Chapter 10 - Neurofeedback in Practice

Chapter 10 - Neurofeedback in Practice

Accuracy means that the signals accurately reflect the brain processes of interst. If the feedback is not accurate, then it can introduce false feedback. In the extreme, spurious reinforcement can lead to confusion, and even superstitious thoughts and behavior (Skinner).

The feedback must also be aesthetic, so that the brain will seek the reward. There must not be undue effort or confusion associated with receiving the reward. If the reward is cryptic or obscure, the brain will not readily adapt to it.

Effective Feedback

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  Fast – provides timely information to allow temporal binding
  
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  Accurate – so brain has good information to work with, not ambiguous or superfluous
  
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  Aesthetic – so brain will respond well to the content of the feedback without undue effort or confusion
  

Neurofeedback is first and foremost an educational process, and it should be understood in that context. It is not a replacement for medication that can simply be administered in isolation. It should be used as a means of implementing train self-regulation and normalization, in the context of an overall clinical program. The clinician should be able to understand and anticipate the effects of brain normalization with neural feedback, and plan for its use as an element of the overall therapeutic program.

One of the most important factors is the instructions to the trainee. More than one research project has gone astray because a trainee was placed in front of a neural feedback system with no guidance or additional feedback. The process of neural feedback is largely automatic, and is certainly not difficult. However, the context and expectations of the trainee must be taken into consideration so that the learning process is facilitated.

It is not surprising that an uninitiated observer might question how neurofeedback could possibly work. There is something mysterious about a child watching a computer monitor, and for some reason, spontaneously getting better. Indeed, neurofeedback may appeal to some who have crystals on the table, and seek alternative therapies. Neurofeedback is in fact an alternative treatment, but is moving into the mainstream. More than one parent has certainly watched their child staring at a simple game screen, and wonder how this could possibly be helping. However, it is a fact that the brain will respond to its environment in an automatic fashion, and that minimal coaching or guidance are needed, if the system is well designed and configured. Even a very simple bar graph and tone feedback can be effective in the hands of a knowledgeable clinician.

One of the most common questions from clinicians is “what should I tell the client.” There is little or no published research to guide this decision. However, in experience with clinical art, it has emerged that the simplest and most effective instruction is essentially to “relax and allow the display or sounds to come.” If asked “what should I do,” the response should be “you do nothing.” If asked “so I should try to do nothing,” the response is “no, you should not try to do nothing, but you should not try to do anything.” Trying to do nothing is not the same as not trying to do something. Allow yourself to learn what it feels like when the feedback comes.

This may seem a somewhat odd topic to discuss in a technical foundations book, but this aspect is critical. Neurofeedback is not a simple treatment that fixes problems. It is a scientifically-based technique that can allow the clients brain to learn self regulation skills. These skills have clinical relevance and changes in brain regulation will be manifest in symptomatic and subjective changes. It is by defecting these changes that neural feedback has its clinical value. As a clinical tool, neurofeedback should be understood as well or better than any other clinical tool. If a clinician has all the scientific and technical concepts, but does not integrate neurofeedback into practice in a clinically sound manner, then the benefits will be limited at best.
Aside from observing the screen and allowing one's self to learn, there is really little else to the experience of neurofeedback. The clinical impact is realized when the trainee begins to experience subjective changes and the clinician then puts these changes into context.

While the intent of the neurofeedback is not to put the trainee under task, it is still possible to allow them to engage in other activities while attending to the neural feedback sounds. A partial list of possible activities is shown here. This is also a controversial topic, and some clinicians will insist that neural feedback should either be done with a task, or without a task. The reality is, that as long as the client is able to relax and be focused, and allow the operant learning to occur, that neurofeedback can be effective.

Operant conditioning is the process developed by behaviorists including J.B. Watson and B.F. Skinner. It depends on an action performed by the organism, and can be basically anything at all. Operant conditioning has been used on cats, mice, pigeons, and flatworms. This type of learning occurs when a reward is paired with some action.

It is not necessary for the trainee to be consciously aware of the properties or changes themselves. There is a naïve impression that trainees somehow “learn how to make the brain waves voluntarily, and then do it themselves later on”. This is not as accurate a depiction as the recognition that the brain has its own ability to internally self-regulate, and that this self-regulation is largely outside of voluntary, conscious control. There is a famous example of operant conditioning in which a psychology class, as a prank (or as an applied experiment), successfully trained the instructor to stay on one side of the room, simply by paying attention to him when he was on the left side, and ignoring him when he was on the right side (Sabado, 1970, p. 127). Without any awareness that he was being conditioned, the instructor learned to stay in one particular corner of the room, in response to the differential attention provided by the students. According to this account, the professor eventually fell off the left side of the stage. In another version, the students even reversed the experiment later, and simply by shifting their behavior so pay attention when he was on the other side of the room, got him to go there. An online video (Youtube, “How to condition your professor,” http://www.youtube.com/watch?v=khrjRonCkhw) demonstrates how to use this technique to induce your professor to end the class early. This shows that even a complex behavior can be operantly conditioned, without any conscious awareness on the part of the subject. Indeed, this procedure will only work of the professor is not aware of what is happening, as awareness in this example would actually subvert the effect of the conditioning behavior.

