain chemistry (Russell, 1997a, 1997b).

The periodical Alternative Therapies published a systematic review and analysis by Huang and Charyton (2008) of 20 of the major studies done on brainwave entrainment using photic stimulation, aural stimulation, or a combination of the two to improve cognition or treat stress, anxiety, pain, headaches and migraines, mood, and premenstrual syndrome (PMS). The authors summarized:

Preliminary evidence suggests that alpha stimulation was preferable for trigram recognition, short-term stress, and pain relief, whereas beta was used to enhance attention, increase overall intelligence, relieve short-term stress, and improve behavior. The alternating alpha and beta protocol was used successfully to improve behavior, verbal skills, and attention. A protocol that alternatively ascended and descended from beta to gamma enhanced arithmetic skills and attention. A protocol that alternated between 14 and 22 Hz increased overall intelligence. Several protocols, including a combination of theta and delta and a progressive slowing over 30 minutes to delta, were effective in relieving short-term stress. Migraines were prevented with a 30-Hz stimulus that alternated between left and right hemispheres, and a few studies that allowed the subject to choose the frequency of stimulation were successful in alleviating long-term stress, pain, and migraines. However, this review concluded that research had yet to prove the effectiveness of brain wave entrainment for addressing mood issues. (Huang & Charyton, 2008, p. 48)

A pilot study reported by David Cantor (2007) at the annual conference of the EEG and Clinical Neuroscience Society suggested that the research to support such a conclusion may be forthcoming. The pilot study included 16 patients with a mean age of 45 years who had a long history of refractory depression that was minimally responsive to medication. Patients were required to stop all medications one month prior to the start of the study. Half of the group received 20 minutes of AVE therapy daily for 4 weeks at a frequency of 14 Hz. The other eight patients wore the AVE equipment for 4 weeks but did not get the stimulation treatment. After 4 weeks, testing revealed a significant decrease in self-reported depression scores in the treatment group and no change in the untreated group. QEEG testing also showed neurophysiological changes in the treated patients (but not the untreated group) that corresponded to their reports of improved mood. The groups were then reversed, so that the untreated group received treatment, and vice versa, for the next 4 weeks. Similar results were noted in the newly treated group, and the group that had received the first phase of treatment showed a sustained effect of treatment, both behaviorally and neurophysiologically, even 4 weeks after discontinuation (Cantor, 2007).

Many companies now offer brainwave entrainment devices, biofeedback and neurofeedback equipment, and various software products suitable for professional use. Of those currently on the market, we discuss a few that we feel are representative of each general type of equipment and are among the “best of breed.”

Neurofeedback certification and licensure requirements vary from state to state. The therapist who considers integrating any of these feedback devices into his or her practice may wish to look into the various professional societies, such as the Biofeedback Certification Institute of America, the International Society for Neurofeedback and Research (ISNR) and the Association for Applied Psychophysiology and Biofeedback, which provide treatment standards for using these approaches.

The DAVID PAL (Digital Audio-Visual Integration Device—Portable and Lightweight) equipment combines flashes of lights and tone pulses to effect brainwave entrainment. The manufacturer’s specifications note that the equipment is about the size of a mobile phone, plus headphone and eyeset (wraparound “eyeshades”). It includes 18 preprogrammed protocols for a variety of brainwave stimulation sessions, including (1) a brain “brightener” (for ADD and cognition); (2) fractionation hypnosis (the process of moving in and out and then back into trance in order to deepen the trance state); (3) an alpha–beta mix (for depression); (4) Schumann resonances (specific very low frequencies) with dissociation and heart rate variability (for meditation); (5) a beta “perker”; and (6) theta (for improved sleeping).

To disperse the light evenly, the eyesets for the DAVID PAL use eight blue-tinted white LEDs mounted over a silver reflector behind a translucent screen. The eyesets allow the left and right visual fields of each eye to be stimulated separately. The lights flash alternately into the left visual fields of both eyes and then into the right visual fields of both eyes. This alternation makes it possible to stimulate the two visual cortices differentially. For example, a person who functions strongly from the left brain might receive 8 Hz in the right visual field (and therefore the left brain) to slow down left-brain function and receive 18 Hz in the left visual field to increase right-brain function.

