Journal of Neurotherapy: Investigations in Neuromodulation, Neurofeedback and Applied Neuroscience “Native Americans, Neurofeedback, and Substance Abuse Theory”. Three Year Outcome of Alpha/theta Neurofeedback Training in the Treatment of Problem Drinking among Dine' (Navajo) People Matthew J. Kelley Ph.D. a a Na'nizhoozhi Center (NCI) , 2205 E. Boyd, Gallup, New Mexico, 87301, USA Published online: 20 Oct 2008.

To cite this article: Matthew J. Kelley Ph.D. (1997) “Native Americans, Neurofeedback, and Substance Abuse Theory”. Three Year Outcome of Alpha/theta Neurofeedback Training in the Treatment of Problem Drinking among Dine' (Navajo) People, Journal of Neurotherapy: Investigations in Neuromodulation, Neurofeedback and Applied Neuroscience, 2:3, 24-60, DOI: 10.1300/J184v02n03_03

To link to this article: http://dx.doi.org/10.1300/J184v02n03_03

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THIS OPEN-ACCESS CONTENT MADE POSSIBLE BY THESE GENEROUS SPONSORS "Native Americans, Neurofeedback, and Substance Abuse Theory" Three Year Outcome of Alphdtheta Neurofeedback Training in the Treatment of Problem Drinking among Dine' (Navajo)People

Matthew J. Kelley Ph.D.

This three year follow-up study presents the treatment outcomes of 19 Dine' (Navajo) clients who completed a culturally sensitive, alpha ltheta neurofeedback training program. In an attempt to both replicate the earlier positive studies of Peniston (1989) and to determine if neurofeedback skills would significantly decrease both alcohol consumption and other behavioral indicators of substance abuse, these participants received an average of 40 culturally modijied neurofeedback training sessions. This training was adjunctive to their normal 33 day residential treatment.

According to DSM-IV criteria for substance abuse, 4 (21%)participants now meet criteria for "sustained full remission", 12 (63%) for "sustained partial remission", and 3 (16%) still remain "dependent" (American Psychiatric Association, 1994). The majority of participants also showed a significant increase in "level of functioning'! as measured by the DSM-IVAxis V GAF.

Subjective reports from participants indicated that their original neurofeedback training had been both enjoyable and self-empowering; an experience generally different from their usual treatment routine of talk- therapy and education. This internal training also appeared to naturally stimulate significant, but subtle, spiritual experiences and to be naturally compatible with traditional Navajo cultural and medicine-ways. At the three-yearfollow-up interview, participants typically voiced that these experiences, and their corresponding insights, had been helpful both in their ability to cope and in their sobriety. From an outside perspective, experienced nurses also reported unexpected behavioral improvements during the participant's initial training. Additionally, administrators and physicians generally found the objective feedback and verification quality of neurofeedback protocols compatible with their own beliefs.

An attempt has also been made to conceptualize the outcome analysis of this study within both a culturally specific and universal socio I bio I environmental context.

This three year follow-up study presents With this in mind, participants were the treatment outcomes of 19 Dine' (Navajo) thoroughly trained in relaxation-based clients who completed a culturally sensitive, neurofeedback skills and other self-regulation alphdtheta neurofeedback training program. techniques in an attempt to allow them to Their initial training, provided in addition to "make their own medicine." their 33 day inpatient substance abuse In an attempt to tie this study into the treatment program, was an attempt to reduce construction of an applied neurotherapy theory the chronic stress patterns commonly found in and its application in substance abuse people who have alcohol-related problems. treatment, an unusually broad literature Stress (and its emergent neurological matrix) discussion is included. In addition, many is considered by some to be one of the complex cultural context factors are involved in significant (and most neglected) factors understanding this project and its outcome, It contributing to problem drinking (Johnson & is inherently difficult, for example, to Pandina, 1993; Peniston & Kulkosky, 1989). accurately appreciate the outcome of any type

FalVWinter 1997 24 Journal of Neurotherapy Copyright © 1997 ISNR. All rights reserved. of treatment program, and especially this one. Disorders (DSM) (American Psychiatric Treatment outcomes can only be evaluated Association, 1994) (including the DSM 111-R, against the background of clearly understood DSM-IV) and the ICD-10, in an attempt to predictive variables such as the client's social better present the dimensional nature of stability, seventy of dependence, alcohol-use problems, distinguish between psychopathology, stressors, physiology, and "alcohol abuse" and "alcohol dependence." environmental support (Lettieri, 1992). These three manuals also recognized that individual patterns within these two categories Outcome analysis is even further can be quite varied. Alcohol abuse is roughly complicated because the scientific and the defined (in all three manuals) as at least a one public understanding of the spectrum of month pattern of alcohol usage which causes "alcohol-use-disorders" (and their psychological or physical harm to the user. corresponding causality) is often imprecise and However, within different social or cultural confusing (US. Department of Heath and contexts, this criterion itself may vary Human Services, 1990). In addition, because (Westermeyer & Canino, 1994). The DSM-lV cultural norms strongly influence the etiology, defines alcohol dependence as a persistent dynamics, and the various problems inherent pattern of alcohol usage (for at least one in alcohol consumption, a meaningful month) involving at least three of the following understanding of the dynamics and outcome of symptoms: (a) a subjective sense of having a neurofeedback training within this specific compulsion to drink; (b) a difficulty in rural Navajo context is even more complex controlling intake; (c) using alcohol to relieve or (Westermeyer & Canino, 1994). avoid withdrawal symptoms; (d) the experience of a physiological withdrawal state; (e) an Although this study involves Navajo increased tolerance to alcohol; (f) making participants, its outcome potentially has a drinking a priority over important activities; (g) much wider application. If the outcome shows continued use of alcohol even after positive results within these challenging and experiencing physical or psychological culturally powerful contexts, many of the same complications; (f) an increase in time spent self-empowerment and stress reducing drinking or the interference of drinking (or components of the protocol could also be withdrawal) with other important activities. applicable to other populations, including the dominant US.,non-native culture. In an attempt to acknowledge this wide spectrum of problem-causing drinking behavior To illustrate the research context, the (ranging from infrequent but problematic drinking dynamics of both the non-native and binge-drinking, to full-blown alcohol the Navajo population must also be briefly dependence) the terms "alcohol dependence or described. This includes the current theories of abuse", "alcohol-use disorders", "alcohol-use the etiology of excessive drinking, the problems", "problem-drinking",and "excessive- relationship of stress to problem drinking, and drinking" will be used instead of the term the application of alphdtheta neurofeedback "alcoholism.'I training to treatment. A discription of the study's purpose, the assessment methods used, Literature Review the outcome results with their inherent The Problem of Assessing Treatment Outcomes limitations, and a discussion will follow. Because of the vast range of physiological, psychological, sociological, and The Definition of Problem-Drinking cultural differences among populations, and Because of the widely varying meanings even between people within a racially and of the word "alcoholic" and ''alcoholism'', the culturally homogeneous population, Diagnostic and Statistical Manual of Mental understanding of the dynamics of excessive

FalWinter 1997 25 Journal of Neurotherapy drinking remains both complex and understood unless there is a fill understanding controversial. In addition, because of the of the client's original predictive variables necessarily multifaceted nature of treatment (Lettieri, 1992). Others suggested that the programs) and due to the inherent difficulty in analysis of specific relapse rates is too both the definition of successful treatment and simplistic and does not place the problem in an in the non-invasive assessment of treatment appropriate perspective (Moos, Finney, & outcome, the meaningful evaluation of Cronkhite, 1990). Furthermore, these authors treatment efficacy is difficult. Understanding suggest that "treatment" is only one of the these dynamics in the various Native American many factors that contribute to successful societies is even more challenging due to the outcome. For example, it is possible to identify strong persistence of inaccurate cultural environments so suppressive they would generalizations, the inherent difficulties of eventually encourage even a normally happy, accurate cross-cultural investigations, as well highly productive, and neurologically "resilient" as the frequent biases, polarizations, and person into a pattern of excessive drinking. The prejudices common within many treatment, criteria for success must always be relative to administrative, and scientific communities the individual's problem and conflict (IOM, (Heath, 1983). 1990).

To understand the impact of treatment Patterson, Sobeli, & Sobell (1977) upon a problem drinker's experience it is first suggested that the most appropriate evaluative important to understand both the reliability of question to ask when assessing treatment outcome data, and then the etiological context success might be "what kinds of individuals, in which the chinking problems occur. Thombs with what kind of alcohol problems) are likely (1994) and the Institute of Medicine (1990) to respond to what kinds of treatments, by both pointed out that, in spite of considerable achieving what kinds of goals, when delivered effort, there has been remarkably little success by which kinds of practitioners" (p.143). in assessing the outcome of alcohol treatment. They stated that, in most cases, the relapse Some of the other challenges of accurate rates of treatment facilities are significantly treatment evaluation are the desire to respect higher than what is publicly presented. This the client's private world and the frequent, public over-statement is ofken due to the lack of non-reliability of the client's self-report. One research resources, the inevitable variation of study concluded, after attempting to verify self- treatment quality from group to group, weak reports with collateral interviews and blood research methods, and the facility's both and urine testing, that only 65% of those people unconscious and conscious vested-interest in reporting total abstinence were truthful about presenting positive results. their drinking habits (Fuller, Lee, & Gordis, 1988). In another study using collateral Several other researchers suggested information to cross-check the client's self- that outcome investigation is as complex as report, about 50% of the cross-verifications did both the phenomenon of alcohol-use disorders not correspond to self-report (Watson, and the individuals involved (Sanchez-Craig, Tilleskjor, Hoodecheck-Schow, Pucel, & Jacobs, 1986). Thombs (1994) also maintained that 1984). relapse rates should be only analyzed by taking into account specific client characteristics such To make such analysis even more as individual pathology, amount of aftercare complex, success is defined in different ways by support, motivation, and the clients' original various facilities. Some treatment facilities drinking characteristics. The National Institute describe "abstinence" as 'In0 drinking at all" of Alcohol Abuse and Alcoholism stated that while other facilities expand the definition of outcome data cannot be functionally abstinence to include clients who might have

