Remote Therapy and Neurofeedback amid Social Distancing

18 Apr

Tom and Terri Collura

BrainMaster Technologies

Stress Therapy Solutions

 

In this discussion we will address some of the clinical, technical, and medicolegal aspects of remote training.  Fundamentally, remote training consists of sending EEG neurofeedback equipment into the home, school, or office, where it is used in the absence of direct supervision of the responsible clinician.  We are seeking a new model, in which the EEG instrument becomes more like an electronic dispenser, that administers treatments according to specific protocols and parameters set by a supervising clinician, and administered in a remote location (home, school, office).  We seek provisions that ensure that the clinician has access to ongoing information regarding the progress of training, and maintains a level of control sufficient to ensure the quality and effectiveness training, without the need to be physically present during all training sessions.

 

There are certain barriers to effective remote neurofeedback that must be cleared, if progress is to be made.  It is an unavoidable fact that neurofeedback is a procedure that requires clinical supervision, and that the requisite equipment is regarded as a prescription device.  Moreover, the clinician is responsible for the conduct and results of neurofeedback training, even if sessions are not conducted in the office.  Finally, it is clear that remote neurofeedback will not gain the acceptance it needs, unless there is a way to ensure that quality is assured, even when equipment leaves the office.

 

Remote neurofeedback training should not consist of simply sending a clinical instrument home with a trainee, while expecting a parent, companion, or the trainee themselves to become a neurofeedback therapist.  Rather, the remote-based system should have a level of simplicity and control that makes it easy to use, while ensuring compliance.  The clinician requires ongoing indications of the progress of treatment, the time, duration, and outcome of individual sessions, EEG changes, behavioral notes, and so on.  The key necessity is that clients can easily perform the training that has been defined, and that the clinician can be made quickly aware of how things are progressing, and has the ability to make changes as necessary.

 

We believe that in order for neurofeedback to reach the next level of acceptance and deployment, costs must be decreased, and time in the clinic must be reduced.  We see the conventional series of 40 in-office visits at $50 to $100 apiece, being replaced by a small number of in-office training sessions, which punctuate the remote training.  We seek a new way of looking at equipment, software, and clinical activities, which will help to transform neurofeedback from a primarily clinic-based activity into one that can be conducted any time, any where, while maintaining a level of clinical supervision and confidence that sufficiently approximates what can be achieved in the clinic.

 

If we can achieve these goals, the following realities may come to pass:

 

  • A reduction in the cost of a typical neurofeedback regimen from the current level of $2000-$4000, to $500-$1000.  This will have a profound effect on the attitudes of insurance providers, schools, parents, and other entities that bear the financial burden of the training.

 

  • An increase in the number of clients that a given practitioner can serve, from 20-40, to 100 or more.

 

  • A shift in the professional and financial picture of clinical neurotherapy, in which charges for professional services, equipment rental, remote supervision, and ongoing assessment supplement or replace the usual office visits, making the clinical task less labor-intensive, and more cognitive in nature.

 

  • A broadening of the client base of all clinicians, who now can overcome geographical and financial barriers, as they serve a wider range of clients than ever before.

 

  • An increased awareness and acceptance of neurofeedback, as more clients are able to afford training, and reap the benefits.

 

Many practitioners believe that effective remote training requires some form of real-time connectivity, so that the training session(s) can be monitored live, to ensure that all is necessary is to ensure that the training is proceeding as planned, but this can be managed by a system that allows the supervising clinician to see results, review self-assessments and related reports, and discuss progress over the telephone.  Indeed, one of the more active clinicians we know has more than 30 EEG systems in the field, in various states, some thousands of miles from the office.  All clients must being with an in-office orientation and training, and then proceed to a home-based training program, in which geographical distance is not so much of an issue.

