Alice in Neuroland
Can machines teach us to be more human?
It is a rainy morning in early March. I am in a hotel conference room near MIT in Cambridge, Massachusetts, running a dressmaker's tape measure through the reddish blonde locks of a mildly anxious physician named Marcia Lipski. At tables all around us, assorted psychotherapists, MDs, and speech pathologists are clustered in groups of three, with laptop computers, electrical wires, plastic tubes of unfamiliar goop, and white Styrofoam heads bought from a wig-supply house and pasted with orange stick-on dots denoting various parts of the brain. We are in the midst of a training presented by EEG Spectrum and accredited by the Biofeedback Certification Institute of America in the fundamentals of neurofeedback: a hybrid of biofeedback, old-fashioned counseling, and cutting-edge brain science. Attendance is restricted, on the whole, to health care professionals.
The clinicians around me are attempting to integrate their 20th-century therapeutic skills with 21st-century electroencephalography (EEG) and affective neuroscience. Those who once aspired to be sages, healers, and wise women will struggle over the next few days to make sense of hertzes, thalamocortical relays, frequency reward bands, and inhibitory postsynaptic potentials.
I feel like a student at a beauty school run by the Bride of Frankenstein.
Consulting my wig-head, I move my finger to a point on Marcia's scalp about two and a half inches above her right ear. In the spot below my finger, beneath a quarter-inch of bone, lies a cluster of 20,000 pyramidal neurons stacked three deep on the outer layer of her brain's sensorimotor strip, which governs body sensation and movement. Marcia's companion, Marvin DeVoe (a handyman by avocation and the only unlicensed trainee in the room besides me) squeezes a salty, gritty paste called Nu-Prep onto the spot I've indicated and scrubs.
I smear a chickpea-sized lump of clear, viscous wax onto an electrode--it looks like a tiny, gold cokespoon with a long, yellow, electrical wire attached--and press it onto the freshly cleaned spot on Marcia's scalp. Like a stethoscope pressed against a wall to eavesdrop on a party, this little spoon is capable of "hearing" faint electrical signals pulsing from neuron to neuron beneath the bone.
We clip earring-like electrodes to Marcia's ears, run a few electronic tests, and plug the electrode wires into a small amplifier leading to a laptop. Marvin hits a computer key. On the screen, four squiggly lines, like tracings from an earthquake-monitoring machine, dance grayly across a dark field. It's Marcia's EEG--a display of the electrical activity occurring in about one-millionth of the total of 20 to 40 billion neurons in her brain. It's magic.
No longer is the skull a black box, its clockworks invisible, as it was to Sigmund Freud, Carl Jung, and the seminal thinkers and clinicians who have shaped 20th-century psychotherapy. For the past decade, in well-funded university neuroscience laboratories from Boston to Madison to San Francisco, the black box of the skull has been opening and spilling out diamonds. And in offices across the country, therapists today are struggling to make sense of this treasure.
What practical difference does it make to the average therapist that happiness can not only be intuited from a smile, but can be viewed on a home computer as an EEG pattern of moderately quick and intense neuroelectrical firings behind the left temple and forehead? That different forms of depression don't look alike in brain scans or on EEGs, and that some are characterized by slower bioelectrical activity on the left front of the brain than on the right? That feelings of compassion are no longer merely a religious ideal, but have been recorded as rapid brain waves coursing in the left foreheads of Tibetan Buddhist monks who have meditated intensely for decades?
Here, in this rented room, the demarcations between the psychological and the neurological are melting. With the help of a couple of laptops and a $5,000 computer program, Marcia Lipsky's skull is thinning like an eggshell before our eyes--sensitive, vulnerable, semitransparent.
In one wiggling line on the laptop screen, we can see some of her neurons firing in the rapid patterns associated with tension, while on the next band up, other brain cells fire at the moderate speeds associated with relaxed alertness, and on a third band, still others fire in the slower rhythms typical of withdrawal, depression, and daydreaming. We see through a glass darkly. We don't entirely know what to make of what we see, but we see something.
Marvin presses another computer key, and on a second linked laptop, a yellow Pacman-like face appears. For the next six minutes, Marcia, without moving a muscle, will try to keep Pacman running through a maze, simply by firing her neurons fast enough to make the computer beep. When she's too tense, the beeping stops and Pacman goes dark. When she withdraws or daydreams, too many of her brain waves enter the slow, theta range (firing only four to seven times per second), and the beeping stops again. But the laptop is configured so that when she's in a sweet spot--calm yet focused, with neurons firing away on the right side of her brain at 12 to 15 times per second--Pacman gobbles away and the beeping is continuous. At tables all around us, other therapist-guinea pigs are staring into similar screens, and the air fills with a syncopated, off-rhythm chorus of electronic beeps.
We're doing more than just looking into Marcia's brain--we're resetting its inner clockworks. Neurons close to the surface of her skull will, we hope, come to fire in slower, calmer rhythms. They, in turn, should entrain other neurons deeper in her brain, relaying their calming influence from her cortex to her thalamus, which helps govern physiological regulation. The fleeting, repeated, bio-electro-chemical patterns of neural functioning that Marcia calls mild anxiety--once thought to be hard wired by temperament, early childhood development, and fate--are turning out to be malleable after all.