FalVWinter 1997 26 Journal of Neurotherapy had major slips but who stayed relatively problems). Based on this experience they healthy and out of trouble (IOM, 1990). claimed that the currently popular theory that alcohol dependence and abuse is a genetically Relapse statistics can also be skewed by dependent, progressive disease has not been other variables. Many studies wrongly observed within this population. eliminated clients who were difficult to contact, or clients who have what they called "unstable" Surprisingly, the Institute of Medicine situations such as being unmarried, or those study (1990) also concluded that treatment can who are non-compliant (Wallace, 1990). actually encourage some types of people to drink more. They also reported that a The wide variation of outcome results significant number (more than 25%) of people reported in the literature reflect the complex stop (or modify) their drinking without formal range of assessment standards, assessment treatment. These researchers also suggested protocols, treatment qualities, population that there are no clear predictors to identify differences, etc., which continue to frustrate which people will respond, and which will not. . researchers. Most of these studies make little After studying over 250 outcome studies (60 mention of either their assessment protocol or included random assignment), they their relapse criteria. For example, even the summarized the findings: (a) no single DSM-ZV stated that 65% of all %ighly treatment is effective for all people; (b) a functioning" treatment participants become specific and appropriate treatment modality for abstinent for at least one year (American a certain person can significantly improve Psychiatric Association, 1994, p.202). outcome; (c) brief interventions can sometimes Definitions of %ighly functioning" and be very effective; (d) treatment of other life "abstinent" were not offered. problems besides drinking is essential; (e) the quality of available therapeutic skill can In an important note, the DSM-ZV influence outcomes; (0 outcomes are influenced concluded that an estimated 20% or more by an assortment of individual, treatment, and people with alcohol dependence will eventually post-treatment factors; (g) successful outcomes establish their own long-term sobriety even are relative for different people and different without treatment. The successful self- situations. treatment rate (spontaneous abstinence or spontaneous controlled drinking) seems to vary Designing Useful Outcome Assessment according to the age of the person (Fillmore, The Institute of Medicine's (1990) report Hartka, Johnson, Speiglman, & Temple, 1988). on the assessment of alcohol treatment These researchers found that young men from programs suggested that randomized controlled 17-30 years who are chronic problem-drinkers comparisons, although usually preferred, are have a 50-60% chance of self-induced sobriety, not always essential (or practical) for useful women from 17-30 years have a 70% chance, data collection. They stated that quasi- men from 30-60 years have a 30-40% chance, experimental designs, and even individual case women from 30-60 years have a 30% chance, studies, have proven helpful. They also men from 60-80years have a 60-80% chance, suggested that, in spite of their previously and finally, women from 60-80 years have a 50- mentioned shortcoming, self-report 60% chance. Regarding Navajo people assessments are viable methods if done specifically, Kunitz and Levy (19941, in a 25 correctly. They, along with other researchers, year study, found that 80% of their original believe that self-reports are neither inherently chronic use disorder population eventually valid or invalid and that the circumstances stopped drinking when they reached the ages of where such reports are given can either 40-60 years. (Six percent of this original increase or decrease their validity (Lettieri, population, however, died of alcohol-related OFarrell & Maisto, 1987; 1992, Skinner, 1984;

FalVWinter 1997 27 Journal of Neurotherapy Sobell et al., 1987). In his report to the within both the treatment and the medical National Institute on Alcohol Abuse and community (Milam & Ketcham, 1983). Critics, Alcoholism, Lettieri also stated that validity such as Fingarette (1988), Peele (19881, and actually depends on the methodological Alexander (1988), believe that the disease sophistication of the person gathering the data, model best serves the economic and social the personal characteristics of the respondent, interests of those involved in spite of having and the quality of rapport between the little scientific support. Others (Institute of interviewer and respondent. Medicine's Study of Alcohol Abuse and Alcoholism, 1990) suggested that there are In order to increase the validity of a different types and combinations of pre- verbal self-report these authors recommended disposing causes; Some drinkers are that: (a) the client is free of alcohol at sensitive to genetic assessment; (b) the client is medically stable factors; some drinkers are sensitive to with no major health symptoms; (c) the environmental conditions; some drinkers have intenriew is structured and carefilly developed; personality disorders; some drinkers have (d) the client suspects that. his or her psychobiological traits such as impulsivity and statements will be cross verified; (el there is an affinity for risk-taking. good rapport between client and interviewer; (f) the client has followed the aftercare Because the genetic pre-disposition suggestions; (g) the client has no obvious theory is becoming socially popular and is often motivation in distorting facts; (h) the client is over-emphasized, Tombs (1994) pointed out assured that all comments will be confidential; that the findings of the Goodwin, Schulsinger, (i) the interviewer, and related staff, appear Hermansen, Guze, & Winokur (1973) study neutral and nonpunitive; (j) two or more commonly used to support it has been greatly assessment instruments are used. exaggerated over time (Goodwin, 1988). In that study, only 18%percent of the sons of parents In addition, Sobell, Sobell, Leo, & who suffered from alcohol-use disorders Cancilla (1988) suggested that the use of a actually developed drinking problems. In the graphic time-line chart, where the client fills in control group, 5% of the sons of parents the periods and quantities of his or her without a history of alcohol-use disorders drinkinflfe-problem pattern, has been shown developed drinking problems. Several to be both an expressive way to gather data reviewers have suggested this study offers no and appears reliable over time. statistically significant evidence on the genetic predisposition of alcohol-use disorders, and has Problem-Drinking Within All Populations even less clinical applicability (Lester, 1988; The causes of excessive-drinking have Murray, Clifford, & Gurling, 1983). Tombs also been hotly debated throughout history. Alcohol pointed out that the frequently cited twin related disorders have been looked at as a studies (Health, Jardine, & Martin, 1989; character weakness, a disease, a maladaptive Kaigi, 1960; Kaprio et al., 1987; Kendler, behavior pattern, and a coping mechanism. Health, Neale, Kessler, & Eaves, 1992; McGue, While each theory has its advantages and Picken, & Svikis, 1992) actually illustrated a disadvantages, in this study, problem-drinking complex inter-related "loading" relationship is viewed as complex and variable phenomenon between genetics, environment, age, sex, and of inter-dynamic pharmacological, biological, social factors, the exact nature of which psychological, social, and environmental remains unclear. Other researchers believe factors (Thombs, 1994). that they have actually located a "tendency" gene (DRD2A) which appears to be ethnically The disease theory of alcohol-use loaded (Blum, 1991). At the very least, because disorders remains the most popular model behavioral traits are usually influenced by

FalWinter 1997 28 Journal of Neurotherapy more than one gene and are usually integrated and internal mental restlessness (Walters, with environmental factors, the clinical 1992). It is also relevant that alcohol applications of this evidence remains limited. temporarily stimulates a rise in both alpha brain wave coherence and EEG amplitudes (part of the subjective warmth and Tombs (1994) also reviewed several neurological-quieting felt during studies which suggested that people suffering intoxication)(Pollock, Volavka, Goodwin, from alcohol dependence (and their relatives) Mednick, Gabrielli, Knop, & Schulsinger, tend to metabolize alcohol in a more- 1983). In this model, drinking oRen becomes a pathological way (Fringarette, 1988). People sort of self-normalization, or self-medication, suffering from problemrinking often appeared for a person who wants to disengage from to have higher levels of acetaldehyde (the uncomfortable thoughts. metabolized by-product of alcohol) than others. This was thought to correspond with an When scrutinized, many other increased tolerance for alcohol and may be established assumptions also begin to weaken. what stimulates physical dependency For example, Tombs -(1994) criticized the (Schuckit, 1984). Others believe that this popular notion that alcohol biologically or research is inconclusive due to the difficulties chemically %hox-t-circuits" the problem in accurately measuring acetaldehyde and in drinkei's ability to control his or her establishing a casual or consequential consumption after the first drink. Although this relationship (Institute of Medicine, 1987; apparent "loss of control" is a common Lester, 1988). experience among many abusers, more than 60 laboratory experiments have shown that Other physiological differences have problem drinkers can control their intake if the been noted. Tombs stated that the reduced perceived costs and benefits of controlled amplitude P3 brain wave deficit seen by drinking are sufficient (Pattison, Sobell, & Begleiter, Porjesz, Bihari, & Kissin (1985) in Sobell, 1977). It now appears that the the non-drinking sons of alcoholics was not frequency and quantity of drinking among seen by Polich and Bloom's (1988) matching problem drinkers is not determined solely by study. Even if this slow cortical response endogenous mechanisms. This does not deny, "signature" eventually becomes established, however, that many drinkers find alcohol just what significance it might have in a neurologically intense, addictive, and clinical or applied situation remains unknown. overwhelming. (It is assumed here that by using the word "alcoholic" the authors mean someone suffering Although individuals naturally differ in from alcohol dependence.) their metabolic dispositions, the negative grip of alcohol can also be complicated by diabetes, Other researchers have shown that poor nutrition, head injury, stress levels, health alcoholdependent persons (as well as the non- factors, and expectations. These conditions, drinking sons of alcohol-dependent persons) themselves, can stimulate the cravings for both generally have a lower level of brain wave calories and liquid. For example, stress- synchrony and a lower level of overall alpha triggered, blood-based Beta endorphins often brain wave amplitude than non-alcohol stimulate the desire for calories (Baile, dependent persons (Volavka, Pollock, Gabrielli, McLaughlin, Della-Fera, 1986; Naber, & Mednick, 1985).(These authors use the word Bullinger, Aahn, 1981; Riley, Zellner, Duncan, "alcoholic" as determined by unspecified Dutch 1986). In turn, the physiological craving for standards.) Although often slight, this calories is often linked with the desire to drink abnormal neurological signature may alcohol (Kulkosky, 1985). contribute to a feeling of depression, emptiness,

FalVWinter 1997 29 Journal of Neurotherapy Blum's (1991) Reward Deficiency lack of energy; (h)poor nutrition; (i) metabolic, Syndrome model (RDS) emphasizes the hormonal, and neurological factors; (j) complex integration between enjoyment, entertainment, and taste neurophysiology/psychology/environmenuand appreciation; (k) lack of awareness of a genetic design. He suggests that drinking is problem; (1) dependence upon external loci of largely an effort to medicate the neurologically control; (m) little perceived vested interest in based "Feel Good Response" (FGR). the outcome of drinking; (n) time-out, or reward taking; (0) punishing others or self- Tombs (1994) also pointed out that the punishment (Institute of Medicine, 1987). concept of alcohol dependence as an inevitably progressive and chronically persistent disease In addition, several researchers have is not supported by the empirical data. pointed out that most substance abusers are Although such progressive destruction does seeking better moods, thoughts, and behaviors frequently happen, a larger population of by pursuing an "altered state of consciousness" problem drinkers are able to drink excessively typical of their preference; they want to feel . and chronically with few physical problems.. better (or different), if even for a short time These "more fortunate" drinkers never report (McPeake, Kennedy, & Gordon, 1991). This for treatment and often "mature out" of these apparent internal drive for the behaviors on their own (Fillmore & Midanik, neurophysiological and mood changes was well 1984; Fillmore, 1987a; Fillmore 198713; Peele, expressed by Weil (1972). He theorized that 1985). many people have a natural and originally healthy urge to occasionally modify or shift Other assumptions are challenged by their consciousess; e.g., when a child the research. Controlled drinking, for example, intentionally spins until dizzy or when a singer can become a naturally comfortable position for or "devotee" sings, chants, or prays until many once-problematic drinkers (Heather & entering an altered state. This Robertson, 1981; Marion & Coleman, 1990; neuropsychological urge is also often interpeted Miller, 1982; Kunitz & Levy, 1994). To better as a "spiritual" craving. These researchers illustrate this point, Sobell & Sobell (1976) believe that the use of mood altering presented evidence, much to the dismay of substances is often an attempt to fulfil this many people in the treatment field, that inherient and significant need. controlled drinking may produce better R. Daw (personal communication, June outcome results that abstinence-oriented 14, 1995), the Director of Na'Nizhoozhi (a treatments for a large percentage of people. "safe-place" detox center in Gallup, New Mexico which accepts an average of 1,800 intoxicated In summary, problem drinking involves people per month), summarizes what he sees as a complex continuum of biological, behavioral, the cause of repeated relapse; "Most of the social, and environmental forces (Institute of "chronics" see no other option at the moment Medicine, 1990). Some of the possible, but to get drunk." interacting and contributing factors of excessive-drinking include: (a) high levels of The psycho/sociaVphysiological benefits of alcohol unemployment; (b) low levels of education and On a more positive side, alcohol been career opportunity; (c) repressive economic described as a sometimes beneficial medicine to conditions; (d) the self-treatment of depression, both individuals and society (Horton, 1943). hopelessness, frustration, feeling of Other authors have proposed that drinking is inadequacy, and low self-esteem; (e) an escape a form of taking "time-out" from a culture's function; (f) cultural and social pressure or behavioral expectations and can actually serve modeling, sharing, reward, social status, risk- as an important stabilizing factor for both taking and daring; (g) high stress levels or a individuals and communities (MacAndrew &

