A delightful rumor heard recently had it that a university research project studying the utility of EEG Neurofeedback had its Tobacco Company sponsored funding pulled when it became apparent that the treatment was too effective. Not having access to this unidentified university study, I set out to design a protocol using the Peniston - Kulkosky protocol as a model. Also, since my subjects were private patients, I needed to include appropriate cognitive and behavioral components, with informed consent for Neurofeedback. Three patients ( 1 male, age 49, 2 packs/day, 1 female, age 35, 2 packs/day, 1 female, age 33, 1-2 packs/day, all smoking more than 10 years) were initially given a rationale explaining the mode of action of Neurofeedback, and asked to keep a small notepad attached to their cigarette pack. For self-monitoring, they were asked to record their reason for smoking each cigarette before they smoked it. Any reason was sufficient, as this was designed to get them to focus on their smoking behavior and frequency. These records were reviewed at the beginning of the each session. Patients were also trained from the outset to do abdominal breathing, and to learn to count while inhaling and exhaling to produce even and slow breathing. This may have enhanced the patient's ability to increase alpha and theta, as detailed by Fried (1993). Breath control was enhanced and extended at each session.
EEG Neurofeedback training began during the second or third session after sufficient information about personal problems and smoking patterns had been collected. A baseline was established using an API Neurodata Physiograph 2 channel EEG biofeedback device, with later incorporation of an API Research System I-410. EEG biofeedback training proceeded directly, as all three patients demonstrated either high skin temperature (>90 deg.F) or good ability to produce skin warming. Training was done one time per week, one-half hour devoted to EEG biofeedback, with the remaining twenty five minutes devoted to discussion and relaxation training.
Part of the treatment consisted of developing imagery to be presented as in Peniston - Kulkosky. The imagery was jointly developed between therapist and patient, with the understanding gained during previous sessions aiding in prompting the patient for material. Each of the three patients showed a facility for learning to increase alpha and theta production.
As the sessions progressed, additional tasks were added to the patients' record keeping assignment. These included practicing deep breathing for two minutes after writing their reason for wanting the cigarette; practicing progressive muscle relaxation, which had been part of their training.
When depression is, or has been present, and is exacerbated by withdrawal, there is a high likelihood of failure to complete withdrawal. If withdrawal is completed, it is probable that the patient will not maintain
abstinence (Hall et.al., 1993). One of the patients fit this category, and attempts were made to develop alternative behaviors to replace the "reward" she believed she was getting by having a cigarette, the activities she would do when having a cigarette, and the way she used smoking to avoid certain issues. Issues surrounding her depression were also addressed with Cognitive Therapy. Hall (1993) recognizes that negative affect increases with withdrawal and that for some, there may be an emergence of preexisting psychopathology. She also cites evidence of the similarity of nicotine and antidepressant effects in the dopaminergic and adrenergic systems. Depression may have to be addressed as part of a smoking cessation program when a patient presents with a history of depression.
Preliminary Results
The 2 pack per day male had been seen for one month prior to beginning Neurofeedback, and had begun behavioral smoke cessation through self monitoring and establishing a behavioral chain of events to occur before he would smoke a cigarette. At this time he had cut his smoking down to one pack per day. He stopped sessions for three months, then resumed, beginning EEG Biofeedback at that time. He attended an additional nine sessions before stopping therapy. With alpha-theta training he reduced the amount he was smoking down to 1/2 pack per day. He also reported a "side-effect" of the training to be an increase in his ability to listen more carefully, without immediately reacting, to his wife and co-workers. He also reported a new sense of calmness that he had not previously experienced. Imagery used included scenes of developing a distaste for smoking. He reported that he was, in fact, developing an actual distaste for cigarettes after using this imagery. Therapy was discontinued at this time for personal reasons.
The thirty-five year old female 2 pack per day smoker began therapy with skin temperature training and relaxation training. By the second session she could reliably hold skin temperature over 94 deg.. F for more than 15 minutes. Anxiety-related issues, presented by the patient as related to smoking, were addressed through Cognitive Therapy. By the fourth session the patient had been abstinent for two days, at which time alpha-theta training began. The patient came in for two more EEG Biofeedback and Cognitive Therapy sessions. She remained abstinent, and reported a clearer understanding of the connection between stress related to her former husband and her smoking, along with an ability to break that connection.
The 33 year old female smoker is in treatment at the time of this writing. She shows good ability to enter theta and alpha states. She has been through Smokenders program unsuccessfully. This program does not address issues of underlying depression, and it was clear that her slipping was integrally related to her depression and reward expectancy. Relaxation training and behavioral chaining are part of her ongoing treatment, as is Cognitive Therapy for depression. She reports that she is experiencing deep relaxation, and has fewer negative reactions to her children and husband than she had before treatment. She has not yet reached the point where abstinence or reduced consumption can be discussed. A point of training to note is that in the protocol used, cessation of smoking is not required or suggested before treatment. The patient is encouraged to determine their quitting schedule on their own, based on the level of their brain's re-regulation and balancing. The focus is on natural healing and the ability of the individual to achieve this. A suggestion is given that this will occur, and that the patient will experience instances where they will put the cigarettes away instead of smoking them. The need to alter this part of treatment has not yet arisen.
References
Fried, Robert (1993) The Psychology and Physiology of Breathing. New York: PlenumPress.
Hall,Sharon, Munoz,R., Reus,V., Sees,K. (1993) Nicotene, Negative Affect, and Depression. Journal of Consulting and Clinical Psychology,61,761-767.
Peniston, Eugene, Kulksoky, P.J. (1989) Alpha-Theta Brainwave Training and Beta-endorphin Levels in Alcoholics. Alcoholism: Clinical and Experimental Research. 13(2), 271-279.
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