Our hope is that after just six minutes of training, Marcia will feel at least temporarily less anxious--without a DSM-IV diagnosis, a massage, a few minutes of meditation, a shot of Jack Daniels, or any other mood-altering technique of East or West. We'd like her to be able to sleep better and worry less.
We're exploring a new pathway to healing. We aren't viewing her anxiety hydraulically, as Freud did--as pressure that needs releasing through talk; nor as a chemical imbalance that needs carpet-bombing with Zoloft; nor as the product of distorted cognitions that need challenging. Instead, on the basis of a 14-page questionnaire she filled out, we're thinking of her as "overaroused" and are trying to teach her brain to reregulate itself at its most basic, cellular level.
Our healing technology isn't the imperfect body and soul of a therapist or meditation master, both of whom, in slow, time-tested ways, attempt to teach the psyche self-regulation. We are diving down a new rabbit hole into the psyche. We are early adopters of a wordless, computer-to-human therapy--a natural fit for a culture in love with iPods, GameBoys, and wired isolation. Our therapeutic tools are an electrode, some wax, a software program called the EEGer, and two Toshiba laptops. We've come a long way from Freud's couch.
The six minutes are up. Marcia pushes away from the table and stands up, her forehead knotted, her cheeks pale. She pulls the electrode off her scalp and unclips her ears. She doesn't feel better, she says. She feels sad. She feels worse. All around the room, the beepings are tailing off as the exercise ends and low, murmured reports from other guinea pigs--some pleased, some disappointed, and some perplexed--take their place. From the table behind us, I can hear a hospital-based psychologist say that the chronic pain she's had in her knees since the age of 19 has disappeared, at least for the moment.
We're groping and blundering in the dark, tapping along the shadowy wall of a cave with our canes. We're sailors jumping on board with Columbus, sketching new maps as we sail into regions marked, "Beyond, There Be Monsters." Welcome to garage brain science.
The Origins of Neurofeedback
Neurofeedback is not new. It was first explored in the late 1960s, decades before the laptop computer, by psychologists who used big, expensive, primitive EEG feedback machines to help subjects generate more of the slow, regular, alpha brain waves characteristic of blissful states of meditation. At the same time, in southern California, a hardheaded neuroscience researcher named Barry Sterman (now retired from UCLA's school of medicine) was accidentally discovering that generating brain waves in slightly faster rhythms could do something perhaps more miraculous: it could make the brains of cats highly resistant to epileptic seizures.
Sterman wasn't a therapist. He had no interest in altered states. He was curious about the brain mechanisms involved when behavior is inhibited. In 1965, in his lab at the veterans' hospital in Sepulveda, California, he trained 50 cats to wait until a tone sounded before they pressed a lever and got a ladle of milk. The cats became physically relaxed but mentally alert, as though crouched motionless in a garden waiting to pounce on a mouse. Their EEGs--recorded along the strip of their skulls where Alice in Wonderland wore her headband--showed odd, spindlelike tracings, indicating that clusters of the surface neurons were firing synchronously in short, repeated bursts. If you could have heard them, they'd have sounded like mini-drumrolls or brief surges of rain hitting a window at about 12 to 15 times per second, punctuated by intervals of silence. Sterman named this frequency, which is faster than alpha rhythms, Sensory Motor Rhythm, or SMR.
In his next experiment he trained the cats to generate SMR at will, for hours on end, rewarding them with milk flavored with chicken broth whenever their EEGs displayed it. He published the results, intriguing but of no obviously earthshaking significance, in Brain Research in 1967.
Sterman's federal funding for this research later dried up, possibly because alpha-wave biofeedback researchers were viewed by federal bureaucrats as blissed-out ninnies. So, in a fusion of rocket science and brain surgery, Sterman moved on to investigating the neurological effects of toxic rocket fuel. (The research had its genesis in fears that the early astronauts, who'd reported seeing South Sea islanders waving at them like sirens, were getting hallucinations from exposure to rocket-fuel fumes.) On a contract from the Defense Department, he injected monomethylhydrazine into 50 lab cats and recorded their EEGs while they panted, drooled, and had epileptic fits. As described in Jim Robbins's 2002 book, A Symphony in the Brain, most of the cats had seizures within an hour of being injected, and some died soon afterward. But seven cats held off seizures for more than two hours, and three had no epileptic seizures at all. When Sterman went back over his records, he discovered that the seizure-resistant cats were the ones he'd trained earlier to generate Sensory Motor Rhythm.
That discovery tantalized him. Just exactly what had happened in those cats' brains? How had a low-key, noninvasive, behavioral intervention--training brain waves with a milk reward--made cats capable of resisting epileptic seizures? To understand how earthshaking this was, imagine the healthy brain as a huge sports stadium where clusters of neurons sit in the bleachers playing millions of semi-independent versions of the child's game of gossip, whispering messages to one another down interlocking daisy chains. In an epileptic seizure, ever-growing numbers of those neurons stop passing messages critical to body functioning and join instead in a slow, synchronized version of The Wave.
