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USING NEUROFEEDBACK TO CORRECT THE INCORRIGIBLE

A chapter from the Textbook of Neurofeedback, EEG Biofeedback and Brain Self Regulation
edited by Rob Kall, Joe Kamiya and Gary Schwartz
The E-book is Available on CD Rom

USING NEUROFEEDBACK TO CORRECT THE INCORRIGIBLE

George von Hilsheimer & D.A. Quirk Page -

George von Hilsheimer Douglas A. Quirk*

ABSTRACT
Quirk learned to apply Mary Cover Jones' method of desensitization to psychotics despite Wolpe's self-reported inability to make Reciprocal Inhibition Therapy (RIT) work with psychotics. Von Hilsheimer suggested that he monitor stress by GSR and Quirk developed a library of lantern slides to substitute for verbal statements in the hierarchies of stressful stimuli. He automated this method and named it SCARS (Stimulus Conditioned Autonomic Response Suppression)

Quirk then applied the same methods and Sterman's EEG biofeedback training (increasing SMR at C-3/C-4) in a pilot study of 40 matched pairs of jailed felons; and in a larger pilot study of 110 matched pairs. From 1970 through 1995 Quirk trained 2776 felons by this combined method (temperature, GSR and EEG)

15% were rearrested in the 3 years following release. This compares well to the range of rearrest in studies summarized by Alter et al (1996) - 42 % to 78%.

INTRODUCTION ICTAL AND SUBICTAL DYSFUNCTION

Two of Quirk's colleagues, North and Breen, liked a method of scoring the Bender-Gestalt published in a book by Hutt. However, the Bender figures weren't really adaptable to the Hutt method. So North and Breen created new figures and called the test the Diagnostic Differential Test (DDT). Quirk took a course in administering the DDT and became expert at its interpretation.

One of the neurologists on staff who used Doug as a consultant gave him a list of 10 patients whose serial EEGs eventually demonstrated epilepsy but who did not have seizures. He was asked what test to use to figure out how to recognize them more reliably than with the EEG. Doug found a file into which he had put the DDT's those individuals' had taken. Quirk had considers those particular DDT's as uninterpretable.

About the same time Quirk had been wandering around the halls at McGill on a trip to Montreal and had a casual conversation with a psychologist who told him of some work he had been doing with pigeons demonstrating that when an ablation was made in the region of the brain's septum the pigeons that had been trained to respond to angular signs were post operation unable to differentiate the angles from curves.

The performance of his 10 puzzling patients on the DDT indicated that they couldn't handle angles as well as they could handle curves. So Quirk decided that he had found an indicator of deep diencephalic epilepsy. The first 70 patients he found with this sign on the DDT were all diagnosed by a neurologist as epileptic. All but one had typical seizure spindles on the EEG.

Quirk applied the DDT to a large number of arsonists, assaultists and rapists. Forty per cent of the serious arsonists, 30% of assaultists, and 25% of rapists demonstrated the sub-ictal sign on the DDT. This last group, the rapists with anomalous DDT performance, also demonstrated visible anomalies of the temporal lobe in CAT scans.Quirk's insight that a great deal of maladaptive behavior might be epileptoid was reinforced by Jonas in ICTAL AND SUBICTAL NEUROSES, and by Alvarez in NERVES IN COLLISION.

Quirk moved from Queen Street Hospital to the Clark Psychiatric Institute in Toronto around 1965 where he continued work using the SCARS GSR biofeedback we had earlier developed refining the process by which SCARS works.

Quirk was a pioneer in the use of volunteer workers in psychotherapy and most of the procedures he used were administered through automatic equipment monitored by volunteers. In his setting the doctoral level staff were free to diagnose and order treatments which worked.

BARRY STERMAN

In 1970 Quirk went to a meeting in Boston and heard Barry Sterman talk about his work with cats and human epileptics. Doug had lunch with Barry and on Sterman's recommendation bought an Autogen 120a EEG feedback device

From the Clark Quirk moved to the Ontario Correctional Institute (OCI) where he has spent more than 20 years improving an excellent facility. OCI had the lowest recidivism rate in the Western World.