 

While this practice has been successful so far, it clearly taxes the abilities of clinicians and trainees, as well.  Home users are obligated to learn to use equipment according to the same procedures as a clinician, including setting up the protocols, managing thresholds, monitoring progress, reviewing summary information, and determining whether the progress is satisfactory.  We seek to relieve much of this burden on both sides, while ensuring the quality and effectiveness of remote training.

 

Overall, we see the use of home/school/office EEG increasing 10-fold or more, as a result of simple, yet crucial changes in how we approach the total set of issues.

 

To these ends, we see the following components as being critical to the effectiveness of remote training:

 

  • Provisions for clinicians to design protocols and sessions on one system, that can be conducted on another system.

 

  • Means to convey protocol and session settings to the remote system via inexpensive and simple means (email, floppy disk, internet, etc).  This should include a method for remote trainees to incorporate this information into their system in a simple, fail-safe manner.

 

  • Means to ensure that remote trainees are limited to the prescribed activities, and cannot go outside the boundaries that have been defined.  This should also include a means to ensure that trainees have actually conducted the prescribed training, for the recommended times and durations, and that the resulting EEG data reflect appropriate changes.

 

  • Means to convey results to the clinician, again via inexpensive and simple means (email, floppy disk internet, etc). Results should include general session data (time, duration, etc), training results (points scored, percent rewards, etc), specific EEG results (amplitudes, etc), and associated self-report and behavioral data.

 

  • Means for the clinician to review training results, make changes when indicated, and convey these changes back to the remote location.

 

Based on a focus on these simple requirements, it is possible to configure systems that effectively address remote training needs, without increasing their complexity or cost.  Indeed, it is possible to produce home-based systems that are considerably affordable, with an initial capital cost of $1000 or less, and that can be leased, loaned, or otherwise allotted to remote trainees who do not have to bear the purchase cost of equipment.  Overall, we see it possible for remote trainees to subscribe to “pay as you go” plans, in which EEG training is made available for on the order of $100 or $300 a month, thus reaching a considerably enlarged client base, while providing effective, quality training.

 

 

Information, Entropy, and Freedom of Choice – How the Brain Decides

28 Apr

Source: Information, Entropy, and Freedom of Choice – How the Brain Decides

Information, Entropy, and Freedom of Choice – How the Brain Decides

28 Apr

When we work with the brain and neurofeedback, we enter a unique realm of intervention, compared with conventional modalities. Our culture has been built upon an emphasis on the physical and chemical reality within which we live. Our healers tend to be surgeons who work with bones, tissue, and organs. Mental interventions are dominated by chemical diagnoses and medical treatments to “put things right.” Neurofeedback appeals to the “soft” concept of information, rather than the “hard” concepts of chemistry and physics.  Neurofeedback can produce lasting change at the synaptic level, but the mechanism of change is one of information management, not direct physical effect.  It is appropriate to ask, “what does it take to make a decision?” In the most abstract sense, the following things are needed: The ability to discern, the energy to make a change, and the intention to choose. These three factors, discernment, energy, and intention are sufficient to cause any individual or system to change, and to use that change to lead in a particular direction. If any of these factors are missing, directed change is no longer possible.  Neurofeedback operates by making the unseen seen, and by making the unfelt felt. By providing information to the  trainee, neurofeedback provides the key element of discernment (of brain state, via the EEG).

Because we are not normally aware of our brainwaves, this information is missing in everyday experience. Given that brain state can be discerned, what are the factors that allow positive change to occur? Quite simply, they are the presence of the intention to change, and the energy to make that change.  The amount of energy needed to change a system can be exceeding small. James Clerk Maxwell is responsible for the concept of “Maxwell’s Demon.”  This is an imaginary agent that has the ability to determine the temperature of a particle, and to open or close a door that allows that particle to pass from one chamber to another. It can be shown that such an agent could cause a contained gas to become hot in one chamber and cold in the other. In principle, such an agent could create an unlimited amount of energy, simply by letting tiny particles selectively move. In reality, no such demon exists. However, this concept shows us in principle, the immense power of the simple ability to make a decision. And fortunately for us, our brains are endowed with  the ability to make discernments and decisions that facilitate our progress in life, given that we choose to make decisions. This capacity leads to the possibility of learning, or operant conditioning, which is the guiding principle that leads intelligent beings to understand and adapt to their environment.  In neurofeedback, each point earned, each moment of progress, constitutes a tiny decision.