The DAVID PAL has three types of sound output: isochronic pulsed tones, monaural beats, and binaural beats. To enhance the effectiveness of audio entrainment, the isochronic pulsed tones are evenly spaced, of equal pitch, and are turned on and off at a specified rate. The monaural beats are similar to the isochronic pulsed tones, but turn on and off more gently and therefore are smoother, fuller beats. This pattern is recommended for those who find the pulse tones too stimulating. The binaural beats are two pure tones (one in each ear) that are perceived as a beat.

The DAVID PAL has no input function. It does not track the user’s brainwaves, heart rate variability, or other biological data. With only output functions (the various protocols), it has no capacity to modify its output based on such data; however, there is a version of the DAVID PAL that can be programmed to individual specifications. We have found it helpful for clients to take the DAVID PAL equipment home and use it in between formal neurofeedback sessions at the office. We have also used it with people to stop food and alcohol cravings while they work with us.

One client, deeply grieving after the death of her father, began to drink wine excessively. As her drinking grew increasingly serious, her husband became extremely upset and finally demanded that either she had to stop drinking or he would leave her. She did not want to put her marriage at risk, but she had great difficulty stopping and would deal with stress at the end of the day by sneaking a glass of wine. We suggested that she purchase the DAVID PAL and use it before she had any wine. Eventually, her desire to drink disappeared and her marriage remained intact.

Another woman, who had tried all kinds of diets in vain, still desperately wanted to lose weight. Strongly suspicious that this tool was just like all the other diet “tricks” she had tried, she purchased the DAVID PAL and began to use it at work before she ate junk food. Her desire for sugar and carbohydrates diminished significantly; she lost over 80 pounds and kept it off for many years.

The ROSHI® combines photic and aural stimulation with a neurofeedback system. The device was created by Chuck Davis in conjunction with Ray Wolfe of Photosonix. Davis said that he was inspired to design this device by the state of healing and regeneration naturally achieved by meditating monks. Using the ROSHI, an individual can increase brain metabolism and blood flow, experience improved concentration, and stay in the “zone.”

The ROSHI monitors how the brain is responding to the stimulation and modifies its output in response. For example, it can be set to follow the dominant frequency of the brain and change as the frequency changes. The unique aspect of the ROSHI is what Davis calls its “complex adaptive” visual stimulation (Olesen, 2004):

The raw EEG is fed through an algorithm that treats the complex EEG as “chaos” and modulates the LEDs accordingly. Thus the intensities of the lights are constantly “adapting” to neuronal conditions in realtime. What the user sees in the light goggles is a complex, constantly changing flicker, based on changes in his or her own brainwaves. It’s like the brain “seeing” itself. (p. 4)

The ROSHI can both entrain brainwaves and disentrain them. For example, it can reduce certain frequencies, such as the slow frequen-cies associated with ADD, as well as increase desired frequencies. Davis suggested that this process encourages the brain to discard old patterns and develop flexibility (Davis, personal communication, September 18, 1999). The changes occur at an unconscious level, thereby circumventing any conscious resistance such as might occur in any other psychotherapeutic approach. Research by D. Corydon Hammond (2007) on the treatment of clients with depression has shown the ROSHI to be effective in cases that were resistant to more conventional treatments. Other applications for the ROSHI include the treatment of anxiety, strokes, headaches, bipolar disorder, age-related cognitive slowing, and brain injuries. The ROSHI is also used in training for peak performance, for example, by training the brain at 40 Hz. This frequency is being researched in terms of its relevance to experiences of transcendence in which people have reported feeling at one with the universe.

The LENS (Low Energy Neurofeedback System), developed by Len Ochs in the early 1990s, is a neurofeedback system used to treat CNS problems. Different from traditional neurofeedback systems, the LENS equipment is designed to both map a client’s brain (standard EEG) and to deliver minute electromagnetic impulses as short as one second to 19 different scalp locations simultaneously. Utilizing the same wires that carry the brainwaves to the amplifier and computer, the LENS software generates the feedback based on the EEG signals that it records. Feedback occurs in the form of a radio frequency carrier wave, administered at a positive offset frequency from the person’s own dominant EEG frequency, or the one highest in amplitude, using a 19- or 21-site topographic brain map. The electromagnetic feedback is of such low intensity that, although the brain perceives it, it is not consciously perceived by the client. However, when exposed to this feedback frequency, the EEG amplitude distribution shifts in power and ultimately improves the brain’s ability to regulate itself.