The brain-wave training had somehow taught the cats' brain cells not to take up The Wave, even when awash in an excitatory poison. An intervention so simple and subtle that even a cat could do it--involving no drugs, therapy, or surgery--had changed how neurons communicated, possibly even rejiggering their structure at the cellular level. It was early proof of what scientists now call neuroplasticity--the brain's ability to reshape itself physically.
If a machine could modulate the brain waves of cats, what could it do for humans? Five years later, Sterman hooked up a severely epileptic Veterans Administration lab tech to a clunky EEG biofeedback device that blinked a green light at her whenever her brain waves fell into SMR. After 24 sessions over three months, the tech, Mary Fairbanks, reduced her thrice-monthly seizures virtually to zero, recovering enough to get a driver's license.
Fairbanks was only the first epileptic to improve. According to a survey of the scientific literature by Sterman published in Clinical Encephalography in 2000, at least 166 medication-resistant epileptics have since been trained with neurofeedback, reducing their seizures on average by 50 percent.
If brain-wave training could modulate epilepsy, how about another presumably hard-wired impairment--AD/HD? In 1976, a psychologist who'd worked with Sterman named Joel Lubar, now at a lab at the University of Tennessee, improved the school performance of an 11-year-old boy with AD/HD by hooking him up to an EEG machine that rewarded him for reducing his overabundance of slow, daydreamy brain waves in the theta frequency range (4 to 7 firings per second--about the speed of a pheasant beating its wings).
Lubar saw true AD/HD as a purely neurological problem. He conducted his research carefully, screening out kids with concurrent depression or anxiety. Over the next three decades, he and other researchers published dozens of studies, describing successful, simple, systematic neurofeedback training with more than 1,000 AD/HD children. Although only one neurofeedback study was a gold-standard, controlled, double-blind study, the others--using control groups, but not double-blinded--suggested that, in the short term, neurofeedback improved the children's behavior and school performance about as well as Ritalin. In the 1980s and 1990s, at the height of the Prozac and Ritalin crazes, only a handful of people noticed.
In longer-term studies--all performed by proponents of the new technology--neurofeedback frequently outperformed drugs. In 2002, for instance, in the largest controlled-group study conducted so far, psychologist Vincent Monastra of Binghamton University in New York compared 51 AD/HD children receiving a Cadillac package of treatments (stimulants, individualized school help, parenting education, and a six-month course of neurofeedback) with 49 kids in a control group, getting the same package without the neurofeedback. Both groups did equally well in the short term, improving behavior at home and attentiveness in school. But in a follow-up study three years later, only neurofeedback's effects persisted after medication was temporarily withdrawn. Even more tellingly, 80 percent of the neurofeedback group had reduced their dosages of stimulant medication by at least half in the intervening three years, while none of the control group had reduced their medications, and three quarters had increased their dosages.
Powerful evidence. But therapeutic revolutions--especially ones requiring expensive equipment and nerdlike technical skills miles outside the average therapist's comfort zone--need more than scientists to become known. They need explorers, promoters, and innovators--Columbuses, P.T. Barnums, and Thomas Edisons. They need word-of-mouth buzz, training programs, and the cash to develop them.
Sterman and Lubar could provide none of these things. The National Institute of Mental Health and the pharmaceutical companies had no interest. So neurofeedback slipped out from under the laboratory door on its own, like a purloined spell.
Living With AD/HD
I have a confession to make: I didn't pursue this story strictly out of journalistic curiosity. I was hoping that neurofeedback might help me, where years of psychodynamic therapy, seven months in a Buddhist monastery, countless hours in self-help groups, and even a two-week experiment with Ritalin had failed.
All my life, I've collected ribbons and demerits. I learned to read when I was 4, edited my high school literary magazine, aced my SATs, and squeaked into a competitive New England college. Yet, since the day I lost my first mitten, I've sensed I wasn't playing with a full deck.
My mother called me scatterbrained. My father pulled out his hair. My French teacher called me an underachiever and once held up a messy paper I'd labored over, saying, "This oozes 'I don't care.'" Impulsive, disorganized, and endlessly procrastinating, I swam through life in a flotsam of pinned-up hems, minor car accidents, forgotten appointments, lost sweaters, exasperated tax accountants, and puzzled friends. I packed for trips at the last minute, got lost for hours in newspapers I didn't want to read, blurted out things I later regretted, and got breathless and dizzy at even the prospect of assembling an Ikea bookcase.
Spinning through my days, I felt like a butterfly tethered to a concrete block. Some dreams, whether writing a book or just keeping my bedroom neat, seemed to be forever just out of reach. I wanted to Photoshop my personality. I wanted to be me without the angst.
So, late last winter, I began driving 75 miles from my home to the toy-filled offices of Mark Steinberg, an educational psychologist in San Jose, California, and coauthor of ADD: The 20-Hour Solution. After running me through a battery of neuropsychological tests measuring concentration and attentiveness (I scored execrably on both dimensions), Steinberg devised a neurofeedback protocol for me, my own custom recipe. He'd give 9 minutes of alertness brain training by putting an electrode on the left side of my head--the seat of engagement with the external world--encouraging my brain waves to fire there at 15 to 18 times per second. Then he'd switch the electrode to the more nonverbal, mood-regulating right side of my head for 21 minutes of calmness training, encouraging slightly slower, SMR brain waves.