Each decision produces a change in direction, and with proper care, that direction is well determined and purposeful. The presence of information, permitting change, produces no less than the freedom of choice that separates us from all other beings on earth. We  are capable of making discernments, and of making decisions based upon them. When a system is deprived of the ability to discern, or the information necessary to make a decision, free will is compromised. Freedom requires good information, and the clarity to make decisions. In summary, the power of neurofeedback lies in the simple ability of the brain to discern small events, and to make small decisions. Through the progress made during thousands of tiny decisions, great change can become possible, and significant order can be achieved. And what ar e the elements that make this possible?

Belief in change, a willingness to change, and the intention to use the information provided.  Given these precursors, only a tiny amount of energy and  effort are sufficient to reap all the benefits and progress that are there for the taking.

Cost of health care and public policy

9 Mar

I ran across this graph recently, and it underlies the main concern with health care in the U.S. We have an increasingly expensive, yet less effective, health system than any other country in the world. The factors beneath this are many of the same ones we emphasize as mental health and neurofeedback practitioners. Proper diet, exercise, life habits, and avoidance of toxic substances and medications, would do much to alleviate this situation. Yet we do not see much activism in this area. Instead, health costs spiral, and increasing amounts are fed into the insurance industry and big pharma.

us-healthcare-system

Another related article can be found at:

https://www.theatlantic.com/health/archive/2016/01/middle-aged-white-americans-left-behind-and-dying-early/433863/

Positive steps by government and policy makers to address these concerns, and to provide funding for mental health and interventions based on prevention and brain plasticity would pay off big time,

Something to think about,

Tom

Brain and Mind in a Comprehensive View of Mental Health

9 Feb

The science of mental health is converging on a brain-based model of emotional responses and decision-making into a readily accessible format. There is a need for models which can be used by counselors and other mental health professionals with or without the use of extra physiological monitoring or biofeedback equipment. The creation of such a model, however, can make use of scientific methods and processes, that reveal brain activity related to thoughts, feelings, and behaviors, in a global context.

From our perspective, the brain is a pattern-recognition and decision-making machine, that is tailored to operate in the body of an organism. Even though it is a part of the organism, it has its own goals, and its own means of seeking those goals. Whereas an individual may have goals that include safety, nourishment, comfort, social interactions, and other high-level goals, the brain itself has much simpler scope. The brain’s goals are better understood in terms of the mechanics of recognizing patterns, detecting danger, considering options, determining the safety of various options, and, finally, controlling the motor functions that allow the organism to operate in its environment.

In one sense, the brain can be thought of as a parasite, a “rider” that is using its position in the organism to pursue its own goals. The brain uses its host to implement a program that ensures that it will have adequate food, oxygen, heat, and protection. It has further goals that involve thermodynamic and physical optimization, minimization of energy expended, and the seeking of novelty and pleasure, as examples. Indeed, one of the most important roles of a therapist is to help the client get their brain’s goals in line with their own goals. Many disorders, from depression and anxiety, addiction, and compulsive thoughts and behaviors, stem from the brain’s seeking of locally optimized results, blind to the overall goals of the host. According to Gregory Bateson, “The major problems of the world are the result of the difference between how nature works and the way people think.” What we typically think is not “real” and may have little connection with reality.

This is why neuroscience provides a unique perspective on human behavior and mental health. By understanding the underpinnings of the brain’s roles and priorities, we can better understand why an individual would think, feel, and act in a certain way. The individual may believe that he or she is in control of their life, making their own decision, and setting their own priorities. But the fact that everyone is dependent on a properly functioning brain for this to happen means that what we think is going on may be far from the facts. Future posts will describe the relevance of neurophysiology, particularly quantitative EEG and neurofeedback, to understanding and working with these issues.