In several years the OCI was recognizedby professional correctionists as the "best" correctional facility in North America

CRIMINALS IN JAIL

Quirk completed two preliminary studies of recidivism among OCI felons who had been discharged. He compared 55 pairs of high risk felons half of whom were treated by temperature biofeedback, by SCARS and by Sterman's EEG method and half of whom received only counseling. These violent felons demonstrated the subictal pattern on the DDT (viz., they didn't handle visual angles as well as visual curves) and on the EEG. The treatment of the 55 felons included volunteer administered temperature biofeedback training; SCARS GSR training; and EEG training of the sensorimotor rhythm at C-3 and C-4 as described by Sterman. These felons received 33 half-hour sessions of training. Subsequently he trained another group of 55 pairs of felons

Two years after his initial study of 55 pairs of felons 22 or 40% of the treated felons had been arrested again. Two years after the second study of 55 pairs of felons 11 or 20% of the treated felons had been rearrested. This rate of recidivism compared to 85% and 65% rearrested among the matched felons who were not treated by biofeedback. In other words, 60% and 80% of the treated felons were still free, while only 15% and 35% of the untreated felons had managed to remain outside of prison.

Quirk treated 150 more felons using the same method of SCARS and SMR neurotherapy, matched with felons receiving only counseling. We have been unable to verify the data on recidivism in this last study.An intriguing finding is that recidivism is a function of the number of training sessions. Half as many felons who were treated for 16 sessions were successful at remaining out of jail as were those who received 32 sessions. There is some effect of training even in a few treatment sessions.

In a careful study of 260 young violent prisoners Quirk was able to demonstrate that it is possible significantly to reduce recidivism from using relatively inexpensive, volunteer applied techniques. In an earlier study of 150 women whose average time on a closed ward had been 9 years Quirk demonstrated that 128 could safely be discharged after using inexpensive, volunteer applied biofeedback technique.

Quirk's elegant combination of several hypotheses implies that our own success using milieu therapy to remediate a different population of young felons may be enhanced by structuring our own assessments more elegantly in terms of a similar hypothesis as to the nature of the disorder which leads adolescents into treatment centers. These EEG responsive disorders appear to have a common characteristic in that they seem mediated through the physical structures in the diencephalon within which the limbic system functions. These disorders may be a special form of partial seizure with complex symptomatology.

BIOFEEDBACK IN PRODROMELESS PSYCHOSIS:CAN YOU FIX PATIENTS WHO GIVE NO WARNING?

INTRODUCTION

We are here concerned with the applicability of biofeedback treatment to some major disorders in which there appear to be no observable and no conscious prodromes to cue re-institution of learned corrective habits.

In some conditions, pain (e.g., migraine) or an aura (e.g., some cortical epilepsies) signals the need to activate self-regulatory behaviour which has been trained into a person by biofeedback. In contrast to migraine and grand mal epilepsy certain psychomotor seizures give nowarning at all, indeed the patient may not even know that he has hada seizure when it is over. In these conditions the afflicted person is unlikely to be aware of any cues that signal the imminent onset of a deep brain subictal foci causing bizarre behavior. These seizures used to be known as psychomotor, or templar lobe epilepsies.

PARTIAL COMPLEX SEIZURES

Today they are more likely to be called partial complex seizures (a shorthand which arised from Partial Seizures with Complex Symptomatology, [PSCS]). These subictal foci typically do not result in the motor seizures of cortical epilepsies; but, they are sometimes associated with dangerous criminal automatisms, or with the emergence of symptoms of some schizophrenias. In undertaking biofeedback treatment of these latter conditions, it may be necessary to adopt a different training procedure from the self-regulatory 'informational' feedback most commonly used as biofeedback.

In one study the present writers tested for deep-brain partial and complex seizures in the various types of offenses encountered in one year's admissions to a correctional treatment facility. We found that 40% of the arsonists, 30% of the assaultists and 25% of the rapists were subject to deep-brain paroxysms -- perhaps mediated by accessory activation of reinforcement, rage and/or sex centres of the drive centre.

By way of contrast, fewer than 2% of the remaining 'garden varieties' of less dangerous offenders exhibited this deep-brain epileptic syndrome. In several other studies we found that there was a consistent and strong relationship between strong emotional reactivity or weak emotional control and dangerous criminal actions.