The left-brain training would rev up the more cognitive side of my brain and help my inattentiveness--a symptom of neurophysiological underarousal, as is mild depression. The right-brain training would mellow out the hemisphere specializing in mood regulation and tone down my impulsivity (a sign of overarousal). So, with an electrode pasted to my left scalp, I sat back in a leather recliner. A technician hit some keys, and I looked at a video screen showing the white wake of a boat stretching toward a brown volcano on the horizon.
When I was in the right zone, the computer beeped, I got a point, a star appeared in the video sky, and a wide strip of white spread toward the horizon. Sometimes the screen fell silent; at other times, I produced a river of continuous beeps. Whenever I earned 500 points, the volcano released a pretty cascade of colored balls.
On the first day, I hunched forward in the recliner, determined to succeed. I stared at the computer screen with narrowed eyes, afraid I'd miss something. The beeps hiccupped on and off like a car starting up on an icy morning. Then I consciously soft-focused my eyes and relaxed my clenched hands, and the beeps picked up.
In the next couple of sessions, I noticed that when the beeps stopped, I was usually monitoring and grading my performance. In time, I somehow monitored myself less, and got more beeps. After sessions four and five, I left the office feeling calm and buoyant. The long drive home was a breeze, even though I missed one exit and had to loop back. As I passed by San Francisco Bay, its gun-metal waters looked extraordinarily vivid.
My shift in mood was so palpable that my mate, Brian, noticed it immediately when I walked in our door. I touched his hand and, for the first time since we'd met, mine was warmer. I'd felt calm and aware after a seven-day meditation retreat in the past, and exhilarated after a one-mile swim. But mostly I'd oscillated between two modes--alert-but-clenched or relaxed-but-in-a-dream. I hadn't known how to be calm and alert at the same time, and I hadn't even considered that possibility as a goal. This stuff works, I thought. It isn't rocket science. Why isn't there a room of these machines in every school!?
To widen the research sample beyond my own experience, I recruited two friends, both self-diagnosed with ADD, to be fellow guinea pigs. One was Patrick Dougherty, a Minneapolis psychotherapist who'd taken the anti-AD/HD drug Strattera, with great benefit, but had had to give it up because of side effects. The other was my younger brother, Jonathan, a scattered, talented mechanic who lives in a trailer in the Southern California desert, surrounded by broken-down vehicles and half-finished projects, dreaming of designing custom cars from scratch, but barely making the rent.
All my adult life, I've stood on the sidelines, yearning to help or change my brother, much as I've wanted to change myself. When I told him that a neuropsychologist named Christine Kraus in nearby Canyon Lake was willing to give him 10 free sessions, Jonathan, a therapy virgin, shrugged and agreed. His last job, as a $10-an-hour truck driver, had ended in November 2004, and he was humping along, trying to start an auto-body shop in a rented barn with sweat equity, salvaged wood, debt, side jobs, junk, and dreams. "I know I'm smart, but my life isn't getting out of first gear," he told me on the phone. "You and I tie our shoelaces together and try to dance ballet. We're legends in our own bathroom mirrors."
Out of the Laboratory
In the 1970s, one of the few people intrigued by Barry Sterman's research was Margaret Ayers, an idiosyncratic young graduate assistant working in his lab. It was she who first smuggled neurofeedback out the laboratory door. In 1975, she secretly persuaded one of Sterman's technicians to build her an EEG feedback machine and lease the contraption to her. Much to Sterman's disgust, she then set up her own unsanctioned, one-woman show in an office on Wilshire Boulevard. The genie was out of the bottle, and nobody could stuff it back.
Ayers mostly specialized in brain injury. Desperate people, many in wheelchairs, found their way to her door. She taught them to inhibit the slow waves that are signatures of brain injury and to amplify production of beta waves--a slightly faster speed than Sterman's Sensory Motor Rhythm. Many of her clients reduced their muscle tremors or began to speak or feed themselves. Word spread. Ayers moved to a charming and eccentric building on Beverly Hills' fancy Canon Drive that had once housed Will Rogers's film studio. She works there to this day, enjoying a powerful but sub-rosa reputation as a miracle worker to ordinary Angelenos and the occasional movie star.
Ayers's results, dramatic though they sometimes were, drew little attention from established psychology, neurology, or medicine. An unsanctioned irregular, she was part of no established professional community, practicing a hybrid, orphan discipline, with no credentials beyond voluntary biofeedback certification and her own growing reputation. Had she not crossed paths with a distraught and equally unconventional couple named Siegfried and Sue Othmer in 1985, it's likely that neurofeedback would have remained a curiosity, a sort of therapeutic Veg-O-Matic, promising wonders but practically unavailable outside a few university labs and a quirky office in Beverly Hills.
The Othmers didn't come to Ayers to sell themselves as promoters. They came because they were contemplating putting their 17-year-old son, Brian, into residential treatment. Brian had been deprived of oxygen at birth and was born blue. In the Middle Ages, he'd have been called possessed. Today he'd probably be labeled bipolar or as suffering from a combination of Tourette's disorder, epilepsy, Asperger's disorder, learning disabilities, and AD/HD. He was on high doses of the antiseizure drugs Dilantin and Tegretol. He didn't listen in class or complete his homework. As a child, he'd wandered the hills, climbed cliffs, barked like a dog in his sleep, kicked holes in doors, and beat up on other children without warning or explanation. He'd said he wanted to commit suicide, that he was "evil" and a "warlock," and would go to prison when he grew up.