FalWinter 1997 30 Journal of Neurotherapy Edgerton, 1969). One Navajo client, for a physical stressor such a tension or pain. example, after surviving intense childhood From another point-of-view, Cowan (1994) trauma, foreign war, and numerious family suggested that alcohol does not actually make crises, stated that alcohol had kept his soul people feel good, but produces a "negative intact over the years. When questioned about euphoria" which tends to make drinkers forget his developing liver disease and long arrest that record, he shrugged, "It's better than the they feel bad. To both the casual drinker and bullet." In his case, although admittedly the problem drinker, alcohol can initially act as destructive, he felt that alcohol allowed him to an effective, stress reducing, mood-enhancing continue functioning within the society, at least medicine (stimulating the FGR). on some level. ("It's better to have a bottle in front of me that to have a frontal lobotomy.") In The Relationship Between Stress and many social situations, the use of alcohol is also Problem-drinking an important, culturally-accepted form of "Stress" refers any complex of stimulus bonding, relaxation, and reward. that disturbs or interferes with the normal physiological (or pychophysiological) Several researchers (Blum & equilibrium of an organism (Schwartz, 1987). Tractenberg, 1988) have identified brain Ninety-three percent of a group of 2,300 people receptor sites which may respond to potential suffering from problemdrinking stated that metabolic products of alcohol. They believe that they drank in order to relax or to avoid feeling the "craving" which excessive drinkers often "stressed" (Stockwell, 1985). The majority of develop may be related to a deficiency of non-problem social drinkers expressed the naturally-occurring opiate-like same motivation, including a desire to escape neurotransmitters . This neurological anxiety, depression, frustration, fear, and deficiency may be caused by a combination of several other negative emotional states genetic and chronic stress conditions (the RDS (Brown, 1985; Conger, 1956; Masserman, model). This deficiency may, of course, become Jacques, & Nicholson, 1945; Wanberg, 1969). exacerbated by the extended use. Although this stress-related factor is almost universally acknowledged by drinkers, Tombs Alcohol also temporarily stimulates (1992) pointed out that the medical community alpha brain wave coherence (Pollock, Volavka, is largely resistant to the idea that people Goodwin, Mednick, Gabrielli, Knop, & drink in an attempt to relieve stress. Schulsinger 19831, improves peripheral blood Apparently the simplistic "tension reduction flow, decreases respiration rates, and relaxes hypothesis'' (TRH) does not fit the commonly muscles tension. This pleasant and reinforcing held medical disease model. Several more experience is common to a large (but not all) recent researchers have concluded that the percentage of consumers. most careful empirical studies support the TRH model (Cappell & Greeley, 1987; Langenbucher Accordingly, the widespread popular & Nathan, 1990; Powers & Kutash, 1985). notion that alcohol is a depressant is often This statement is usually qualified with the misunderstood. Although alcohol is indeed a addition that alcohol's effect upon stress relief CNS depressant, many problem and non- is complex; it can depend upon the user's problem drinkers paradoxically feel highly expectations, the dosage used, the individual's stimulated, more social, and even energized metabolism, behavior, values, and perception of when drinking. In many mildly intoxicated their own life-stressors. Blum's (1994) individuals, hand-eye coordination, reflex time, integrated theory of the Reward Deficiency and certain abilities may even temporarily Syndrome (RDS) and Feel Good Response increase especially if such performance had (FGR)presents a more neurologically-oiiented been previously limited by mental inhibition or model of this stress-integrated complex. In

FalWinter 1997 31 Journal of Neurotherapy Blum's theory, drinking becomes an attempt to harsher, as well as appearing to have a lower self-medicate an uncomfortable neurological tolerance threshold or a higher sensitivity, deficit caused by the interaction of than do non-drinkers. genetidcultural/ environmental factors. Stress Reduction as Treatment Technique Ironically, high amounts of alcohol can The value of a significant stress actually exacerbate both short term and long reduction program within a treatment regime term physiological stress in spite of the has been controversial. In this review, a stress drinker's intention, subjective experience, or reduction technique must necessarily and belief. It is also worthy to note that, although significantly increase the parasympathetic stress provides a common motivation to drink, activity of the autonomic nervous system. In many people cope just as well, or better, other words, it must cause measurable, restful, without drinking. This implies that stress healthy, and enjoyable changes in both alone, although significant, is only one of the physiology and neurology (Andreassi, 1989). components o€ excessive-drinking (Johnson & Pandina, 1993). A major problem .when evaluating the efficacy of stress reduction on sobriety is the Mail (1992) also stated that alcohol difficulty in first assessing the quality and eventually exacerbates both a physiological impact of the learned stress-relieving skills. In and emotional stress condition, especially when other words, to what degree did the relaxation, used excessively. Mail went on to say that or stress management training, actually when alcohol is consumed under stressful produce relaxation or physiological value, and conditions, its euphoric properties tend to how often was it maintained? Shellenberger become reinforced. Eventually larger quantities and Green (1986) point out that many such can be consumed with less obvious intoxication. self-regulation-type studies have often failed Excessive use, in spite of the drinker's belief because researchers commonly attempt to use and experience that alcohol makes him or her complex learning skills as if they were a form of feel momentarily better, actually raises stress- external medical treatment, rather than skills related blood cortisols, contributes to which must be internally mastered before immuneosupression, raises blood pressure and producing significant results. When the desired heart rate, and increases the risk of heart, outcome does not appear, these researchers cancer, and liver failure (Gibbons, 1992; Pens question the "medication's effect" rather than & Cunningham, 1986). questioning whether the skill was actually learned and applied to a specifically recognized In spite of this paradox, stress is the level (e.g., trained to a measurable criteron). A most frequently cited cause of relapse (Brown, related challenge involves the effective Vik, Peter, McQuaid, Patterson, Irwin, & "dosaget' of any stress technique. Unlike an Grant, 1990; Hunter & Salmone, 1986; inoculation or surgical procedure, any form of Milkman, Weiner, & Sunderwith, 1984; stress or self-regulation practice training will, Marlatt & Gordon, 1979). Tombs (1992) at best, only improve the probability of categorized stress-related relapse into four resilience and recovery. For example, a 20 types: (a)intrapersonal negative emotional minute practice of relaxation may significantly states (37%); tb) social pressure (24%); (c) impact one person but may have little effect on interpersonal conflict (15%); (d) other reasons another person who tries to cope within a more for drinking (24%). Some of the stress-related extreme environment; or may not effect one problems are, in themselves, directly related to whose psychophysiological makeup does not the consequences of excessive-drinking. These respond to the offered technique for various same authors concluded that relapsers tend to reasons. evaluate negative life situations as being

FalWinter 1997 32 Journal of Neurotherapy In several outcome studies researchers VA hospital residential treatment programs, have found that stress reducing techniques are were of low and middle economic backgrounds, effective in promoting sobriety (Miller & and were of European, Hispanic, and Afro- Hesster, 1986; Rohsenow, Smith, & Johnson, American decent. Peniston reported that these 1985; Rosenberg, 1979). In other cases, participants showed significant improvement relaxation training had little overall effect on from pre-training to post-training MMPI sobriety (Miller & Tayor, 1980; Miller, Taylor, personality scales (including hypochondriasis, & West, 1980; Sisson, 1981). Two studies, depression, hysterical, psychopathic deviate, however, showed a correlation between the paranoia, and pasychasthenia). They also practice of TM meditation and a reduction of experienced a decrease in stress-related, blood- general substance abuse (Aron & Aron, 1980, based Beta endorphins. In several cases, these 1983). The EEG modifying correlates of such clients did attempt a few drinking bouts meditation techniques have been extensively without success. Quite significantly, when they studied Murphy & Donovan (1988). did drink, they reported a "more appropriate" physiological reaction to excessive alcohol, In an attempt to address the complaining of low tderance, unusual relationship between stress and drinking hangovers and even an allergic-like reaction. problems of specific groups worldwide, Apparently, these "experimenters" eventually McIGrman and Peterson (1988) proposed a stopped trying to drink. A three year follow-up "stress vulnerability theory." They suggested indicated that these results remained stable. that a general pattern of sociocultural stressors This data was independentlycorroborated with can induce substance abuse problems among a second series of participant interviews by the people who: (a) are discriminated against Menninger Foundation (Walters, 1992). socially and economically; (b) are experiencing chronic employment difficulties;(c) fear verbal In a similar study completed by the or behavioral harassment; (d) develop a University of North Texas, 16 clients with complex of mild depression, low-self-esteem, chemical dependence were trained in a similar alienation, and trait anxiety. Again, these neurofeedback protocol against a controlled and ideas are compatible with the RDS and the matched group. Twenty-four months later, 77% FGR model (Blum, 1994). were reported near-abstinent and 23% were reported to have significantly improved their Peniston's AlphafTheta Neurofeedback Training as an behavior patterns (Bodenhamer-Davis & New Component deBeus, 1995). The controlled groups showed In Peniston's (1989) controlled, no significant improvement. In another recent neurofeedback study, ten clients who were experiment, this time within the Kansas state suffering from chronic alcohol dependence and prison system, 39 chemically dependent felons, chronic treatment relapses were trained in who were trained in neurofeedback, showed alphdtheta neurofeedback. These participants significant improvement after an extended were taught to intentionally increase the period of freedom over a matched "state-of-the- amplitude and coherence of their transient art" traditional treatment group (Fahrion, alphdtheta brainwaves in their occipital lobes 1995). with the use of a a specially designed EEG feedback devise. Eight of these remained Several researchers (Ochs, 1992; generally abstinent at least three years after Peniston, 1994; Walters, 1990) suggested that treatment. The specific criteria used in this the most active (and apparently ''abstinent'' classification is unknown. Each of transformational) properties of neurofeedback the clients experienced approximately 40 30- training may involve teaching the participants minute alphdtheta brain wave training to intentionally increase the amplitude and sessions. These clients had all failed previous coherent interaction of both their alpha and

FalWinter I997 33 Journal of Neurotherapy theta brain wave frequencies in either the a superficial level. He suggested that, without occipital or the central brain locations. Fahrion improving an addict's neurophysiology, (1995) also stated that this apparent treatment is often fruitless or incomplete. This neurological "normalization" is responsible for criticism is easily illustrated by the highly shifting the trained client into a physical state motivated addict who is left with a "white of comfortable sobriety. Fahrion suggested that knuckle" version of sobriety often involving when chemically dependent persons are sober depression and tension. Many clients, for they often have a neurologically-based inability example, leave treatment facilities with higher to experience pleasant feelings from simple measurable stress levels than their pre- stimulation. Blum (1995) concurred with these treatment condition (IOM,1990, Peniston & ideas and suggested that neurofeedback Kulkosky, 1989) yet few treatment programs training may be triggering a neurological- effectively address this stressor-neurological normalizing shift, as explained by his RDS complex. Those which do, seldom have time for model of the endless quest for neurotransmitter more than a few, relatively insignificant balance. mental or physical exercises.