BEHAVIOURAL CHARACTERISTICS

There are several reasons for selecting dangerous criminal offenders and schizophrenics as the subjects for the present study. The first obvious reason is the importance of these two types of conditions in society and in clinical psychological practice.

The second obvious reason is that both of these conditions pose particular problems for therapeutic intervention, and thus warrant study in the context of any emerging technology. A third reason is that criminals and schizophrenics have been found in many studies to demonstrate anomalous psychophysiological measures. These physical measures of psychological processes might be susceptible to modification by means of biofeedback treatment.

THE RELEVANCE OF CUES

Most conventional biofeedback training involves relatively continuous feedback tracking changes in the physiological responses being monitored. One point of view concerning the efficacy of such training is that the treated conditions are associated with detectable stimuli, and that these stimuli serve as cues to arouse the subject to reinstate the learned self-regulatory behaviour. Cuing stimuli might include prodromes such as pain in migraines, aura in epilepsies, the characteristics of settings such as a classroom or a verbal text in attention deficit or dyslexia, or even just the passage of time in meditation training, sleep regulation or chronic pain control.

It seems likely that most conditions possess some readily perceived cues that might be used to activate learned corrective behaviour.

PARTIAL COMPLEX SEIZURES

Some conditions are such that it would be extremely difficult for the subject to achieve such a conscious awareness of the cue as to be able to trigger a trained therapeutic response. This difficulty is probably most true in the cases of complex partial seizures and of psychotic disorders.

It is generally agreed that some deep-brain complex partial seizures are facilitated by alcohol ingestion. In these cases the act of drinking an alcoholic beverage might serve as a cue if the corrective biofeedback training were to be undertaken in the context of drinking. Failing this, the use of alcohol would come to serve as a cue only if the subject undertakes the necessary anticipatory training on her own. Otherwise, the patient has to rely on some other kind of cue.

The most common prodrome in deep-brain complex partial seizures seems to be heightened intensity of emotional arousal -- perhaps sometimes due to associated activation of the Olds and Milner 'drive centre'. The difficulty encountered by most people in using strong emotional arousal as a cue for behaviour is that emotional arousal tends to distract attention from conscious cortical self-regulatory habits. High emotional intensity tends to disengage the subject from such moderating habits. Distracted attention and disengagement is intensified by alcohol, by recreational and medical drugs, all of which are often involved in scenes of intense emotionality.

Stated differently, emotional arousal is mostly pretty confusing and, if intense emotion activates any habits, the habits engaged tend to be ones which were learned early in life and are relatively rigid habits in contrast to the more recently learned adaptive and regulatory habits. The patient learned to be disruptive as a child, what the therapist is ableto train in the adult is often weak and ineffective.

ISN'T IT A DISEASE? You Can Treat It And Cure It!

In 1967 von Hilsheimer published IS THERE A SCIENCE OF BEHAVIOR? reviewing particularly the success of replication therapies among the behavior therapies. Quirk had already been demonstrating the utility of our automated GSR biofeedback method with psychotic patients. By 1971 Quirk had dramatically demonstrated the effectof temperature and GSR training on schizophrenics who had beenin hospital for 2-45 years (average 9).

Both of us remarked that a consistent problem occured when working with dangerous criminals and with young patients whose early delinquency later proved to be a prodrome for psychosis. This problem was the absolute absence of a prodrome for destructive explosive episodes of behavior.

Clinicians of great intuitive skill were helpless when it came to a type of criminality for which no one had a solution. The common rate of recidivism in correctional institutions in the United States was generally believed to be 98% within two years of discharge. Prisons are so bad that it could be said that we were failing to criminalize only 2% of the juvenile population enrolled in our higher institutions of learning (correctional institutes). It happened that this general belief (even general in the correctional professions) was not true, but that is another essay (Alter op cit).

ANOTHER METHOD FOR REHABILITATING CRIMINALS: EEG

Joe Kamiya's extention of Shagass' earlier demonstration that electroencephalographic (EEG) activity could be altered and deliberately shaped by feedback of that activity, launched EEG biofeedback as a clinical reality. Kamiya's demonstration also suggested that the electrical activity of the brain is just a kind of behaviour that can be trained like any other. Let's phrase that in another way. We can condition the electrical activity of the brain. If this is true then any recognizable feature of the EEG whether it is pathological or healthy, desired or undesired can be changed. If behavior is associated with EEG activity then behavior can be changed by changing the EEG.