He began neurofeedback training on Ayers's machinery in March 1985 and was taught to inhibit his overabundance of slow, theta brain waves. By May, he'd stopped beating up his younger brother and was finishing his homework for the first time in his life. In June, his family physician reduced his medications and said he appeared to be "outgrowing" his learning disabilities. He still had many problems and took Tegretol, but in the fall of 1986, he went off to college--something his parents had thought would never happen.
Siegfried Othmer, who had a Ph.D. in physics and worked in the defense and aerospace industries, recalls bringing Brian to Ayers's office, watching her patients go in and out, and thinking he was looking at the equivalent of a wall of crutches at Lourdes. He and his wife, Susan, who'd done graduate work toward a Ph.D. in neuroscience at Cornell, decided to bring this neurological Lourdes further into the mainstream, first in collaboration with Ayers, and then despite her.
Over the next two decades, the couple ran up credit-card debt, spent a family inheritance, found small investors, and hired computer-software designers to create sophisticated EEG-feedback programs that looked like video games. The Ayers-Othmer collaboration quickly broke down, and much to Ayers's disgust, Sue Othmer began treating acquaintances on a new prototype, charging $40 for the sessions she held in her guest room in the San Fernando Valley. Ayers, who'd quietly patented the new equipment and software, sued for patent infringement.
Susan Othmer, like Ayers before her, soon developed a reputation as an excellent, intuitive, outsider clinician. Unshackled by the conventions of university-based research, she tackled just about anything--PMS, depression, insomnia, migraines, phobias, autism, manic depression, and panic disorder. At the time, many researchers assumed that semiautonomous neural circuits separately regulated emotions, thinking, and physiological functions. Sue Othmer assumed no such firewalls.
Instead of pigeonholing problems via the DSM grid, Othmer first sorted out whether her client was overaroused, underaroused, or unstably aroused--neurophysiological categories that make a hash of 20th-century distinctions between the physical, emotional, cognitive, and neurological. Asperger's, autism, panic disorder, and trouble falling asleep were lumped together as expressions of overarousal. Depression, perfectionism, and trouble staying asleep were characterized as signs of underarousal. Bipolar disorder, migraines, and epilepsy were slotted as manifestations of unstable arousal. This was a new form of clinical categorization.
At first, Susan Othmer's treatments followed in the conservative footprints of Sterman, Lubar, and Ayers. Like them, she placed her electrodes at the midline of the head or else along the sensorimotor strip, which runs above the top of the forehead. She revved up the underaroused with left-brain training in the beta brain-wave frequency range and soothed the overaroused with right-brain training in slower Sensory Motor Rhythm.
But soon, she struck out for unmapped territory. Cautiously, she began moving electrodes to other spots on the scalp, playing with frequency-reward bands, and asking clients how they felt. One day, she placed an electrode on the left side of a migraine sufferer's head. The migraine "jumped" to the right side. She moved the electrode to the right, and the migraine jumped back again. She tried putting an electrode on each side of the head and configuring her computer so that it integrated data from both hemispheres. The migraine stopped. The closer she moved her electrodes down toward the ears--closer to the primitive, emotional, limbic system, packed in deep in the center of the skull--the more powerful, stabilizing, and physiological the effect became.
By then, the Othmers' business--named EEG Spectrum--had mushroomed and moved into rented offices. Margaret Ayers's lawsuit against them was settled through arbitration in 1991, the same year the Othmers' son Brian, having apparently suffered a seizure in his sleep, died in his bed in his college dorm.
The Othmers forged on. By 1995, their clinic occupied a suite of offices, employed two technicians working under Susan, and delivered some 4,500 neurofeedback sessions a year to more than 100 clients. More important, they'd become the Johnny Appleseeds of neurofeedback. They talked up neurofeedback on TV shows, trained others, spoke at support groups for parents of learning-disabled children, and presented papers at the Winter Brain Conference in Palm Springs and other professional gatherings.
By the mid-1990s, when the affordable personal computer and the video game met the Decade of the Brain, the Othmers had helped catalyze a nationwide community of sometimes groundbreaking, sometimes chaotic and haphazard, clinical experimentation. They'd trained therapists by the hundreds--even though, as Siegfried Othmer later put it, for most therapists, learning about neurofeedback is "something like eating for the first time with chopsticks."
Some of the Othmers' trainees were psychologists and psychiatrists with teaching positions at major universities. Others were clinicians with little background in neuroscience, who emerged from four-day trainings with their electrodes and expensive new EEG software programs in hand, eager but bewildered. Among the bewildered was John Demos, a masters-level counselor in Brattleboro, Vermont, with a specialty in integrated medicine, post-traumatic stress, and biofeedback. Trained in 2000, he had a few inexplicably miraculous successes, including several with clients with PTSD. But his overall success rate hovered around 30 percent--little better than that of placebo.