With a different but not necessarily Problem-Drinking Among the Navajo People contradictory emphasis, Cowan (1993) Although this study specifically involves suggested that the apparent effectiveness of Navajo people, problem-drinking is a human such training may be due more to the enhanced problem which crosses many cultural and all imprinting of positive sobriety suggestions and racial boundaries. Special care must be taken the feeling of inner empowerment which the to avoid assuming that the drinking dynamics alphdtheta state seems to encourage. of the Navajo people are necessarily different McPeake, Kennedy, and Gordon (1991) from, or the same as, the general U.S. suggested that self-induced altered-states such population or other Native American tribes. as those found in various forms of meditation Rebach (1988) warned that the literature on can sometimes replace the self-destructive substance abuse among minorities is often pursuit of alcohol induced "highs." limited, imprecise, and incorrectly generalized. It is also important to realize that there are In another opinion, Rosenfield (1992) significant environmental, social, and cultural questioned whether there would be any differences among tribes, and that there is no difference between Peniston's neurofeedback standard Native American response to alcohol protocol, general relaxation, and hypnotic (Watts & Lewis, 1988). suggestion. Others suggest that the same results can be accomplished with meditation Within the Navajo Nation, problem- procedures alone (Taub, Steiner, Smith, drinking, and the alcohol related problems of Weingarten, & Walton, 1994). increased disease, poor nutrition, violence, and automobile accidents, is the leading cause of In an article reviewing Penniston's mortality (May, 1992). Alcohol-related deaths (1991) neurofeedback study, Erickson (1989) among &lU.S. tribes nationally account for a suggested that effective treatment for disproportionate 16.7%of & Native American substance abuse will always require a deaths. This can be compared with 7.7% combined physiological and psychological alcohol-related deaths in the overall US. approach. He criticized clinicians for frequently population. In spite of this statistic, however, ignoring the more complex, underlying, May (1992) pointed out that fewer Navajos physiological and environmental mechanisms. actually drink (52%)than do members of the For example, few treatment programs address general U.S. population (67%). (Note: this is a the neurophysiological issues of addiction (such Navajo specific statistic and may, or may not, as depression and neurometabolism) except on be typical of other tribes.) Of six studies in the

Fall/Winter 1997 34 Journal of Neurotherapy literature, May also cited three studies which attention. For example, a large percentage of indicated that the average Native American alcohol related deaths in the Navajo consumer drinks less than the average US. environment are due to cold weather exposure. non-native consumer. He found one study In comparison, for example, several rural, non- which showed that Native Americans consume native counties in the Southwest have almost the same amount of alcohol as non-natives, and identical alcohol-related deathlinjury statistics two studies which found that Native Americans (May, 1992). have a slightly higher drinking level. May did not make a distinction between tribal groups in May (1992) also pointed out that Native this assessment. It is also important to American substance abuse, magnified by the recognize that the majority of Native American limited economic and environmental-logistical drinkers, like most non-native people, enjoy context, places a disproportionate strain on the alcohol socially without problems (Mail, 1992). already limited reservation-based medical, Gregory (1992) also stated that although social, and criminal systems. For example, a alcohol-related problems are indeed serious, the mildly injured Navajo problem-drinker is more prevalence of Native American drinking is likely to become a mortality statistic because commonly exaggerated. Mail also reported that his or her accident occwed many hours from a many Native American communities have hospital. Additionally, if this person does reduced this trend significantly. As an manage to get treatment, the hospital may be illustration, unlike at most popular U.S. illequipped and understaffed. events, the majority of Navajo meetings, ceremonies, dances, rodeos, and public events Navajo-specific causes of problem-drinking are alcohol free. In towns within the Navajo It is a common idea among both non- Nation there is little evidence of public Native American and Native American people intoxication (personal observation). At the that "Indians" have both a genetic metabolism Gallup National Indian Pow Wow in 1991, of and cultural heritage which pre-disposes them several thousand celebrating Navajo people, to substance-use-disorders (Levy, 1992; May, the only people publicly drinking were German 1992). Milam & Ketcham (1983), for example, tourists. This does not mean that excessive- stated that a significant percentage of Native drinking does not occur privately, but does Americans lack the metabolic, hormonal, and illustrate the recent change in public values. neurological factors which permits the smooth metabolization of alcohol. In strong objection, In spite of this improvement, a however, May (1992) and others (Beauvais, disproportionate percentage of Native 1992; Dorpat, 1992; Fleming, 1992; Gregory, Americans who do consume alcohol still 1992; Heath, 1992; Peters, 1992; Wolf, 1992) experiencedrinkingrelated problems. Although argued that, although there are some unique statistics are often skewed by the extremely and specific differences, in general, Native high rates of some smaller, urban-surrounded Americans react to alcohol much like other tribes, May believed the Southwest Native people. American population experiences a 18.4% mortality from alcohol-related deaths. This can In an attempt to lessen the importance be compared to a 7.7% of the overall US. of racial predisposition towards alcohol abuse, population. He attributed the higher mortality May listed five studies which show that Native ratios (in spite of the apparently near-similar Americans metabolize alcohol as (or even more) drinking prevalence percentage) to a rapidly than non-native people (Bennion & Li, combination of social and cultural factors 1976; Farris & Jones, 1978; Reed, Kalant, magnified by the environmental situation of Griffins, Kapur, & Rankin, 1976; Schaefer, extreme poverty, poor nutrition, and the long 1981; Zeiner, Perrez, & Cowden, 1976). distance and low availability of medical Additionally, two biopsy studies concluded that

Falwinter 1997 35 Journal of Neurotherapy the livers of -Native Americans and Western relationship between blackouts and genetics Europeans were similar in both structure and again remains unclear. phenotype (Bennion & Li, 1976; Rex, Bosion, Smialek & Li, 1985). May and others (Bennion Mail (1989) suggested that American & Li, 1976;Leiber, 1972) found only one study Natives, along with many other suppressed which indicted that Native Americans might peoples, suffer disproportionately from both have a slower alcohol-processing metabolism "acculturationt' and 'ldeculturationll stresses but they all believed this study was (e.g., the combined demands to integrate with significantly flawed (Fenna, Mix, Schaefer, & the dominant culture and the loss and Gilbert, 1971). devaluation of their own historical traditions and economic standing). In such cases, alcohol It is true, however, that certain racial appears to help cope with feelings of groups, such as the Japanese and some specific inadequacy during periods of rapid personal, Native American groups, sometimes experience cultural or social trauma (Rotman, 1969; an unpleasant "flushing'' sensation when Savard, 1968;Topper, 1974). Other researchers drinking alcohol, . an experience that is stated that 200-500 years of physical uncommon among Western Europeans. Some suppression, domination, depopulation, and researchers speculated that this sensation is relocation of Native American populations have caused by the slower metabolic processing of produck a generalized cultural trauma which ethanol due to an enzyme deficiency (Okada & would naturally lead many into excessive- Mizoi, 1982). Although, Japan now consumes drinking (Ackerman, 1971; Berreman, 1964). more alcohol per capita than any other nation This situation then becomes magnified by (and much of .it during excessive-drinking environmental stresses such as limited "bouts"),the relationship between this flushing resources, barren land, and harsh weather. phenomenon and excessive-drinkmg remains These stressors can tumble even further out of unclear (Gibbons, 1992). This correlation control when additionally fanned by the became even more confused when Japanese resulting negative-feedback cycle of anger, researchers reported that their alcohol rebellion, family breakdown, hopelessness, and dependence rate is less than 3%. Western substance abuse (Norick, 1970). It is very likely observers believe, however, that the actual that this chronic trauma eventually will impact hidden prevalence of Japanese drinking the neurotransmitters (as postulated in the problems is much higher. Some researchers are RDS model). predicting that problems in Japan will become more apparent as time goes on (Saitoh, May (1992) and Reed (1985) both Steinglass, & Schuckit, 1989). warned that although alcohol consumption, metabolism, and the negative consequences of Wolf (1992) observed that Alaskan alcohol dependence and alcohol abuse can differ Natives are much more likely to experience among ethnic (tribal), social, and "black-out"periods of unconsciousness during environmental groups, there is often a great periods of heavy drinking than the average variation within the same group. May, and U.S. non-native population. May (1992) others, concluded that the etiological complex maintained, however, that the ethnic which contributes the most to substance abuse differences between people are not as lies within the social, culture, and significant as the differences of individual environmental realm (including subcultures) of metabolism, diet, body weight, drinking their communities, and the social structures of history, state of health, speed of consumption, the surrounding regions (Bach 8z Borstein, intention, context, and history of head trauma. 1981; Bennion & Li, 1976;Dozier, 1966;Kunitz Because many Alaskan Natives suffer & Levy, 1994). disporportionally from these conditions, the

FalVWinter 1997 36 Journal of Neurotherapy A historical perspective is also helpful. dependency (Kelley, 1992). It is unknown The heavy use of alcohol among Southwest whether the mean EEG baselines of non- tribes was often encouraged and manipulated drinking Navajo people tend to be different by the US. Army, was intentionally from the non-native US.population norms. perpetuated by many missionaries and traders, and is still actively and aggressively The Cultural Components of Excessive-drinking encouraged by the liquor industry (Levy & The often traumatic dissonance between Kunitz, 1975): As an example, several New the Navajo cultural and the dominant, non- Mexico legislators implied that they would not native U.S. culture significantly contributes to vote for an increase in liquor tax (which would the disproportionate ratio of drinking problems have been applied to better treatment to the amount of alcohol actually consumed, to programs), or vote for restrictions on liquor the low number of Navajo problem-drinkers advertisements, because the liquor industry who seek treatment, and to the lack of was their primary source of election treatment success among those Navajo people contributions and represented a substantial who do enter treatment (Christmas, 1978). part of the state's economy (personal Anthropologistshave identified some social and communication). "he alcohol industry is a cultural factors which may pre-dispose the significant and integral part of today's US. Navajo society to this pattern. MacAndre and society, especially in reservation border-towns. Edger& (1969) suggested that societies often "get" the type of behavior which they allow. Additionally, the majority of non-native Some of these identified, possibly pre-disposing, government leaders still believe that drinking Navajo social characteristics are as follows: (a) problems are triggered more by character a nomadic-warrior individuality placed within weakness than by social factors. They continue a now-sedentary matrilineal society which to believe that a solution simply demands more increases male-role frustration and the quest self-responsibility, discipline, and education; for personal independence (Waddel & Everette, and that it's solution does not require 1975); 03) a history of psychoactive plant usage legislative protection (personal observation). (peyote and other herbs) to induce spiritual power, dreaming, visions, and spiritual contact; Differences in Drinking Dynamics (c) the lack of recent historical self- Some behavioral aspects of average determination, and externally imposed control Navajo consumers differ from those of average (Hurlburt, Gade, & Fuqua, 1983); (d) peer non-native drinkers. For example, many conditioning from childhood to consume both Navajo problem-drinkers tend to "binge drink" rapidly, excessively, and extensively when (or drink rapidly) in contrast to the more drinking; (e) aberrant role models from early, typical urban problem-drinker's tendency to non-native contact; (0higher rates of tough- drink steadily throughout the day (Heath, mindedness, introversion, and emotionality 1983). Binge drinking is common among social than non-native US norms as scored on the groups who are temporarily removed from Eysenck Personality Inventory corrected for more stable, domestic situations. The rapid, cultural differences (Hurlburt, Gade, & Fuqua); excessive-drinking habits of some college (g) little, or no, "stake" in either the dominant students and young soldiers commonly society or the outcome of their drinking illustrate this phenomenon. problems (Levy & Kunitz, 1975).