The recognition that brain activity is direct maleable was the seed from which grew Forester's habituation training for triggerable epileptics and Sterman's conditioning of sensorimotor rhythm (SMR) to inhibit epileptic seizures. EEG conditionability also made it possible to normalize learning performances of people exhibiting attention deficiencies and hyperactivity. But how widely might this idea be applied? (1) Some epilepsies, whose focus lies in the deep recesses of the old brain, are variously referred to as partial seizures with complex symptomatology (PSCS) or "complex partial seizures". These are non-convulsive seizures, or paroxysmal events, sub-ictal states, or seizure equivalents.

These deep-brain seizures have features that make them difficult to recognize.

They are hard to recognize, first, because sub-ictal states are seldom associated with convulsions; partial seizures do not cause dramatic losses of consciousness; the complex symptoms do not seem to have prodromes or even periodic unusual events that might suggest the need for a specific investigation (see Spiers, Schomer, Blume and Mesulam, Chapter 8, Temporolimbic epilepsy and behavior, in Principles of Behavioral Neurology, Mesulam, F.A. Davis Co., Philadelphia, 1985; Jonas, Ictal and SubIctal Neurosis and also see Alvarez, Nerves in Collision).

Second, these sub-ictal neuroses are not readily diagnosed by means of the EEG, partly because they are not easily triggered, as the cortical epilepsies can be triggered, by means such as photic stimulation or hyper-ventilation.

Third, the sub-ictal states or epileptic equivalents often seem to be accountable as behavioural derivatives of the developmental and social history of the criminal. Which is to say the victims often seem just to be bad boys with a long consistent history of bad behavior arising in a bad neighborhood with other bad boys.

Fourth, the behaviours associated with these sub-ictal states tend to distract the observer because they are intense, gruesome, unappetising and usually criminal activities. The underlying disorder is simply ignored. If the epileptic discharge in these seizures involves the Olds and Milner 'drive centre', the person may exhibit uncontrolled paroxysms of rage, sexual drive, hunger, satiety, alcohol use or other excitant automatisms such as fire-setting. The individual may seem perfectly normal in just a few seconds after the explosion of aberant behavior.

It is not too surprising that when you examine people in prisons that you find that the correctional population contains relatively large numbers of people exhibiting this paroxysmal syndrome; but it is the criminality, rather than the pathology of the behaviour which is most likely to attract the observer's attention.

If Barry Sterman's procedure for SMR training of the EEG is effective in treating some epilepsies, we thought it would be interesting to discover whether or not it could be used in these deep-brain partial and complex seizure states to modify their future criminal conduct. If their criminality could be reduced then the value of Sterman's method would be substantially greater than mere neurology suggested. In SMR treatment, the training feedback tends to be discontinuous and contingent on SMR occurrences -- that is, it is operant training, rather than self-regulatory training. Consequently, if SMR training reduces criminality, we reasoned that the SMR learning could be said to have become a stable new habit requiring no maintenance exercises. We could detect no recognizable prodrome in these cases to serve as a cuing stimulus to re-activate any learned self-regulatory strategy. So this self-sustaining response is exactly what we needed.

Of course the issue did not seem to us to be quite as simple as that. Clinical experience with offenders exhibiting complex partial seizures suggested that, whether or not it served as a recognizable prodrome, emotional arousal did appear to function as a triggering eventfor seizure equivalents in these people. There is a subclass of criminal which is floridly emotional and that emotionality is almost always associated with grotesque and extreme acting out.

If our observation was accurate and if we were to achieve a stable corrective habit by means of SMR training, it seemed necessary also to ameliorate the intensity of emotional arousal as part of the treatment. Accordingly, we applied the same SCARS method we had used with chronically hospitalized schizophrenic women to our criminal males. That is we included discontinuous and contingent training of the GSR at the same time we were using the EEG to train SMR. Von Hilsheimer'sexamination of the records after Quirk's death indicates that every singlefelon who received EEG training had first been trained in the SCARS method of GSR training. Aside from a few pilot cases where rather weak effects were achieved, we did not perform a formal investigation of the effects of SMR training alone on criminality.