The system does not require the client to pay attention and is efficacious even if the client has difficulty sitting still. It can be used with other neurofeedback devices or alone as the case demands. Hammond (2007) said that the LENS has been shown “to produce rapid resolution of difficult cognitive, mood, anxiety, clarity, energy, movement, and pain problems when compared with more traditional forms of psychotherapy or medication treatment” (p. 8).

Cygnet software is a suite of functionalities including EEG training, hemoencephalography training, and alpha–theta training. The software works with a digitizing device that measures EEG signals, performs real-time analysis of the signals, and controls feedback devices such as video, audio, games, and tactile systems based on rules defined by the therapist. Cygnet is a two-component training system, involving both a reward function focusing on a particular EEG frequency and an inhibit function that operates on the EEG broadly. The inhibit function is handled in the background entirely by the software. The clinician only selects the overall level of difficulty to match the client’s needs and retains full control of the reward frequency. The system’s basic configuration is that it runs on one computer with two screen displays. The main screen, (therapist screen) displays the Cygnet user interface and allows the therapist to access all the software functions. The second screen (client screen) shows the feedback via video display (i.e., video player, DVD player, or flash game). In essence, this software supports multiuser feedback in real time—both client and therapist simultaneously respond to feedback provided by the software and thereby “drive” the program. The Cygnet software is also capable of controlling a tactile feedback device (Cygnet, 2008).

The healthy heart speeds up with every in-breath and slows down with every out-breath. Plotted over time, the variation generates a pattern called heart rate variability (HRV). The degree of HRV is an important indicator of an individual’s resiliency and flexibility under stress.

The research team at the Institute of HeartMath (IHM) has demonstrated that combining intentional heart focus with sustained positive feelings leads to what they have termed physiological coherence in HRV. This coherence is associated with a sine wave-like pattern in the heart rhythms, an increase in parasympathetic activity, greater heart–brain synchronization, and the entrainment of various physiological systems. In physiological coherence, the body’s systems function with an efficient harmony, and healing processes are facilitated. When an individual experiences stress or negative emotions such as anxiety, despair, or frustration, HRV becomes less coherent or orderly (McCraty, 2002).

The IHM has developed the emWave device to train HRV by controlling the breath. The biofeedback training involves a shift in breathing to slow respiration and to generate steady and even heartbeats. Accompanying this practice is an emotional shift accomplished by attending to the heart and holding a positive feeling toward someone or something. This shift in focus is followed by having the user imagine breathing through the heart. What is achieved is a degree of coherence in which emotional stability, self-regulation, and states of well-being are better maintained (McCraty, 2008).

The emWave equipment comes in two versions: as software that can be loaded onto a desktop or laptop computer with a pulse sensor that plugs into a USB port and clips to the user’s ear, or as a small stand-alone, handheld device with a thumb sensor or optional ear clip. The desktop version has greater capabilities in terms of graphic display, interactive exercises, and training games; the handheld version can be carried and used during potentially stressful situations. We use both versions of the equipment. The desktop version can serve as an important diagnostic tool during the initial assessment with clients who have rapid heart rates and are often anxious. In later sessions, we use it therapeutically for clients with anxiety issues. Once the person has a solid experiential sense of the calm state, it can be practiced outside the office. In marital therapy sessions, we may give one of the handheld models to each partner to assist them both in better managing their physiological arousal as we all work together. When both partners practice calming techniques, issues of conflicts often can be worked out without negative emotions taking over.

On our recommendation, the parents of an active 5-year-old daughter with serious discipline problems purchased an emWave device for her. Working with us, she learned to slow her breathing, and her family continued to help her practice with the device at home. She enjoyed the game quality of the emWave and began to generalize the breathing techniques to her everyday situations. As she learned how to calm herself, the dynamics of the entire family system began to shift. As a result, the tenor of the parent–child interactions evolved from often being somewhat adversarial to being generally cooperative.