It was also found that the EEG The Success of Navajo Specific Treatment baselines of most Navajo's suffering from Because most treatment programs for drinking problems were not alpha deficient, Native Americans are largely based upon the contrary to the literature suggesting a values and strategies of the dominant urban predisposing EEG signature for alcohol culture, both the rates of treatment

FalWinter 1997 37 Journal of Neurotherapy participation and successful treatment Methods outcomes for Native Americans are even lower Participants than the reported rates for non-Native Nineteen clients (16 men and 3 women) Americans (Kivlahan, 1985). The current with a history of alcohol abuse or dependence Navajo treatment programs typically involve were trained in alphdtheta neurofeedback "disease model" education, general behavioral during a nine month period ending January and employment counseling, psychotherapy, 1992 (Kelley, 1992). The intensity of their the Christian-oriented twelve-step-program, alcohol-related problems varied, ranging from limited medial attention, and various forms of occasional binge-drinking to childhood alcohol family support. The current rate of success dependence. In spite of this range, 74% (14) of among Navajo-oriented treatment centers is these participants met the DSM-ZV criteria for currently considered to be low (personal alcohol dependence and the additional 26% (5) discussions with Navajo Nation Department of met the criteria for alcohol abuse. Fifteen of the Behavioral Health and RHCH-BHS, 1991 - participants were ordered into treatment by a 1995). court judgment. Clients ranged from 20 to 56 . Improving the Effectiveness of a Navajo-Oriented years old during their initial training and came Treatment Program fiom low income backgrounds. Only a few were In designing a more effective treatment educated beyond a high school level. for Navajo people, several anthropologists suggested that programs must utilize The study participants were chosen by traditional Navajo cultural techniques, the facility nurses. Although the selection traditional settings, and traditional self- process was originally intended ta be empowerment programs (French, 1989; randomized, as the program evolved, the Kavlahan, 1985; Westermeyer, 1988). Besides nurses reported favoring and selecting those addressing the client's specific environmental clients who they felt needed the most help. One and psychological concerns in a culturally participant was selected, for example, because appropriate way, it is very likely that many he began to express excessive anger and traditional Navajo medicine and Native threaten the group. Instead of sending him American Church procedures (such as sweat back to jail, the nurses assigned him to the lodge, "blessing-way", herb-usage, and a wide neurofeedback trial. Although this realistically range of often intense ceremonies) will produce unavoidable selection bias may have skewed significant psychophysiological, neurophysio- the project towards a lower success, it also logiocal, stress-relieving benefits. Currently, increased its immediate value to both the active participation in the Native American treatment facility and the clients. This type of Church is considered to be more effective than a compromised field design is often ethically the standard 12-step treatment or medical essential in clinical settings. treatment protocol (Hill, 1990; Pascarosa, 1976). Christian support, for Christian-oriented Of the 28 clients who were approached, Navajos, has also proven significant. 2 declined participation, 1dropped out because of a conflicting schedule, 1 quit after a few The Primary Research Question sessions, and 1 lefi the residential facility In this study, the following question was against medical advice. Four of these clients investigated: Have the 19 participants trained were not treated but were kept as fully in alphdtheta neurofeedback applied assessed neurological baseline controls, e.g. adjunctively within their residential substance their EEG baselines were recorded but they abuse treatment program, shown a significant were not trained in neurofeedback. These decrease in both their alcohol drinking habits clients were not contacted in this follow-up. and in related behavioral variables three years Initial Training Apparatus later? During the initial neurofeedback

FalYWinter 1997 38 Journal of Neurotherapy training period, thoracic and diaphragmatic was also a recognized "singer" medicine man, breath patterns, heart rate and cardiac- provided encouragement, blessings, respiratory sinus arrhythmia patterns, hand purification, and interpretive guidance. In temperature, muscle tension, electrodermal several cases, for example, clients believed skin responses, and end-tidal C02 breath gas their drinking problems were influenced by a were frequently monitored. EEG baseline levels witchcraft-like curse. Although some had were also taken from 19 head sites for both pre unsuccessfully received traditional purification and post treatment measures. A computerized ceremonies before coming to the treatment J&J1-330 biofeedback module and a Lexicor center, having their neurofeedback sessions Neurosearch-24 EEG was used. sanctioned and blessed with a brief traditional feather and sage smoke ceremony gave them Semi-structured interviews and Beck's added assurance. Because many of the clients Depression Inventory were also given as pre were also Christian-oriented, Christian and post measures. terminology would sometimes compliment these therapeutic ideas. For example, the Culturally Sensitive Procedures .imagined image cf Christ inside the client's All biofeedback and neurofeedback body was used to exemplify both personal techniques were adapted into the Navajo power, health, and a safe environment. Such cultural perspective. For example, in order to tools were adjunctively utilized to maximize begin the project in a culturally congruent communication, develop rapport, establish a manner, the written proposal was reviewed safe environment, and to encourage and sanctioned by a "blessing" procedure physiologically-verified shifts. Although these conducted by a recognized Navajo "singer" techniques were frequently employed, they medicine man. The tribal health committee were not over-emphasized or exaggerated. also arranged for a demonstration of the biofeedback equipment at several Navajo A modest attempt was also made with health fairs to observe the public and religious- room decor to suggest a healing environment, leader response. The project proposal e.g., dim lights, protection feathers, a warm eventually received formal approval fkom all of blanket, the scent of sage smoke, Navajo the required tribal agencies including the US. spiritual posters, and wall-hangings. Soft Indian Health Service. Native American music was often played as a quieting-background for those who wanted it. Navajo terminology, metaphors, imagery, and music were used to supplement instruction. For example, the Navajo image of Initially there was concern that a non- breath Cnilche') contains subtle concepts of native therapist of European decent, such as vitality, health, and "holy spirit." By using this the researcher, would be inherently image, with its traditional connotations, end- handicapped as an instructor. This seemed not tidal C02 to be the case. Many clients commented that breath gas balance-training became easy to although they usually felt more comfortable with Navajo people, they felt safer talking instruct. Although breath balance-training is about private and sometimes culturally taboo an important component of neurofeedback, it or awkward subjects (including witchcraft) usually requires a long practice and with the researcher than with a fellow clan instruction. Other concepts such as self-esteem member. Other factors such as an emphatic and self-appreciation were presented by using "foreign authority" were probably also present. Navajo metaphors such as eagles and flute eagle-like recordings. On occasion as needed Neurofeedback Training Protocol during the sessions, a Navajo therapist, who All neurofeedback training was

FalVWinter 1997 39 Journal of Neurotherapy adjunctive to the participant's normal addition of several initial sessions of guided residential treatment regime. The non- imagery-inductions using Navajo oriented neurofeedback program consisted of symbols appropriate to the participant. More educational talks about chemical abuse, rest, biofeedback, guided imagery and therapeutic recreation, bible study and spiritual suggestion were incorporated than the discussions, group therapy, individual standard Peniston approach. The active EEG counseling, AA attendance, and weekly feedback sensor was place on the head at the participation in a "talking circle" and sweat CZ location (top-center) in a monopolar lodge. Those with diabetes and, or, physical configuration with linked ground sensors problems received a limited amount of medical attached to each ear. Two feedback tones, one attention. representing alpha and the other theta, were fed to the participant through enclosed The neurofeedback program was headphones. The researcher's voice was also designed, implemented, and completed by the routed through the headphones. Quality researcher within the Rehobeth-Mckinley headphone produces a significantly more Christian Treatment Center - Behavioral engaging experience. Both feedback activating Health Services (RMCH-BHS) in Gallup, New thresholds were set at 66% of the participant's Mexico. The initial program funding came from highest,resting-baselinealphdtheta amplitude. the Navajo Nation Department of Behavioral This means that the participant would Health, Window Rock, Arizona. Although generally hear the feedback tones at least 33% RMCH-BHS is an private facility, it is the of the time. Because a theta dominant state is primary treatment facility for the Navajo subjectively deeper than an alpha dominate Nation. state, theta awareness (theta tones) were emphasized. A computer video monitor Participants attended two, 1-hour recorded and displayed the EEG data to both training sessions per day, five days per week, client and therapist. After closing their eyes, in addition to their regular residential the participant would initially listen to a 10 treatment schedule. Within their 33 day minute induction involving "full-body" breath residency, participants experienced an average patterns, sobriety, empowerment, and self- of 40 neurofeedback training sessions. healing concepts. Once a significant increase in the alphaltheta EEG frequencies was observed, After the initial evaluation and an the therapist's verbal instructions were educational overview of self-regulation gradually supplanted by the feedback tones. techniques, participants were trained to raise Before the therapist's voice faded out their hand temperature to 96 degrees completely, participants were given a variety of Fahrenheit. A finger temperature of 96 degrees additional instructions such as: (a) "Increase usually requires significant parasympathetic the power of your healing tones by following relaxation. It is more common for a person's the sounds deeper inside"; (b) "As you sink hand temperature to range from 75-92 degrees deeper into your personal power, the tones will Fahrenheit depending upon their level of CNS increase. As the tones increase, they purify and activity (Andreassi, 1989). Because breath gas cleanse your heart and mind." Scripts were ratios directly influence brain waves and states varied according to the preference of each of consciousness, deep diaphragmatic breath individual. patterning combined with EMG muscle relaxation was also taught (Fried, 1987). Each 30 minute period of internal, private neurofeedback practice was followed by The neurofeedback procedures used in a five minute verbally-guided "coming-back" this project generally followed the Peniston period to shift the client into their normal protocol (1989) (see literature review) with the outwardly-directed awareness. During this