Later, von Hilsheimer (1977) was to discover that his stringently diagnosed population of criminal psychopaths eventually emerged as chronic psychotics and proved to be the most resistant of all populations (including brain injured and chronically mentally ill patients) to the markedly good effects of the milieu and behavior therapy program he demonstrated (ibid).

We have already discussed the development of the method of training a group of chronic schizophrenic patients with a GSR training program suggested by some observations Mednick had made about the characteristic GSR activity recorded in schizophrenia and in individuals with varying burdens of ancestral schizophrenia. GSR modulation training was used with these subjects under the general hypothesis that catastrophic autonomic nervous system reactions are reflected in the GSR and are centrally associated with the maintenance of active symptomatic schizophrenia. The results we obtained after a three year follow-up interval justify the view that the arousal of anxiety, which was modified in the treatment program, may be more of a causal factor (rather than an effect) in schizophrenic symptomatology. The results also hold out some hope that some schizophrenic symptoms are susceptible to suitably designed biofeedback training. Moreover, theresults with our criminal population suggests that a less intense but similar anxiety system is at the root of the criminial character and thatcorrection of criminals demands reduction of their autonomic arousaland especially reduction of their physiologically determined anxiety.

CRIMINAL OFFENDERS

In our first pilot study with offenders, the subjects were 77 incarcerated criminal offenders all males, mostly displaying the most dangerous types of offenses, who gave evidence on the DDT of deep-brain epileptic events. Presumably their deep subictal events were underlying their excitement-seeking actions, their 'blind' rages, their excessive sex drive and other derangements which were involved in their criminal conduct.

STERMAN'S SENSORI-MOTOR RHYTHM (SMR)

By the time we were ready to work intensively with criminals Quirk had heard Sterman give a paper at the 1970 Biofeedback meeting in Boston. He had discussed Sterman's procedures with him and both of us had obtained an Autogenic Systems 120a electroencephalometer feedback instrument and had begun training a variety of subjects to produce sensori-motor rhythm activity (SMR). EEG activity istypically described as delta, theta, alpha, beta (for 1/2-3, 4-7, 8-13, >13). The biofeedback professional adds to this nomenclation the term SMR deriving from Sterman's discovery that while 13 Hz is dominant through the brain, training 13 along the Fissure of Roland results in resistance to epileptic seizure - even that produced by toxins such as hydrazine (an normally infallible producer of seizures of fatal intensity). The amplitude of 13 Hz is notoriously small in epileptics over the RolandicFissure (aka Sensorimotor Strip or sulcus centralis).

We began to train SMR using the 120a Autogen version of the EEG. All of our subjects were also trained to produce an increase in skin resistance (GSR) and skin temperature using the SCARS method we had developed a decade before and used with a wide variety of scores of subjects, including our hospitalized female chronic patients.

NO PRODROME

It is worth repeating that EEG anomalies are notfrequently observed in patients with these deep-brain sub-ictal or complex-partial ictal events. It is also worth repeating that no recognizable warning events tend to occur. In fact, neurological lore is that this kind of seizure requires an average of six nocturnal extended EEG runs in an awake subject using nasal pharyngeal leads where the electrodes are placed close to the base of the brain up through the nose and the pharynx.

The fact that the subject has no EEG anomalies means that the therapist cannot depend on training which suppresses unwanted signals in the EEG. It also means that the subject cannot establish a cue to aid him to learn how to enhance his SMR or to normalize his GSR.

DEPENDENT VARIABLES

During the training phase of these studies on felons, the behaviour subjected to operant training was sensorimotor rhythm (SMR) in the EEG, the temperature recorded at the left index finger, and the galvanic skin resistance (GSR). In all of the studies of felons, both of these responses were recorded and shaped. This is unlike the work with the chronic hospitalized psychotic patients who were only trained by GSR and temperature.

SMR was recorded on an Autogenic Systems 120a electroencephalo-meter. Since absolute SMR values were less of interest than changes in the strenghth of the signal at 13 Hz, we placed the electrodes at C3 and C4. The limits we adopted and set in the equipment to represent SMR activity were 12 to 14 Hz between 10 to 30 microvolts.

It should be remarked that these values for amplitude (10-30 uV) will appear to be high to those who use equipment manufactured in the 1990s. An equivalent amplitude limit on contemporary equipment would be closer to the 2 to 10 microvolt range. We restricted the amplitude in this way in order to limit equipment response to high amplitude artifacts in the low frequencies.