Another client, having difficulty with high blood pressure, was highly motivated to use the emWave daily. By learning to control her level of arousal, she dropped her blood pressure from 147/100 to 110/80. We strongly suggested that she continue to check her pressure at least once daily and consult her physician if she noticed it starting to rise.

Relaxing Rhythms (formerly called Healing Rhythms) is a biofeedback-based training program that teaches techniques of deep breathing and meditation using biofeedback. The software package includes a USB-based biofeedback reader, a device that attaches to three fingers and measures HRV and skin conductance. In this program, experts in the field of wellness, including medical doctors Deepak Chopra, Dean Ornish, and Andrew Weil, guide the user through 15 lessons designed to teach relaxation and stress management. The software allows the user to select either guided instruction or to go directly to interactive exercises, called “energy events,” such as learning to juggle balls with laughter, build a stairway using breath, and meditate to open doors.

Journey to the Wild Divine is a biofeedback-based system in a computer game format suitable for adults but also for children as young as 5. It uses the same type of biofeedback device and covers the same content as the Relaxing Rhythms software. The first game, “The Journey to Wild Divine: The Passage,” encourages the user to explore a fantasy landscape of gardens, cottages, and temples by learning the yogic breathing and meditation skills necessary to complete 40 biofeedback energy events, including levitating golden orbs and releasing a falcon from a cage. The visual confirmation of mastery provides effective reinforcement of newly learned behaviors.

The second title in the series, “The Journey to Wild Divine: Wisdom Quest,” offers a deepening of the relaxation skills practiced in the earlier software. In the “Game Quest” mode, the user can travel through the “Sun Realm” in search of seven precious stones that promote inner peace in the “Realm” and in the user. The “Guided Activity” mode features 20 advanced interactive activities for mind–body training. Also, Wisdom Quest allows the user to select the difficulty level for each activity.

MindHabits Trainer is a suite of four video games designed to train states of self-esteem by limiting attention to social rejection and conditioning attention to social acceptance responses (Dandeneau & Baldwin, 2004; Dandeneau, Baldwin, Baccus, Sakellaropoulo, & Pruessner, 2007). Often, with social anxiety, clients unconsciously tend to search out cues that they construe as indicative of rejection. To maintain positive states, a person needs to develop a mind frame that ignores rejection and looks for acceptance.

Researchers at McGill University in Canada found that cortisol was reduced by 17% in people who played a game designed to have users notice smiling faces and ignore negative facial expressions for 5 minutes a day. Subjects also reported feeling happier and having a reduced tendency to scan the environment for negative responses to themselves. Stress reduction and self-confidence are achieved through accessing positive states and their accompanying automatic thought patterns. Although more studies are needed, the early research suggests that when clients play this game several minutes each day, their positive focus is conditioned throughout the day (Dandeneau & Baldwin, 2004; Dandeneau, Baldwin, Baccus, Sakellaropoulo, & Pruessner, 2007). The game can be a helpful training adjunct between therapeutic sessions.

Only rarely are brain-training devices the primary therapeutic intervention, although we do occasionally have referrals for just neurofeedback when the client has another therapist. Usually, however, the devices are used as an adjunct to the more encompassing therapeutic relationship in which the clinician models both outward styles of behavior and patterns of positive neurobehavior for the client. Nonetheless, they can play an important role in the therapeutic encounter. The majority of brain training is done on the Cygnet device. This is used for ADD, depression, anxiety, and chronic pain when psychotherapy cannot fully address these issues. For mild anxiety and stress, we use the emWave device so that clients can literally see that they have the ability to be in charge of the body. We recommend the DAVID PAL and the MindHabits game for home training; these tools allow clients to practice changing states and reaching the target state. Beyond the fact that brain training devices are intrinsically functional in helping a client to shape brain behavior, they bring two other elements to the therapeutic process: They give the client a visible degree of control over the therapeutic outcome, and their sheer novelty activates the circuit of curiosity, which promotes learning.