FalVWinter 1997 40 Journal of Neurocherapy time further sobriety and empowerment foundation of base-consciousnessor self-idenity. images were suggested. An additional 10-15 It is important to realize that clients is such a minutes were spent debriefing the client and meditative state usually feel protected and cleaning the EEG sensor cream from both the distanced from the abreacted event. The client's hair and the equipment. To prevent majority of small physical movements (such as disorientation (or any lingering spaciness),time foot jerks) and tears are more frequently due to was always talren to mentally engage the client pleasant or neutral sensations, or even before they left the office. emotional appreciation. In tis study, the vast majority of abreactions were allowed to self- The majority of participants reported process through to a pleasant outcome. When that they experienced deep meditative-like necessary, this outcome was encouraged with states during their sessions. This was usually verbal positive imagery or assurance by the verifiable by significant periods of theta therapist, such a telling the client that their dominance on the computer screen. A brain is just re-organizing as well as reminding conscious, inwardly-alert level of awareness the client that they are safe and protected both was usually maintained. although clients in their chair .ad.under the white, warm commonly reported losing awareness of the blanket. There was no attempt to analyze, or to room and even the feedback tones. In a theta facilitate therapeutic regression or the dominated meditative state, although the loss result&g images. In all cases, clients reported of awareness-to-the-outside is typical, a sense feeling safe, comfortable, and protected. Each of "inner awareness" is maintained. This state session concluded by showing the client their can also be characterized by the faint session's trend-over-time EEG graph. awareness of drifting spontaneous images which are more similar to vivid or disassociated During the last few sessions the dreams than they are to active thoughts. majority of participants were given brief Drowsiness, or sleep, (although it can occur) is meditative and self-hypnosis training not neurofeedback therapy and can be easily instructions to use in home practice. Two distinguished with EEG and breath pattern customized, self-hypnosis empowerment audio analysis. It was not uncommon, however, for tapes were given as home-gifts to each some sessions to be subjectively more relaxed participant. An attempt was made to put than others as verified by both the degree of individualized and relevant information on the enjoyable imagery and the level of theta EEG audio tape such as their own name, favorite coherence. Most participants reported periods themes, and children's names. After training, of positive visual subconscious imagery, the released participants were encouraged to pleasant sensations, and a feeling of freshness establish a regular home practice and to attend and clarity after each session. all other regularly recommended supportive functions (such as traditional healings, sweat Abreactions such as unpleasant imagery lodge, church, and AA meeting). of past traumas, quiet crying or tearing, spontaneous regression, and subconscious Semi-Structured Interview movements did occur as typical of deep release The interview protocol consisted of a altered states of consciousness (Spiegel & simplified, verbally administered, hybrid of six Spiegel, 1978) Special attention was given to outcome assessment tools in addition to a creating a positive, pleasant, even sensuous, simplified DSM-ZV Multiaxial Assessment experience for the participant. It is important (American Psychiatric Association, 1994). to realize that even if negative abreactions do Emphasis was placed on life-style outcome occur, the theta-dominant participant tends to variables which may influence excessive- experience his or her thoughts a being subtly drinking (Table 1, p. 45). disassociated from their pleasantly quiet

FalWinter 1997 41 Journal of Neurotherapy For this population, under these often Results awkward field circumstances, a semi- Data Collection and Reliability structured, informal, friendly, slow-moving Because of the transient lifestyle of interview was believed to produce a higher many of these participants, their lack of reliability than a more formalized, structured established residences, their lack of checklist. An attempt was made to make each employment locations, the lack of home interview relatively consistent while still telephones, the large size of the four-comers sensitive to logistical context, rapport, and Navajo Nation, and the justified aversion to Navajo cultural issues. Special efforts were outside "authorities," this three year outcome taken to establish an honest and non- assessment was challenging. Of the initial 21 judgmental dialogue in an attempt to minimize participants, 8 were interviewed face-to face by the self-management of the participant's the author; 5 were personally interviewed over report. This appeared to be largely successful. the telephone; the status of another 6 were confidently established by relatives, friends, and counselors; and 2 could not be located .Participants were questioned about the (Both .were eventlially -located as doing degree and comfort of their sobriety and their relatively well 1 year after the study freedom from both alcohol and drugs. General concluded). In most cases, a significant degree questions were also asked concerning their of collaboration was established by visiting post-treatment life quality, their mood, the each location's aftercare specialists, checking amount of support they have been receiving, their client files when available, checking the and their reflections on their past treatment. regional crises-center database, and talking to local sources such as police, post offices, The interview schedule (See Appendix markets, and neighbors. Each contact was A) contained items condensed from the recorded in written notes. following: (a) Quality-Frequency-Variability Index (Cahalan, Cisin, & Crossely, 1976); (b) The level of confidence in this National Alcohol Program Information System, information for 9 of these participants is rated ATC Client Progress and Follow-up Form "excellent"; enough personal contact was (NIAAA, 1979); (c) Michigan Alcoholism established to fully trust the participant's Screening Test (Selzer, 1971); (d) FIDD Six- response. For 8 of these participants, the month Follow-up Questionnaire (Skoloda, information confidence was rated as "good"; it Alterman, Cornelison, & Gottheil, 1975); (f) is highly likely that the information is accurate Time-Line Follow-Back Assessment Method even though some of the information comes (Sobell, Maisto, Sobell, & Cooper, 1979); (g) from other's opinions. For 2 participants the Addiction Severity Index (McLellan, Luborsky, confidence rating was considered to be "fair"; it O'Brien, and Woody, 1980). The interview also is likely to be accurate but there is not enough contains a modified version of the DSM-ZV collaborative information to be certain due to Multiaxial Assessment. minimal contact. Of the 2 participants who could not be located at all, one man was away Because of the wide range of variables in school and another had moved without affecting each participant, the significant, cost- leaving an address. On the average, eight effective value of this program cannot be hours of field investigation were required for determined by a simple analysis of the rate of each participant contact. This involved long-term sobriety (IOM, 1990). The categories physically finding the client's home or relatives, of outcome illustrated in Table 1represent the asking questions with relatives or friends, general areas thought to be indicative of physically visiting local behavioral health improvement in the substance abuse arena centers and authorities, and numerous phone (Lettieri, 1992). calls. Over 2,700 miles of driving were

FalVWinter 1997 42 Journal of Neurotherapy eventually required. violation and another was recently was released for the same violation. Three years In the majority of both phone and earlier, before neurofeedback training, 14 personal contacts, a small gift exchange was participants were categorized as alcohol made as is appropriate within Navajo culture. dependent and five were categorized as alcohol This might involve buying the client lunch, abusers. sending them a new audio-relaxation tape, a therapeutic exchange, or offering The right hand cluser in Figure 1 is a administrative assistance. Such remuneration hrther break down of the specific changes in has been shown to increase the validity of the the three year post-training history. On this interview results by increasing rapport and by scale of my own design, 2 client's (11%)still defusing the often distorting threat of have serious problems with dependence. One interrogation and authority (Lettieri, 1992). An this 'Inon DSM-ZV" scale, one client (5%) was extensive number of therapeutic telephone classified as a chronic ''abuser'' rather than calls occurred with one participant who is in "dependent" because he appeared to lack the prison. In another case, several free. . .. . usud physical. dependence characteristics of therapeutic sessions have been given to a the DSM-ZV scale but still had significant participant who just left prison. Both have drinking-related problems. Eleven (53%) of been categorized as alcohol dependent. these participants had occasional experiences with alcohol but all managed to avoid Changes in Drinking Status problems. These eleven includes nine (47%) In an attempt to better understand the clients who have had infrequent binges but dimensional continuum of drinking changes without problems, one (5%) client who was found in these 19 participants three year aRer classified a social drinker who consumes their training, two types of category scales regularly (almost daily) but were used.The left cluster in Figure 1 shows seldom excessively, and another (5%)who had that of the 19 participants, 12 (63%) can be a drink about once a week. Five (27%) of the classified within the DSM-ZV criteria of participants have had little or no experience "sustained partial remission." These with alcohol during the past three years. participants have had a few occasional binges Although the same people are involved, the (or slips) throughout the three years period but differences between the DSM-ZV scale cluster do not drink regularly and did not get into any and the Drinking Dynamic Scale cluster significant problems. As the worst case in this illustrates a difference between classification category, one of these clients did have a series criteria. of drinking binges shortly after treatment which landed him an 18 month prison term He Changes in Life Conditions has been non-problematic since his release The significant psychobehavioral more than a year ago so still fits within this improvement between the pre and post DSM-ZV category. Four (21%) of the other training measures in both Figure 2 and Table participants can be classified as "sustained full 2 demand both a complex and cautious remission" which signifies that they may have interpretation. Figure 2 represents my had few minor slips during the past three years subjective estimate of the client's functioning but have not binged and do not experience any according to the DSM-ZV "Global Assessment of drinking related problems. Three (16%)of the Functioning Scale" (GAF). Data to rate original participants can still be classified as alcohol status was extracted from both the pre-training "dependent" according to the DSM N criteria; interview and from the initial clinical intake they have continuing significant problems file. This information was then compared with associated with excessive-drinking bouts. One my ratings from the three-year outcome of these clients is in prison for a DUI parole interview.

FalVWinter 1997 43 Journal of Neurotherapy ~~ ~ ~ ~~ Outcome Variables Changes in alcohol abuse or dependence

DSM N Substance Abuse Scale Dependence - 3 or more symptoms relatively constantdyear Abuse - 1-2 symptoms relatively constantdyear Sustained Partial Remission - 1-2 symptomdyear, but not constant Sustained Full Remission - no symptoms/year

Drinking Dynamics Scale Dependence - same as DSM N criteria Abuse - same as DSM N criteria Infrequent Binger without problems - Some excessive periods but infrequent Social Drinker without problems - Seldom in excess but regular consumption Light Drinker - Drinks occasionally, less than six drinkdinonth Infrequent drinker - drinks on rare occasions Abstainer - never drinks

Psycho/social/behavioralScales DSM N GlobaI Assessment of Functionality

DSM IV,Axis IV PsychosocialLEnvironrnentalFactors

Significant problems with: Family Social Educational Occupational Financial Housing Health care LegaVCriminal Cultural Dissonance (addition)

Amount of aftercare contact

General mood (Beck’s depression scale and subjective assessment by interviewer.)

Only one client experienced no apparent Although such changes are graphically change. The two other clients who are still impressive and statistically significant (M1 = classified as alcohol dependent, reported slight 44, SD = 9.5; N2 = 69, SD = 9.5; t = 9.55, improvements in their lives, even though both ~c.0005)~it is also important to note that the were in prison (one was recently released). participants present status is still indicative of

FaIWinter 1997 44 Journal of Neurotherapy people living under tremendous stress who The mean pre-training BDI score was 25 (SD = have a relatively modest degree of functioning - 9) and the mean post-training BDI score was 4 certainly not a healthy living situation and (m= 4.6). Because one participant's test was certainly one not free from the high risk of invalid, only 18 of the 19 participants were relapse. scored on the BDI. Six of the 18 participants scored their post-training BDI as zero, a Table 2 reflects the DSM-ZV, kisIV, possible indication of testing problems. Four "PsychosociaYEnvironmental Factors Scale". matched, non-neurofeedback controls also On this scale, participants are only rated if completed pre-treatment and post-treatment they have significant problems in these BDIs. Their mean pre-treatment BDI score was categories. In these cases for example, a 24 (SD = 11) while their mean post-treatment significant problem with the job, money, or BDI score was 10 (SD = 9.3). Although this house category means that the client has no small number of control participants is not job, little money, and no real residence. There large enough to present a significant control was no significant improvement apparent in group, it also indicates a significant drop in any of the social, educational, job, aoney, . depression, although -st a3esser rate. Because health care, or legal arenas. This finding was of the timehesource limits and the sensitive not unexpected because these social variables cultural field nature of this follow-up interview, are unusually difficult to change within this a BDI was not given at the 3 year interview. economically suppressed location. Significantly, Several questions during the outcome however, 4 of the 11 participants who interview, however, involved the self-report of originally reported serious family problems did the client's overall experience with depression improve their family relationships. Also during the past three years. Because a significantly, 4 of the original 13 who reported significant amount of depression was reported, no available housing situation three years ago and because there is a correlation between were able to find a modest but permanent depression and the kcis N and Axis V scales, residence. periods of depression are still significant within this population. Several of these participants The category called "cultural may even meet the criteria for a major dissonance" was added to the hisV scale in an depressive disorder. It is my belief that at least effort to acknowledge the significance of this six of the 19 participants would currently score stressor for these clients. In this case, cultural within the 10 - 28 (moderately to medium dissonance was rated when a client reported depressed) as indicated by both their self-report feeling emotionally (and even physically) and Axis JY and V scores. At least two troubled by living within two often-conflicting participants would probably score considerably cultures. A rating in this category also involves higher. a significant and frequent experience of discrimination or inequality. Although there seems to be correlation between periods of depression and the Again, the high and persistent level of participant's relapse-dynamics, within this these participant's psychosociaY environmental study's participants this relationship is not problems keeps them in a chronic ''high risk of always apparent. For example, of the three relapse'' condition. participants rated still in dependence, one participant does not appear to suffer from Changes in Depression significant depression. Two other participants, There was also a substantial who are both rated in sustained partial improvement between the client's pre-training remission but who still occasionally binge drink Beck's Depression Inventory (BDI) scores when without obvious problems, usually only drink compared to their final post-training scores. during happy, social events.