The 120a Autogen EEG does not have an Inhibit command, so that so-called 'inhibits' have to be all of that activity which is excluded by the setting for reinforcement. The 120a is supplied with verniers, that is knobs which are infinitely adjustable, and so lend themselves to the behaviorist technique of 'shaping'. We shaped the frequency down from a window opened to 10 Hz through 16 Hz and slowly moved the verniers to a setting of 12 Hz through 14 Hz, viz. 13 Hz. The amplitude remained fixed thoughout training. I have been slightly flabbergasted to receive telephone calls asking me to explain what I mean by "shaping". One shapes the behavior from broad limits to narrow. The dolphin is rewarded for lifting his head from the water, then for lifting higher, andall the way up, then backward and finally for a flip. "Shaping" is the fundamental principle of learning theory and technique.

We now call the method, using temperature biofeedback training, GSR feedback training (in Mary Cover Jones' model of successively more stressful stimuli) and EEG training of the SMR, "Quirk's modification of Sterman's (1970) neurotherapy". An aside to those of you who bill insurance, when the insurance officer says "experimental" look horrified and say "1970!??".

The feedback used by Quirk was a frequency modulated whistle that occurred discontinuously and contingently upon this SMR activity; the machine will also utter a white "shhhhhh" sound and this option was used by von Hilsheimer.

In the typical case, the percent of the time in which this SMR activity occurred tended to average around 10% during the first few half-hour training sessions, and to rise to 45% to 55% during the last training sessions. I should say that today I urge practitioners to shape the behavior so that the client is achieving more than 85% feedback success. This arises from the consensus of the practitioners I have sampled. GSR was recorded on a locally constructed treatment unit. A digital display changes in thousands of ohms of skin resistance. The SCARS procedure described above was followed in exactly the same manner as with the hospitalized schizophrenic females. However, by the time we began working with felons, computer technology had become more economical and user friendly and instead of slide projections, in the more recent studies (1985 onward) computer graphics were used rather than projected pictures from slides. Any GSR increase ('less arousal') of 1K or more automatically (a) entered the new GSR value in a memory chip for comparison between chip and meter, and (b) changed the slide the subject was watching or advanced the picture by computer. The slide contents represented areas of emotional arousal selected for each subject from her responses to a fears survey schedule. More individualization was available once the pictures were computerized. Video feedback (slide change) was provided discontinuously and contingently depending upon successive increases in skin resistance. In the typical case, GSR values tended to be in the range 50K to 100K. As reported by Mednick, and consistent with our own experience in widely varying treatment environments with widely varying populations diagnosed as schizophrenic, the BSR of criminals was consistenly closer to that of normals than was the BSR of schizophrenics. The latency of change, the depth of change, and the lenghth or sluggishness of time to change was markedly less in felons than in schizophrenics.

The shape of graphed GSR change was sinusoidal especially in contrast to the graphs of schizophrenics. The more schizoid the characteristics of the GSR, the more severe the behavior and less positive the response of the felons to treatment.

We remarked that schizophrenics and felons tended to normalize their GSR/BSR values as well as the intensity of response in the last treatment sessions. The GSR values during the last treatment sessions tended to vary from 150K to 550K ohms.

I should also remark here that I am continually being asked that ifschizophrenics have such a high BSR in contrast to normals, "why do wetrain it up?" The real reason I do it is that Quirk told me to do so; and that for more than 40 years I have enjoyed success doing so. The BSRcontinually normalizes and comes down when you continue to train it up.At least that is true in all the clients I have observed in all that time. Presumably an increase in ohms of resistance is an increase in the comfort of the organism. Why such highly uncomfortable and dysphoric humans as schizophrenic patients should have such enormously highskin resistance is really unanswerable.

The dependent measures for the main effects of the studies of felons were re-occurrences of condition relevant behaviour during an eighteen month follow-up interval after discharge. Offenders were followed up through their cumulative justice system offense records a year and a halfafter release from the sentences in which they were treated.