"The education I'd received left me with one question: why am I doing this?" says Demos, who's since written Getting Started with Neurofeedback, a practical, neuroscience-based primer he wished he'd had when he began. "One week, clients would say they felt better, and the next week they'd say they were feeling worse. It was pure guesswork. I was moving sensors from place to place, chasing all over the brain."
Demos has since taken up a more systematic and technological approach, starting with taking a quantitative EEG (qEEG)--a computerized innovation that reads brain function simultaneously at 21 different electrode sites on the skull and compares them to a database of "normal" brains. Demos uses the subsequent "brain map" to decide where to place his electrodes.
Hit-and-miss or not, the miracles kept on coming. Psychologist Ed Hamlin took neurofeedback back to his Pisgah Institute group practice in Asheville, North Carolina, in 1998 and began experimenting. He and a fellow Pisgah partner, psychiatrist Stephen Buie, eventually hit on a protocol that stabilized more than 30 severely manic-depressive clients who'd been repeatedly hospitalized, despite massive doses of anticonvulsant and antipsychotic drugs.
Before neurofeedback, Hamlin said, his work with his patients had been pretty much limited to getting them to keep taking their meds, no matter how zombielike they made them feel. At best they stabilized on the drugs at what Hamlin calls "a sort of negative static hum," rating themselves at a zero on a -5 to +5 mood-rating scale.
After neurofeedback, the clients reported they'd stabilized at +1, a mildly positive state. "The results are so unrealistically positive that I know we sound like an infomercial sometimes," Hamlin says "Before, we were teaching these clients coping strategies. Now we're actually treating the disorder. We're doing something that directly impacts the neurophysiology of their problem." The results are so universally positive, Hamlin adds, he now considers it "almost negligent" not to treat bipolar patients with neurofeedback.
In 2000, psychologist Laurence Hirshberg, an assistant professor in clinical psychiatry at Brown University, returned from neurofeedback training to a Providence, Rhode Island, psychology practice full of children with AD/HD and autism spectrum disorder. He now supervises six technicians who deliver 105 treatment hours per week at his office at 13 neurofeedback stations. Another 16 families, many with autistic children, do neurofeedback training at home under Hirshberg's supervision, on leased machines.
"Part of the problem with this field is that the stories are so amazing that nobody believes them. I'm trying not to sound like a wild man," says Hirshberg, who guest-edited a major positive review of neurofeedback research for the January 2005 volume of Child and Adolescent Psychiatric Clinics of North America.
The treatment, Hirshberg adds, has transformed his understanding of the neurological substrates of some disorders he once considered primarily psychological. "You take a child with reactive attachment disorder who's struggled for years with expressing any feeling of warmth and affection. You do five or six [neurofeedback] sessions, and, suddenly, the parents report, 'O my God, he's showing warmth and affection.' He sits next to them on the couch, he smiles.
"Or take a child with autism. A mother may report something as mundane as her child's recognizing that she's carrying bags of groceries and holding the door open for her. This relatively innocuous intervention certainly suggests there's a primary contribution from the brain."
The View from the Trenches
The longer a therapist stays with neurofeedback, the more complex their view of the technology becomes. Therapist Sebern Fisher, for instance, was an early adopter who took neurofeedback training from the Othmers in 1995 and returned to Northampton, Massachusetts, to a private caseload of trauma survivors. She'd tried teaching them self-regulating strategies drawn from Dialectical Behavior Therapy, but she'd often run up against their ingrained physiological reactivity. That changed when she added neurofeedback. One of her clients, a talented young teenager with a childhood-abuse history and Asperger's disorder, had no friends, had been hospitalized with bulimia, and was prone to violent outbursts, in which she threw things at walls. Over several years of neurofeedback and conventional psychodynamic therapy, the girl developed the capacity to empathize with others, stopped her violence and bulimia, and went off to a demanding college.
Over the years, Fisher, one of the consortium of therapists who bought the Othmers' EEG Spectrum company out of bankruptcy in 2002, came to believe that neurofeedback could help rewire brains that had failed, because of neglect or abuse, to develop crucial, early neural connections in the frontal cortex, and could reregulate primitive brain parts deep in the skull, like the fear-driven amygdala. But she soon found that neurofeedback was a double-edged sword. Placing electrodes on both sides of the head simultaneously made unstable people more stable, for instance. Too much of it made them rigid. A little left-side training made the depressed more confident. Too much made them sociopathic.
Fisher's young client with Asperger's, for instance, started stealing things from her boarding-school dormmates about two years into her neurofeedback training. When Fisher finally found out (the girl kept it from her for months), she stopped left-brain training, and got the girl to go to the principal and admit what she'd done. Fisher's bearded and respectable husband John, after doing left-side training, found himself zipping in and out of traffic one night, self-righteously pursuing a 19-year-old who'd cut him off, flipping the boy the finger and intending to teach him a lesson--the kind of thing John hadn't done in 30 years.
Sebern Fisher became a Cassandra at conferences, warning anyone who'd listen that good neurofeedback should always be held within a container of psychotherapy and human relationship. Someone--hopefully someone with some wisdom--had to decide which brain changes to target, and in what order. Someone had to notice when a change made a client feel better but act worse. Someone had to notice when an excess of virtue became a vice.