FalUWinter 1997 45 Journal of Neurotherapy Aftercare Maintenance and Home Practices was sober and healthy because he had moved Only one participant had been involved into the positive influence of his girlfriend's in significant aftercare (including two family. Several members within this new additional residential treatment programs) and family were well known Native American AA meetings. This individual, who was scored Church "road men" (spiritual escort-guides as in sustained partial remission, was regularly during ceremonies). Because of the private, involved in both AA and in traditional practices subtle, and cultural nature of such experiences such as numerous sun dances, Native most participants were unwilling to elaborate American Church ceremonies, and vision in more specific detail. Of the 12 participants quests. He attributed his drinking episodes to interviewed in person, or over the phone, at times when he was depressed or confused least 9 implied that their neurofeedbacw about his sexuality. He also reported PTSD biofeedback experience had had some sort of symptoms due to childhood sexual trauma. spiritual impact.

For the majority of participants with Although none of the participants families, their primarysupport appeared to be .reported that they were.regularly doing the family oriented. About half of the participants suggested home practices (such as daily had also participated in at least one traditional meditation, breathing exercises, and hand Navajo practice. When asked to elaborate on warming), many reflected that listening to what had been most helpful in establishing their guided audio-tapes had been useful over their sobriety, participants commonly cited the years. Several talked about remembering "spiritual" explanations, often integrated with to breathe diaphragmatically and fully during the nature-oriented images developed during times of stress. Most alluded to now knowing their neurofeedback training. Most of these how to remain more relaxed than before. They comments were simple statements such as "I were not specific about how they did this. Many need to be closer to nature", or references to commented (when asked directly) that their ''my higher self', "my inner spirit" and hands were now warmer; a partial indication of "harmony." At least six clients reflected back to a relaxed physiology. New relaxatiod very specific imagery events which occurred in motivational tapes were requested by six the original neurofeedback training sessions. participants during the interviews' For example, one woman said that she frequently saw herself (even now, three years All clients who were personally contacted aRer the initial vision) flying above a group of volunteered that they felt bad about their hogans, children, and horses at sunrise. This relapses. Fifky percent of these clients also was obviously an important and stabilizing reported that their hangovers and physical image to her. Five participants also reported response to alcohol were now different. having gone through a family sponsored medicine (blessing or enemy-way) ceremony during these years. There were other reports of &Overthe three year period, five participants attendance in sweat lodge ceremonies, Native called requesting new tapes. Numerous American Church (NAC) ceremonies, and additional tape requests also came from Navajo Christian practices. The majority of therapists, friends, and relatives. Because respondents reported a desire to attend more customized tape making and shipping is both traditional Navajo medicine-way therapies but expensive and time consuming, I found myself were unable to afford or arrange it. In at least attempting to downplay, or avoid, questions two cases, relatives implied that negative, about relaxation tapes. Over 200 customized witchcraft-like influences were partly to blame audio relaxation tapes were made on this for the participant's relapse periods. In one project. case, a relative reported that the participant

FalWinter 1997 46 Journal of Neurotherapy Anecdotal Observations of the Initial Training Phase variables of this trial. During the initial training phase which occurred three years earlier, experienced As an important but also complicating nurses reported unexpected behavioral caution, several biofeedback researchers have improvements in several of the more warned of the potential distortion, and even "challenging" neurofeedback participants. inappropriateness, of trying to isolate variables These positive observations encouraged them to better fit experimental criteria and design to sometimes route their more "difficult" clients (Shellenberger & Green, 1986). Furthermore, into neurofeedback training. the self-regulation techniques found in neurotherapy and biofeedback (applied It also appeared that the objective and psychophysiology) are necessarily multifaceted, computerized nature of neurofeedback interactive, and emergent in their active training, along with constant tracking of EEG variables (Shellenberger & Green, 1989). data, was psychologically supportive to Effective self-regulation training necessarily observing therapists, physicians, and involves large amounts of personalized, special administrators. Additionally, .many of these athntion and high-.txh equipment which interested obsemers, after trying an potentially and often deliberately encourages experiential session themselves, reported both Hawthorne and other placebo effects. The experiences of relaxation and therapeutic very nature of a trained psychophysiological insight not unlike those experienced daily by response implies the intentional triggering of the study participants. the body's natural, largely non-conscious, self- regulating systems. Such a response, by itself, Discussion could be considered a placebo except that it is Limitations deliberately trained and consciously Although significant information and appreciated (Green & Green, 1977). experience was obtained, this study has, of course, many limitations. Additionally, the unique challenges of the current Navajo biocultural and As a pilot study, control was severely environmental context, and the general limited by both the lack of staff and funding, as consensus by the Navajo Nation Department well as the challenge of conducting research of Behavioral Health that their contracted under the dynamic and ethical conditions of a treatment programs are not very effective, desperately-serious real-life situation. The made the establishment of a formal control positive outcome of this study, while group seem premature. encouraging further investigation into this protocol, still presents a complex mix of both Other complicating factors which active, complementary, and passive variables. confuse meaningful outcome comparisons Due to a historical consensus that substance between research projects include the lack of abuse treatment usually has limited efficacy in standardization of pretreatment assessment, this population, and due to the limited funding training methodology, outcome criteria, and and exploratory nature of this design, there outcome data collection (Sobell & Sobell, 1976). was no attempt to identify the active variables. With this in mind, great care must be taken to keep the presentation of these results within As a qualification, the inclusion of other their original context. components (such as the Navajo cultural framework, autogenic training, In addition, establishing significant hypnotherapeutic-likesuggestions, and general inter-rater reliability during the data collection biofeedback training) necessarily complicates and analysis would have required two field the empirical identification of the essential investigators instead of one. Such thoroughness

Fa1 Winter 1997 47 Journal of Neurotherapy is not practical and may have even distorted maturity factor as a confounding variable, of the sensitive nature of the interview situation course, is always present in all outcome unless rapport between these interviewers and studies. the participants had been established from the beginning. Finally, a definitive outcome Overall Evaluation analysis is only possible with an invasive With these limitations acknowledged, it program of random urine and breath tests appears that significant long-term changes (which is, in itself, is possibly data-skewing have occurred and that the original study practice). question has been answered positively. Drinking has become a less significant and less In another qualifying note, most of damaging component in the majority (81%)of these participants could be, or were, dual these participant's lives. The general overall diagnosed with other psychiatric and medical life-skill functioning of these clients has disorders in addition to excessive alcohol-usage. improved significantly, even if not yet to ideal For example, post traumatic stress disorder, levels. Although the majority of the diabetes, - closed head injury, deprcssive particirants voiced - appreciation for their disorders, and attention deficit disorders neurofeedback experience and its impact on commonly co-occurred. Because of the lack of a their lives, it is not yet possible to isolate this thorough medical variable alone as the primary cause. examination, the majority of these symptoms and diagnosis were not recorded on the intake I found the encouraging, albeit modest, records. Because of timehesource limitations, outcome results in this harsh environment a these special conditions remained largely pleasant surprise. None of my colleagues were untreated. Such undocumented conditions also optimistic about any of these clients. With one complicates an evaluation of efficacy. exception, none of the participants appeared to experience drinking problems during the The "treatment" versus "person" several months of unannounced and randomly variable was again difficult to isolate. Good conducted interview contacts. The researcher neuro and biofeedback training requires as was also surprised by the apparent frankness much empathy and personal influence as do all of the clients responses. Participants appeared forms of good therapy, education, and medicine. open and interested in reestablishing contact. It is important to also note, however, that Although descriptions of relapse were "person" and "rapport" quality within the understandably linked with embarrassment standard RMCH residential treatment facility and hesitation, there did not appear to be much was also high in spite of the usually impression-management or an attempt to discouraging outcome. manufacture socially pleasing answers. Questions about the participant's drinking Natural maturation-learning dynamics were always asked after a degree of additionally complicates the isolation of active confidence and friendship had been re- variables in long-term outcome studies. Knitz established. & Levy's (1994) 25 year study which observed With only a one exception, all that 80% of Navajo men commonly stop, or participants are still living within persistently taper, their drinking after 50 years of age does high-risk conditions. Because of the limited indicate that some aspect of the remission available resources within the rural Navajo forund in this study may be due to increasing Nation area, as well as the increasing maturity. On the other hand, because the social/econornic recession of the dominate mean age of this participant group is currently society, these conditions are unlikely to get 38 years old, the influence of three years of better. Without exception, these participants additional aging is probably slight. The are intelligent, caring people trying their best