Results

(1) The justice system records of the offenders accepted into this biofeedback treatment programme were reviewed an average of a year and a half after release from their treatment sentences. Of the 17 offenders who received 0 to 4 half-hour training sessions (i.e., essentially no treatment), 65% had been re-convicted of criminal offenses. Of the 10 who had received 34 or more half-hour training sessions, only 2 or 20% had been re-convicted of criminal offenses. Intermediate amounts of training were found to be associated with intermediate recidivism rates. Among these subjects, neither follow-up interval nor age were related to recidivism rates.

STUDIES SUBSEQUENT TO THE PILOT STUDY

The death of the senior author (Quirk) in December of 1997 after he completed a second draft of this paper, and read my third draft, made impossible our plans for a leisurely reporting of a long (25 year) series of studies done with SCARS and Quirk's Sterman treatment of a large (nearly 3000) number of jailed felons.

From 1970 until his retirement in 1995 Quirk continued to work at the Ontario Correctional Institute near Toronto, Ontario with the daily collaboration of his colleague at the OCI, Reg Reynolds. Those of us with more mobile staff may envy the fact that Reynolds and Quirk had lunch together every working day for more than 20 years. Quirk and Reynolds did significant work on Cognitive Behavior Therapy with felons; and Quirk carried out the EEG studies essentially enjoying the benign neglect of his nominal superiors. Reynolds is Quirk's executor and has been most helpful in organizing and mining Quirk's papers.

From 1970 through mid 1995 Quirk used the DDT method of examining felons, appointing them for EEG and SCARS training. The actual work of training was done by volunteers, including correctional guards, college students, housewives and others.

In a series of reports to the Corrections officials Quirk indicated that the three year recidivism rate from the biofeedback unit (using these techniques) had never been more than 45%, and in some groups had fallen to 15%. Overall, among nearly 3000 felons trained by Quirk's volunteers, the rate of recidivism was consistently close to 15%. In every comparative group, the rate of success of the biofeedback group was significantly superior to the results in the Ontario Correctional Institute (OCI) in groups which did not use biofeedback. It should be noted thatthe OCI was generally known as "the best jail in North America".

If you consider the violent crimes which the felons trained by Quirk would have committed and did not because of their training at OCI the Quirk Sterman protocol has saved thousands of lives.

Discussion

It was our intent originally only to discuss the results of the initial pilot study and then go on to the 25 year record which followed this study. The original study did suggest that even some prodromeless conditions would be susceptible to biofeedback interventions using appropriate applications. Adequate results will be obtained if the training is structured to foster the establishment of a new and stable habit to respond in healthy ranges of appropriately selected physiological responses. Lasting and self strengthening resistance to symptoms may be possible.

In these studies, the physiological responses monitored were considered to be operant responses and the responses were subjected to reinforcements to shape new habits independent of voluntary control or understanding. It is assumed that the habits thus developed might well be self-strengthening since, if properly selected, they should eventuate in self-reinforcement by enhancing the efficiency of the person's functioning.

The other issue this report reflects is the physiological responses we monitored and trained. In many conditions, there is a recordable physiological response that varies with the symptoms. It is probably relevant only to the preferences of the particular investigator whether it is the physiology or it is the behaviour drives, that controls or causes the other. Regardless of the 'causal' relationships involved, treatment might be effected by trained modification of the most convenient response to monitor. It is often easier to monitor the physiological response, and by training changes in the physiological reaction we may be able to change the symptoms of the patient. Why else would we do it? Oddly enoughin psychology sometimes whe change a response just to see if we cantrain it. Fortunately, the results here indicated that we were obtaininga more useful result. Modifying the skin resistance changed the behavior - either the felons didn't commit more crimes, or at least theyweren't caught and arrested doing them.

In the second study we talked about in this paper deep-brain epilepsy was detected in a subset of relatively dangerous offenders. In spite of the fact that EEG anomalies were not readily detected among these subjects for treatment modification, under the hypothesis that Sterman's method for SMR training offers a general treatment for epilepsy, we tried using Sterman with these offenders after we had done GSR training. We obtained stable and large effects which reduced the subsequent criminal behaviour of our felons.

Finally since study began 25 years of successful treatment of 2776 violent felons who had sub-ictal indications on a paper and pencil test, the DDT. The conclusions we drew are vital and indicate that the combination of temperature, GSR-SCARS training forming Von Quirk's Sterman method for EEG training are robust and effective training methods which have immediate relevance for today's population of criminals and mental health patients.

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