As an example of a brain-training device functioning at a metalevel as well as fulfilling its intended application, we once worked with a young man who had inherited $13 million when he was 18 years old. Because of that, Roger lacked the motivation to go to school, study anything, or develop any employable skills; he had no life goals. However, he was quite depressed and suffered from frequent and severe headaches. As we explored the circumstances of Roger’s life, initially the only motivations we could tap were in relation to reducing his depression and his headaches. Finding the motivation for change is imperative in being able to activate appropriate neural circuits. Because headaches are often successfully addressed with biofeedback, we started there. Roger became amazed that he could get rid of his worst migraine headaches using biofeedback equipment. That amazement then fueled a curiosity about what else he might be capable of doing, not only in terms of biofeedback but in other endeavors, and eventually he began to be more curious about the wider possibilities in his life.

The use of a brain-training device may also help create an emotional opening to further work with a client who is otherwise resistant to any self-examination. For example, some clients firmly believe that a relationship problem completely rests with the other person. The unconsciously conveyed message is a projection of blame without any evaluation of the client’s potential part in a dysfunctional interaction. Frequently in such a case, the client needs someone outside him- or herself to lower his or her state of arousal before he or she will be able to “hear” any other perspective. For the client to change states of arousal, the therapist must help him or her feel understood and focus on the intent of the other person’s behavior rather than on the effect. However, coaching this client to change states in a direct manner may have poor results.

Complicating this dynamic is the therapist’s countertransference, which may be an accurate representation of how other people in the family respond to the client. The therapist needs to note his or her own reaction, calm his or her emotions, and step back to question whether there might be a positive or benign intent in the midst of the client’s troublesome blaming behavior. Often, after hearing such an explanation, the client will calm down and be able to change states, because his or her feelings have been acknowledged. As an example, the therapist might say: “I am concerned about the amount of stress you are experiencing with your husband and daughter. I don’t want to see you be eaten alive by this circumstance.” If the client responds positively with signs of lowered arousal, then the therapist might say: “How can you protect yourself from these conflicts so that you do not become a scapegoat? And so that you do not end up so stressed, let me suggest a brain technology to help you manage your stress levels better.” As the client’s arousal levels come down, he or she may be open to looking at his or her part in the interactions.

We have worked with several children who were diagnosed as having ADD and who have been able to either lower or eliminate medication. We have found the emWave especially effective for children who present with school anxiety. To help children learn state change, we also use the Journey to Wild Divine in its game mode in the office and recommend it for home use. When the family is relatively functional and does not overreact to the child’s behavior, we can work primarily with the child to improve his or her neurological patterning. When the parents are reacting intensely because the child is inattentive, doing poorly in school, and perhaps lacking inhibitory ability, we may also find it necessary to “coach” the parents.

If parents simply want to drop a child off to be “fixed,” we may introduce neurofeedback fairly early in the therapeutic work with the child—who usually enjoys the video game aspect of it. However, we attempt to engage the parents as much as possible. Lubar, Swartwood, Swartwood, and O’Donnell (1995) extensively studied the use of EEG biofeedback with children and adults who have ADD or ADHD and find that a child who has been doing well using neurofeedback that then goes home to a dysfunctional system will lose some ground by the next session. Our experience has been similar. Every child is part of a family system; changing any one element in it—the child, for example—does begin to shift the entire system. To the extent possible, addressing levels of arousal and resulting behaviors in the entire family system is far more effective.

Matthew, for example, had a severe reading disability and very poor academic performance. His parents had already taken him to every learning center in Houston, to no avail. An initial QEEG evaluation showed that Matthew had unusually high levels of delta and theta frequency waves in the prefrontal cortex and temporal lobes. However, after roughly 30 sessions of neurofeedback training rewarding SMR in both frontal lobes, his brain functioning had improved enough that his attention span increased noticeably. By the end of the school year, his grades had improved so greatly that the principal called to ask what we were doing.

This chapter has discussed a number of devices and software products that can be used to assist clients in learning how to change states and maintain a preferred state. Devices that range from relatively simple output-only ones to some of those that respond through biofeedback to the client’s changing state can be used during the therapeutic interaction and may be suitable for home use by the client. Far more sophisticated software utilizing neurofeedback can pinpoint and reward target states as narrow as a particular EEG frequency. The use of such systems requires specialized training and is appropriate only in the clinical setting.

In the next chapter, we explore deeper states of alpha–theta, which, whether achieved via meditation, hypnosis, or biofeedback, have been found to lower stress and increase positive feelings.

CHAPTER 6

Utilizing Brain Technology Equipment