The role of Intention in Neurofeedback

One of the more fascinating, and possibly daunting, aspects of neurofeedback is the role of volition in instrumenting change. There is a tendency in Western society to think of human actions in terms of “voluntary,” in the sense that we first create a desire to do something, then instruct our brain to take care of the details. The reality is that this is somewhat backwards. As was seen in our earlier example of the movement-related potential, the brain activity that leads to a voluntary movement precedes the movement by up to 1-1/2 seconds. That means that the very idea of the desire to perform the movement comes AFTER that brain activity. As would seem necessary, the very desire to perform the action is a brain event, hence is the result of brain processes. This challenges the idea that the conscious mind is “in charge” of the brain, and puts the cart on quite the other side of the horse.

What this means to neurofeedback is that the brain is the active agent, and that the trainee’s conscious awareness is more of a passenger than a pilot, and is certainly not the engine. The driving force for thought and action consists in the dynamic instability of the brain, and its proclivity to always seek novelty, fulfillment, stimulation, safety, power, and other goals that it perceives.

Neurofeedback does open the question of causality, particularly with regard to how intentions (mental events) and actions (brain/physical events) are interrelated. The elegant thing here is that neurofeedback does not depend on our understanding or articulation of exactly what is happening when. There is a continual feedback loop that involves the brain, its electrical properties, some external hardware, and the client’s sensory/perceptual systems, hence the brain. It is not clear where or if the client’s conscious awareness are particularly necessary for this process. Indeed, Margaret Ayers had worked with patients who were comatose, hence not necessarily aware, and got their brains to wake up using an EEG-controlled light held up to their eyes. The further realization that mice and flatworms can be conditioned shows that conscious awareness is not a necessary component of this process.

What is being trained in neurofeedback is, simply, the brain. The brain in this context can be thought of as a relatively stupid organ, that goes about its business by adjusting synapses and transmitters, in response to various cues. The brain normally processes an enormous amount of information coming from many directions, and does its best to decide what is in its best interests. Note that the brain’s best interests are not necessarily the client’s best interests. The existence of obsessions, ruminating thoughts, compulsive behavior, and other negative processes bear witness to the fact that the brain can set about doing something that seems to suit some need that it thinks needs to be met, but which do not reflect in the well-being of the client.

A possible subtitle for this book, or at least this chapter, might be “Your Stupid Brain.” In this context, neurofeedback is an ideal mechanism for working with and optimizing the stupid brain. Neurofeedback gets involved at a deep, nonverbal level. Neurofeedback does not try to reason with the client, or to alter his or her brain activity like a sledge. Rather, neurofeedback provides new information, which can open up the brain to options in its own dynamical control. Neurofeedback, in its simplest forms, is saying something like “How about less theta for a change,” and allowing the brain to make its own decisions. If the changes result in a new stable state, or one that provides continued benefits to the clients, then it will continue to be reinforced after the session is over. If not, the client will not have been harmed, and the brain can go back the way it was.

Figure 10-1 is based upon some of the thinking of the philosopher Jae Guan Kim, relating to a concept called “supervenience.” This principle asks whether a change in one domain can possibly happen without a change in another. It does not talk about causality, but about what is possible or not. In our analysis, we recognize that there is a physical brain (denoted “P”) which undergoes state changes in time. We suppose that the brain is a physical mechanism obeying the laws of nature, so that each state can properly cause the next state. (With quantum uncertainty, we still assign sequential states to the system, even if they are not entirely deterministic). Kim states that the mind supervenes on the brain, which is to say that if two brain states are identical, then the associated mental states are also identical. This means that while there may be many brain states that produce a given mental state, e.g. many ways to worry, once a brain state is specified, the mental state that it produces is determined.

Neurofeedback, therefore, while it appears to operate on the level of the client watching a screen or hearing sounds, and “knowing” that something is happening, may operate at an entirely different level. In the same way that the professor found himself on one side or the other of the room, the brain finds itself in various configurations, which are either reinforced or not, depending on a complex set of criteria. Neurofeedback introduces entirely new criteria, which have not been part of human experience for all of the millennia of our existence. Within the past several decades, this door has opened, and now provides a new paradigm for assessment and change. While it is biologically based, it is not fatalistic, and does not pigeon-hole clients into diagnoses, or even into symptoms. It looks for dysfunction at the level of self-regulation, and introduces mechanisms of change that have no precedent in mental health care, with the possible exception of Thomas Edison’s brass ball and pie plate.