FalllWinter 1997 4a Journal of Neurotherapy under very difficult and persistent situations. Both of these new studies reported a significant improvement in both usage and behavior. Subjectively, at the end of their initial Although these are different populations with neurofeedback training period three years different environmental conditions, these earlier, clients generally reported finding the outcomes compliment this study. training experience interesting, enjoyable, self- empowering, and refreshingly different from It is important to again emphasize that their previous treatment experiences. The alphdtheta neurofeedback training (and its protocol related stress-reducing skills) are, at best, only emphasized techniques which worked complimentary and adjunctive tools. immediately and could be felt physically, an Neurofeedback training increases the unusual experience for clients more familiar probability that the participant will feel both with talk and educational therapy. The physical and mentally more resilient during protocol also appeared to significantly address their life. When risk conditions become most of the participants desire for spiritual excessive, or if the client does not generalize . experiences. Most also voiced that --these.Tractices into their daily lives, this: effort neurofeedback training had been successfully still may not be enough. The lack of traditional modified, and was perhaps even strengthened, aftercare support, the lack of home practice, by both the Navajo cultural and traditional the absence of ongoing training, and lack of medicine-way context. Experienced facility social support severely limits the continuing nurses also reported significant and unexpected influence of such a program. My surprise at the improvements in some of their most difficult relatively positive results of this study results clients (change which they attributed to from the majority of these participants doing neurofeedback). Additionally, the computerized relatively well in spite their non-supportive objective feedback and verification value of the environments. neuro-biofeedback instruments appeared encouraging to clients, therapists, BDI scores. The dramatic reduction of administrators, and physicians. mean BDI scores between pre and post training probably involved a wide range of other Although no participant appeared to be variables in addition to neurofeedback training regularly practicing biofeedback skills on a such as the relief of completing residential daily bases, all reported that these initial treatment. Because six neurofeedback experiences were significant and helpful during participants scored their post-training BDI as their three-year post-training period. Even the zero, and because there was also a significant three participants who are still abusing alcohol decrease on the BDI in the four, non- were adamant that the neurofeedback neurofeedback controls, the BDI data itself experience had been helpful in their basic may be of limited value. For example, there is survival. no doubt that the 30 day residential stay in the pleasant environment of the RMCH treatment Although not part of this outcome study, facility has a significant positive effect on the majority of Navajo therapists (about 141, depression. who had periodically observed the initial neurofeedback training sessions three years The Peniston Effect earlier, expressed similar opinions after their The researcher was unable to verify own personal experiential trial sessions. what is commonly referred to as the "Peniston effect." Peniston (1989) had reported that his These positive results are also consistent group of neurofeedback trained problem- with two recent studies of Bodenhamer-Davis drinkers appeared to develop a physiological & deBeus (1995) and Fahrion (1995). "allergy-like" response (the more common

FalYWinter 1997 49 Journal of Neurotherapy response of excessive alcohol to most people but describe as a significant spiritual insight. not as typical in heavy users). Although 50% of the interviewed participants did say that These components of neurofeedback drinking alcohol now gives them more side training may someday become an essential effects, such a conclusion is complicated by both modality within the ideal treatment package. the guilt of their relapse and the accepted The effective mechanism of neurofeedback neurofeedback procedure of intentionally appears to address the Reward Deficiency making a mild aversion-like suggestion Syndrome and Feel Good Response model repeatedly during the training sessions. (Blum, 19911, The Altered-State Fulfillment Although harsh or strong aversion suggestions model (McPeake, Kennedy, and Gordon, 1991), were not made, clients were humorously the Natural Mind model (Weds, 19721, and the warned that they might not feel good if they Tension Reduction and Stress-related drank again. All of the participants who hypothesis. Neurofeedback also appears to reported this phenomenon did remember that compliment a wide range of cultural and physical aversion had been originally religious traditions including, but not limited discussed. When asked if they resented this to, both Navajo and Christian faiths. suggestion, all said "no." It maybe significant to note that in the only client situation where a To increase cost-effectiveness, a serious relapse was treated, the observing more .streamlined group approach to nurses reported that they had to heavily neurofeedback is absolutely essential. medicate the neurofeedback-trained client Additionally, although there are numerous during his detox period. This need for detox benefits to using neurofeedback and medication had not been previously necessary biofeedback training and verification during this client's numerous pre-training equipment, it is also possible that non- detox periods; a clear indication that his instrument based neuro-enhancement response to alcohol was now different. Both the techniques (such as meditative or hypnotic-like nurses and the participant voiced belief that procedures) may produce similar this unusually harsh withdrawal/hangover was neurologicallbehavior results. Such due to the neurofeedback training. alternatives, especially if still combined with the unique values of neurofeedback, may even Clinical Implications have some advantages (such as better long- As previously outlined in the literature term home practice). review, the essential ingredients of neurofeedback training have not been Wickramasekera's (1995) model of identified and remain controversial. The active somatizatiodabsorptiodrisk profiles, when ingredients in neurofeedback certainly involve applied to such use-disorder populations, may a complex range of influences including: (a) indicate that problem-drinkers have a higher induction of the relaxation response; (b) than average degree of negative somatic induction of a beneficial neurologically-based response or sensitivity to the environment. altered state of consciousness which produces Wickramasekera's model may also help predict both chemical balance and emotional which participants would respond best to high- satisfaction; (c) the benefits of both Hawthorne tech neurofeedback, soft-tech meditative and placebo responses combined with the other procedures, or more traditional cognitive skills essential psychological values of faith, training. In other psychophysiological expectation, belief, and hope; (d) the new applications, for example, Wickramasekera's experience of physiologicall psychological self- model has accurately predicted which control in a situation where the client had participants would respond best to a hypnotic- previously felt helpless; (e) the apparent only approach versus the more time-consuming experience of what the participants commonly biofeedback-only approach. If participants were

FalYWinter 1997 50 Journal of Neurotherapy found to score high on Wickramasekera's their effective instruction of these practices absorption scale it might be possible that they difficult and often incomplete. Although 58% of could achieve the same beneficial results as all Americans reported an interest in spiritual neurofeedback but by using self-hypnotic or experience, few psychologists ever receive meditative techniques. If this were the case, relevant spiritual training (Lukoff, 1995). Alfa- however, both the quantifymg and emotionally theta neurofeedback training commonly exciting aspects of neurofeedback would still be involves spiritual-like experiences. occasionally warranted to both evaluate and affirm the participant's progress. The demand for self-sufficient psycho- Neurofeedback techniques are also more physiological home practices places even culturally/professionally acceptable to greater demands upon the therapist than psychologists, administrators, physicians, and neurofeedback alone does. For example, unlike (very importantly) church leaders than are self- the more mechanical approach of hypnotic and meditative techniques. neurofeedback training, meditation skills really need to be taught by an experienced The major weakness of neurofeedback is teachedpractitioner . ad.place w;,thin the the over-reliance upon expensive and time- context of the participants life. To make this consuming equipment. While the use of such training situation even more complex, because equipment within treatment facilities has different techniques produce different results, many unique benefits, few, if any, clients have and because each individual client has his or access to this equipment at home. Rather than her own preferences and ability, such training thinking of neurofeedback as a short-term often also needs to be individualized. treatment (or procedural treatment) for substance use disorders, neurofeedback One final factor inhibits the wide-spread training should actually become an use of clinical neurofeedback training within introduction to the life-long practice of various substance abuse treatment facilities. Effective influential psychophysiological self-regulation neurofeedback requires computer and skills. Although such techniques are not for all equipment skills, the complications of hookup clients (or needed by all), those clients who do and cleanup, a wide range of value them should be taught more self- psychophysiological training skills, and time sufficient techniques which they enjoy consuming data analysis. Unfortunately, while practicing on a regular bases. To encourage rewarding to the therapist, and while daily maintenance-practice, these techniques appreciated by the client, this increased work should be also be deeply intertwined with the load is often prohibitive with the contemporary clients own religious, social, and professional tight budgets of most treatment centers. systems. Future Research Another problem of professional A quantitative comparison between the credibility also exists when neurotherapists participant's pre and post training baseline teach their practices to relatively sophisticated EEG signatures and their relationship to the spiritually-oriented clients. For example, participant's post-treatment behavior should be although both the 12-step AA model and the made. Both the subjective-experiential reports majority of traditional therapists vocally of the participants and their EEG data should encourage "spirituality", such encouragement be compared with the substantial literature on rarely amounts to more than lip service. meditative and altered-enhanced-state Professional resistance to the actual techniques. application of spiritual practice is actually common. Very few therapists practice daily Although it is probably important for relaxatiodspiritual skills themselves making this protocol to remain as multifaceted and

FalYWinter 1997 51 Journal of Neurotherapy integrated as possible, it would be worthwhile more formal place, and if the client were to investigate the outcomes associated with compensated in such a way that his or her full, fewer components. undivided attention was both warranted and available. Ideally, the participant will be Many of the reports of these encouraged into a role of co-researcher, rather participants, their therapists, and the nurses than remain a simple respondent. concerned the unusual, but subtle, self- empowering aspect of this protocol. This References important experiential value might be better Alexander, B.B (1988). "he disease and adaptive illustrated and appreciated with a rigorous models of addiction: A framework phenomenological analysis rather than an evaluation. In S. Peel (Ed.), Visions of quasi-experimental or experimental design. addiction: Major contemporary perspectives on addiction and alcoholism, Lexington, Although the quality of information MA: D.C. Heath. exchange during the interviews appeared good, . there are icherent limitstions in this process Alford, G. (1980). Alcoholics Anonymous: An other the obvious concern over the integrity of . empirical study. Addictive Behaviors, 5, 359-370. the drinking self-report. The follow-up interview is a meeting between people who had American Psychiatric Association. (1994). been in an intense therapeutic relationship Diagnostic and statistical manual of mental punctuated by a long period of separation. disorders (4th ed.). Washington, DC: During the interview, both persons are trying Author. to quickly reorganize and understand their new relationship. In most cases, this meeting was a Andreassi, J. L. (1989). Psychophysiology: Human surprise event occurring spontaneously under Behavior and Physiological Response. less than ideal conditions (e.g., standing Hillsdale, New Jersey: Lawrence Erlbaum outside in a strong wind, sitting in a car,inside Associates. a noisy restaurant, inside a small home with Aron, A., & Aron, E.N. (1980). The transcendental other people in the background). Neither party meditation program's effect on addictive could be can be fully relaxed or reflective. With behavior. Addictions and Behavior, 5, 3-12. a list of more than 50 question-guidelines (which must be answered within a limited time Aron, E.N., & Aron, A. (1983). The pattern of frame) many important experiences and reduction of drug and alcohol use among perceptions, no doubt, go unreported. For transcendental meditation participants. example, one of the participants kept Bulletin of the Society of Psychology telephoning after the interview to add Addiction and Behavior, 2,s-33. information such as; Itnow I remember, I actually had a long period of sobriety before Azar, B. (1995, May). NiAA: 25 years of alcohol research. APA 23. quitting that job." Questions such as "what The Monitor, factors were most important in establishing Bach, P.J.,& Bornstein, P.H. (1981). A social your sobriel$ may be understandably learning rationale andsuggestions for answered in an incomplete manner. An ideal behavioral treatment with American Indian outcome study would involve a series of at least alcohol abusers. Addictive Behavior, 6, 75. three interviews; an initial re-acquaintance meeting in the participant's home environment, Baile, C.A., McLaughlin, C.L., Della-Fera, MA., a more detailed semi-structured interview (1986). Role of cholecystokinin and opiod meeting, and a final follow-up summary peptides in control of food intake. meeting. Information depth might also increase Phvsiolonv Review, 66, 172-233. if the second meeting were held in a neutral,

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Matthew Kelly, Ph.D. is currently the clinical director of the Na'nizhoozhi Center (NCI), 2205 E. Boyd, Gallup, New Mexico, 87301. As one of the largest residental treatment centers for substance abuse in the country, the treatment protocol focuses on traditional Native American therapeutic practices as applied psychophysiology. Matthew also has a private biofeedback and hypnotherapy practice in Sedona, Arizona. Matthew has a B.A. in Applied Anthropology from the university of Alaska. He spent

~ 7 years learning metitatice techniques in several countries before launcing into applied psychophysiology. His degree in clinical psychology is from the Saybrook Graduate School. email MatthewKQcia-g.com

FalWinter 1997 60 Journal of Neurotherapy