"Something Just Went Snap"
In April, after 10 neurofeedback sessions with neuropsychologist Christine Kraus, my brother called and said, "Something just went snap." He'd awoken alert and had functioned all day on a single cup of coffee, rather than downing four or five cups without ever really getting out of a fog. He was less anxious. He could go to the next room for a tool and come back with it, instead of getting lost in another half-finished project. The effect held the next day, and the next, and the next.
He took some of the junk surrounding his barn to the dump, earned cash selling scrap metal, and worked a shift as a limousine driver. After barely having opened a book in 15 years, he started spending an hour a day poring over a complex economic and military history of World War II. He talked to me more about how he planned to cover his monthly expenses and less about a distant, glorious future.
Then, in mid-May, an axle on his truck broke, he ran out of money, and he fell into what he called a "reality-based" depression. My heart sank. He kept going to neurofeedback (our mother paid), but the depression didn't lift until mid-June.
I'd hoped he'd magically emerge from his desert chrysalis, out of debt, with steady, well-paying, absorbing work; perhaps even with a girlfriend and a home mortgage. But what has emerged instead are small mercies. The story he tells about himself is less self-critical, less defensive, more hopeful.
"The soil here is decomposed granite," he said after his depression lifted and his alertness returned full force. "If you put grass down, it just doesn't grow, unless you first lay down manure and wood chips. When I tried [to change my life] before, it was like trying to grow something in barren soil. You can read a book on time management, but if your head's a paint-mixer, what difference can it make? This neurofeedback is doing something on a root level that might make a difference. I know now that there's something wrong in the wiring. It's a motherboard problem--and it's repairable."
In Minneapolis, meanwhile, clinician John Anderson, a neurofeedback trainer for Stens Corporation (one of several commercial rivals of EEG Spectrum), recorded a qEEG of my friend Patrick Dougherty's brain. Then he placed an electrode on a spot under Patrick's right eyebrow. Within three to five minutes of training using a highly sophisticated neurofeedback computer system made by the Lexicor corporation, Dougherty felt calmer. Calmness pervaded his life, pooled, swelled, and spilled over. He stayed behind a truck in busy traffic for six blocks rather than cutting in front to save a millisecond before parking. Within four weeks, his scores on the IVA (a test of variable attention) went from highly impulsive and inattentive to the normal range.
He reorganized a "chaos cupboard" of accumulated junk at his home and filed six months' of paperwork piled on his office filing cabinet. He felt more present, more thoughtful, and less impulsive with his clients, and they noticed the change. Navigating a difficult divorce, he didn't spin out in worst-case scenarios and often found a smile on his face. "I don't get as shook up, I don't get as mad--I don't seem to have access to it," he reports. "But what I do have access to is happiness. I'm happier, more peaceful, with a quiet happiness--a steadiness that brings me pleasure."
As for me, I finished an article two hours before a deadline rather than one hour late. I felt more confident and decisive. I slept more deeply. I assembled tax records for my accountant two weeks before April 15, rather than six weeks after. I went to the airport bringing a small rollaboard of perfectly matched clothes that I'd packed two nights earlier, instead of lugging on three heavy bags packed in a panic at midnight the night before the flight. Then I started waking repeatedly at night again, with worries cycling through my head, feeling more self-doubting and obsessive than I'd ever been.
When Alice fell down the rabbit hole into Wonderland, she discovered a huge mushroom and broke off a piece with each hand. When she nibbled from the right-hand chunk, she shrank so fast she hit her chin on her foot. When she took a bite from the left, she grew so tall she could barely see her own shoulders. Only by repeatedly overshooting the mark did she get herself to her right size again. My experience of neurofeedback has been a bit like that.
In the course of this article, I was offered free neurofeedback sessions by many of the people I interviewed. Each had a favorite electrode placement and reward frequency--a personal signature, like a family's special recipe for pecan pie or winter squash soup. One tried left-brain training followed by right-brain training, to soothe my mild depression and anxiety; another put an electrode just above each ear at the same time for neurophysiological stabilization; another plunked two electrodes just back of my forehead to improve my planning and decision-making; another tried two electrodes toward the back of the skull, close to my brain's parietal lobes, to improve my clumsiness, key-loss tendencies, and weak spatial orientation. (My handwriting got better.) Like an impulsive tourist at a gelato stand handing out free samples, I had trouble saying no. And I paid a price.
After one session, I spent the better part of three days in a backyard hammock, as involuntarily relaxed as someone on barbiturates. My sleep got better, and then worse. Another time, I chewed up an enormous wad of gum like someone on methedrine. Why had I let people I hardly knew put a Mixmaster into my brain? At the start, I'd assumed this wasn't rocket science. Now I realized it is a kind of brain surgery.
I write these words after 25 neurofeedback sessions--15 short of the 40 recommended for lasting change. Using equipment borrowed from EEG Spectrum, I still go to our spare bedroom two or three times a week and stick electrodes onto my head, following protocols prescribed via e-mail by John Anderson in Minneapolis, who's radically helped my friend Patrick Dougherty.