Noise in the Brain and Free Will

2 Aug

There is an interesting article authored a couple of years ago by Dr Jesse Bengson’s team at the University of California on how EEG “background noise” appears to be important for decision-making.  I find this particularly interesting because it is consistent with one of my ideas about how neurofeedback works.  I believe that in order for the brain to learn, it must spontaneously explore its operating range, and this only happens when there is chaos or noise.  We all have found that  a “stuck” brain will not learn, and that is one reason we tend to apply “unsticking” interventions such as pEMF, EMDR, ISF, and other methods.  So this article not only shows how “noise” is important for decision-making, but that it may be essential to the very existence of choice, or free will.

 

http://www.dailymail.co.uk/news/article-2665089/Scientists-determine-free-humans-stems-background-noise-brain.html

 

I hope you will “choose” to read this, and ponder its implications.

 

EEG Imaging and Biofeedback in the Traumatized Brain

3 Jun

screen.2013.09.19_13.31.53The attached talk was presented at the 27th Annual Psychological Trauma Conference in Boston on June 2, 2016.  These results show brain activation patterns that found in individuals experiencing traumatic and emotionally charged stimulation and experiences.  We find that the responses of the frontal lobes demonstrate specific positive and negative emotional responses, and underlie decision-making processes.  The frontal hemispheres are lateralized, in that the left hemisphere and right hemisphere perform different functions, and that both are necessary for healthy, flexible, adaptable responses.  Depending on past experiences, particularly trauma, this balance of reactivity may be affected.  The left hemisphere takes care of sequential, logical processing, and produces positive, or “approach” responses.  The right hemisphere takes care of parallel, recognition-based responses, and produces negative, or “avoid” responses.  Both of these are important, so that the individual is able to respond appropriately to positive or negative stimuli and situations.  Examples are given of both adaptive, flexible responses, as well as fixed, inflexible responses.  Inflexibility is associated with reactive, fixed, and maladaptive responses.  Imaging an biofeedback of brain activity according to this model can be applied to counseling and other clinical activity, to help to empower and enable clients to have healthy responses, that are consistent with goals and produce beneficial mental states and behaviors.2016 Trauma Collura EEG

The following link is to a large collection of published papers describing neurofeedback in various clinical situations, showing effectiveness in treating various disorders, including those associated with trauma.  Collected Publications

 

Toward ecologically valid studies of innovative therapies

23 Mar

A key concern in the development and deployment of innovative therapeutic technologies is the availability of validation studies that support clinical practice. Specifically, the fields of biofeedback and neuromodulation have undergone significant evolution in the past 20 years, with emerging methods including advanced analysis of signals from the heart and brain, and increasingly elaborate feedback schema. These are often based on clinical experience, professional judgment, intuition, and repeated experimentation and variations in techniques.

Controlled studies have been put forth as a “gold standard” in the evaluation of emerging therapeutic methods. It has been put forth that a randomized, blind, sham controlled, crossover design is “the only way to go.” History, however, has shown a very different picture. The rigid RCT approach suffers from a number of critical problems that have, overall, served more to confound and obfuscate the benefits of these methods. Among the flaws in using RCT’s are a lack of ecological validity, problems with subject expectations and the experimental environment, unfamiliarity with the workings of practical therapeutic work, and at times, sheer incompetence on the part of the practitioners.

Controlled studies typically cost 100’s of thousands, even millions of dollars, and require significant planning and resources. They may lack ecological validity, and are often conducted by non-practitioners, and may be conducted in other than an active clinic. If methods are to innovate, the control group should be the existing practice standard, including medications. Studies that have taken this approach have been successful (Meisel, Duric). Hammer (2012), for example, demonstrated similar results for an emerging method, compared to a “traditional” neurofeedback treatment, for insomnia.

Another problem with RCT’s is the cost of absorbing all the treatment costs for all participants, for ethical and scientific reasons. This is then confounded with the fact that all participants are getting free treatment, which affects the level of investment and expectation, putting it outside normal clinical parameters. Studies that fit into routine clinical work can be much more flexible, in that the “control” group, which would be treatment as normal, could be conducted and paid for as usual, and compared with an experimental treatment. This would improve the ecological validity, in that clients receiving actual treatments have the same expectations and costs as encountered in actual clinical work.

The Information paradigm and brain/mind health

10 Feb

As science and clinical practice evolve, we move through a series of paradigm shifts.  Things that were once thought of as abstract entities such as ego, motivation, and mood, become successively reduced to different levels of science.  We have a chemical brain, we are told.  We have an electrical brain, we are told.  We are all comprised of vibrations, that we share and use to control and communicate.  Einstein stated that matter itself is merely a reduced vibration of energy.  Students of electrochemistry, quantum physics, and such understand the composition of subatomic particles, how they interact, and how they produce the illusion that we call reality.

Current neurobiology talks about synapses, neurotransmitters, proteins, and networks.  The more we learn, the more we think about the roles of dc potentials, glial activity, subsynaptic organization, and metagenetics.  Microtubules and quantum uncertainty are brought in as possible underpinnings of free will, or even “free won’t.”  More recent work has verified something that many have speculated on for decades, that simple electrotonic conduction of slow fields in the neural tissue can have effects across neurons.  This further provides support for the use of low-power pulsed electromagnetic fields pEMF as a viable form of neuronal modulation.

What is the common underpinning that will incorporate all of these dimensions and considerations, and provide a theoretical basis for neuromodulation and mental health?  It is, quite simply, that of information itself.  The organization of any entity into an information-carrying medium is quite automatic and implicit.   Any system in which a path or decision can be mediated, communicated, or put into action, is basically manipulating information.  What are the scientific principles that we use for this investigation?  Information theory, chaos theory, dynamical systems, nash equilibria, and strange attractors are more fundamental than neurons, ions, synapses, or pharmaceuticals.  The foundational work in mental health for the next century will focus on goal-seeking systems, self-organization, graph theory, and dynamic stability, much more than continuing to pry into details and mechanisms.  By studying the system, how it responds, how it determines and seeks goals, and how it recognizes and makes decisions based upon patterns, will take the forefront as a truly new science of brain and mind emerges.

Who are the names and concepts that we will look upon in the future in this regard?  Names like Norbert Weiner, Bertrand Russell, Claude Shannon, Benoit Mandelbrot, and John Nash.  Concepts such as cybernetic control, self-referencing systems, information content, fractals, strange attractors, and dynamic equilibria are at the center stage of pure information and control theory.  In neurofeedback in particular, the goal is one of providing the salient information to the system, and allowing it to learn.  The form that that information takes and how it is presented are the keys to the evolution of brain modulation technology and the self-modifying systems approach to mental health.

 

Music and the Brain

21 Jan

We recently had the opportunity to study the effect of music on the brain, in an unusual performance and imaging project.  Our friend Samuel Salisbury, who is a master of the Indian sarangi, created a 20-minute immersive soundscape, while we monitored the EEG of a listener.  The sarangi is a stringed instrument that is bowed, and has a complement of “drone” strings, so that the instrument produces a uniquely aesthetic and beautiful sound.  We used a new imaging technique in the BrainMaster BrainAvatar software, to create an individualized 3-D brain activation map that showed the brain activity changes that occurred as the listener became immersed in the music.   We used a new wireless, dry-sensor EEG technology, the BrainMaster Freedom 24, to record EEG without gel, paste, or wires.  This provided a very relaxing and compatible setup, for the performance.

We have posted a video of this perfomance at

SARANGI BRAIN VIDEO

We will be doing more of these performances, and including dance and other art forms, as our continuing interest in art, music, aesthetics, and the brain.