I feel less like a butterfly tethered to a rock. I think more about the next five minutes and less about the next five years. I say fewer things I regret. My scores of impulsiveness have normalized, and my scores of inattentiveness nearly so. Brian and I spent the last couple of weekends assembling and installing an entire wall of Ikea bookcases, and I never once felt overwhelmed or dizzy. My treasured books, hidden in a closet since I moved in four years ago, are now finally on display.
By silently looking at a computer game, without any form of human interaction, I had changed quirks that hadn't responded to meditation or to scrutiny of my subconscious motives. In the grand scheme of things, the improvements may be trivial neurological fixes to anyone but me. But neurological changes don't exist in a vacuum: they set off changes in a wider world. Having my books out has made me more at home in this house and changed the way I'm perceived here. I speak up more. My relationships, and the stories I tell about them, are shifting, too.
I'm grateful for this, and surprised by the emotional sea changes that I hadn't bargained for. I rarely feel mildly depressed anymore. I'm warmer, more flexible, and more forthright with my stepsons. I worry less and express my love for Brian more freely. But I'm not "there" yet--wherever "there" is. I'm still waiting for all the cherries to line up in the slot machine and deliver the jackpot.
At the dawn of the 20th century, just before World War I, Freud speculated about the contents of the black box we call the brain. To a society that still had faith in the power of human rationality and probity, he told a new story: there are aspects of the self outside conscious awareness, and a "talking cure" can help reshape them. Now that we know more about the shifting infinitude of the neurochemicals and electrical pulses that make up the brain and nervous system, his details and logic (such as the notion that depression is anger turned inward, or that nothing is an accident) seem hopelessly formulaic. But his story shaped how 20th-century human beings saw themselves. It gave them hope that a person could change, when held in a net of intimate connection with a therapist. In that intimate connection, one could illuminate one's hidden symbolic life; one could speak aloud half-remembered stories of childhood and relationship that had enslaved one; one could fashion new narratives that would lead, hopefully, to a measure of emotional liberation.
Now, at the dawn of the 21st century, brain technology is allowing us to access corners of the black box that Freud couldn't even imagine. Not coincidentally, odd and apparently effective new therapies--neurofeedback, EMDR, Dialectical Behavior Therapy, Thought Field Therapy--are simultaneously gaining ground. All focus heavily on reregulating a disregulated neurophysiology. And all suggest an understanding of human identity and experience that draws little on the story- and symbol-making dimensions so essential to Freud's narrative.
Those who are informally researching neurofeedback are giving us the most subtle, highly calibrated feedback on brain processes that the human race has ever known. But we're a long way from weaving these data into a more inclusive story of psychological and human change. So far, it's clear only that the old categories--psychology, neurology, physiology, cognition, and emotion--make sense only when you're outside of the black box of the brain, imagining. But what new categories will take their place? And how will those categories interweave with notions of a good human life?
Perhaps, in a decade or so, neuroscience's discoveries will reshuffle all the categories in the DSM, making it the Diagnosistic and Statistical Manual of Emoto-Cognito-Neurophysiological Processing and Disregulation. Just as the Inuits are reputed to have dozens of words for snow, the new brain science has already pointed out the need for words to differentiate between several forms of depression that don't look alike on brain scans, and respond to different medications and neurofeedback treatments. Perhaps, on the other hand, neurofeedback will remain where it is now, somewhat outside the mainstream, practiced by a devoted coterie but dismissed as experimental by the same academic and medical authorities who once dismissed acupuncture.
No matter what happens, these new understandings--of how cellular processes of emotional regulation and disregulation profoundly shape human thought, response, behavior, and even story--are likely to continue to be almost intoxicating. Being able to tweak the activity of a pinhead's worth of neurons is remarkable. In the intoxication, it's easy to applaud the change and forget to ask whether it's good, and how it'll be used. Only wisdom can decide when a longed-for stability crosses the line into rigidity. Only the wise know when increased efficiency and confidence shade into narcissism and even sociopathy. And that is why, no matter how good the machines get, the sages and wise women of psychotherapy and religion will have a place.
Questions about narcissism and rigidity are ultimately moral questions--questions human beings have pondered since people first hung around fires together, telling folktales and epics about the hero's quest and his final return. Such questions can't be answered by machines. Actually, the ancient Greeks have already taught us that every virtue needs its constraining opposite: honesty without kindness, for example, is cruelty. Similarly, the ancient Buddhist masters warned us that each good quality has its "near-enemy": the near-enemy of even-mindedness is indifference; the near-enemy of compassion is pity. Unleavened by such traditional wisdom, neurofeedback could help shape people into ridiculous parodies of the attributes that are so revered in the 21st-century marketplace--making them hyperefficient, capable of unlimited work, and never, ever depressed or self-doubting.
In the 1930s, the blues guitarist and songwriter Robert Johnson was reputed to have gone out to the crossroads alone at night and sold his soul to the devil in return for superhuman musical talent. In legends about such Faustian bargains, the desperate trade always takes place in isolation and involves a desire for some single-pointed form of perfection, outside a larger context of human relationship. As the 21st century advances and neurotherapeutic tools become ever more powerful and efficient, we'll depend more than ever on the great wisdom traditions to keep us away from the crossroads, where we may be tempted to bargain our souls away, and to remind us of where we all came from--hanging around the fire together, telling stories.