What is Neurofeedback?
Neurofeedback is biofeedback for the brain. Simply put, it exercises and helps ‘strengthen’ the brain, calms it and improves it stability. It’s easy—virtually anyone can do it.
Using computerized feedback, the brain learns to increase certain brainwaves that are helpful for improved function. The brain can alter excessively fast or slow brainwaves that interfere with good functioning. Over time the result is a healthier and better regulated brain.
For example, if someone has excessive amounts of certain EEG frequencies (alpha or theta) in the frontal lobe, they might experience depression or OCD (Obsessive Compulsive Disorder). By training the brain to reduce slower brainwaves and increase faster brainwave activity, symptoms are often reduced. Over time the new brain behavior is ‘learned’.
Neurofeedback, psychotherapy, and medications work hand-in-hand. Training can be used for patients on or off medication. There are no known lasting side effects after thirty years of research and clinical use. As the brain stabilizes, other modalities can become more effective.
Helping brain regulation
The brain helps regulate sleep, emotions, thinking, behavior, and much more. The training does not directly change sleep or other problems. It helps the brain become better regulated. Since sleep, emotions, or behavior are regulated by the brain, improvements are generally seen after training. Therapists report that changes can be profound.
When you give the brain information about itself it has an enormous capacity for change. Neurofeedback makes the information available to the brain almost instantly and asks it to make adjustments. This gives the brain a greater ability to self-manage or regulate. Changing the EEG improves activation, inhibition and cortical stability, while impacting regulatory mechanisms such as thalamocortical connections to sub cortical brain structures. These functions are fundamental to brain regulation.
We have all seen someone go from dejected and depressed (the other team just scored) to wild elation (your team just scored and took the lead) in seconds. State flexibility is inherent in the brain. A lack of state inflexibility (being stuck in a particular state) causes problems—from impulsivity, to Attention Deficit Disorder (ADD), to anger, to OCD. Neurofeedback increases state flexibility. EEG training also helps activate specific regions of the brain.
Neurofeedback is not new
In the 1960’s, when a lab taught cats to change their EEG’s with operant conditioning, no-one guessed that it would improve brain regulation and inhibit seizures. Yet, that research launched this field. Neurofeedback is built on the foundations of ‘alpha trainers’ from the 1970’s. But brain science during the 1990’s advanced the field of EEG Neurofeedback by using information from MRI’s, PET scans, and other brain imaging techniques. This information has helped identify sites for training.
How does it work?
First, a special EEG monitor (amplifier) and software are set up with a computer. Electrodes are placed on the scalp to record the client’s brainwave activity. The client is then given visual and/or auditory feedback—such as with a specially designed computer game. As certain frequencies increase or decrease, the trainee gets increased or decreased feedback—including auditory, visual, and tactile feedback.
Results reported by clinicians
A survey of psychologists and therapists who use this therapy report three common findings:
Many psychotherapists comment that it makes them better therapists. When the client’s brain is more stable, they are more available for therapy. Neuropsychologists report that it is effective as a cognitive rehab tool with Traumatic Brain Injury (TBI).
What professionals use Neurofeedback?
Over 2,000 health professionals now use EEG Neurofeedback. The majority are licensed psychologists, neuropsychologists, therapists, counselors, and social workers. There are a growing number of medical doctors, licensed nurses, and other professionals. Neurofeedback is usually an adjunct to existing therapies, not a stand-alone modality.
How is Neurofeedback being used clinically?
The most common problems address by clinicians who use this tool are:
Attention Deficit (Hyperactivity) Disorder (ADD / ADHD)
Panic attacks Anger and rage
Depression Conduct disorders
Anxiety disorders Post Traumatic Stress Disorder (PTSD)
Dissociative disorder Learning disabilities
Reactive Attachment Disorder (RAT) Bipolar disorder
Cognitive impairment (TBI, stroke)
Neuropsychologists and other therapists report that improvement with TBI often occurs even many years after the injury—that neural plasticity still exists. Emotional and behavioral improvements are significant for this group.
Migraines, headaches, and chronic pain
Therapists and medical doctors report that the incidence and intensity of migraines are often reduced—and sometimes eliminated. It appears the increased brain activity reduces the brain’s susceptibility to migraines. Clinicians report that improvements tend to hold and medications are often reduced. Chronic pain improvements (how the brain manages pain) are often significant, even in the most severe pain syndromes.
One of the first changes clients typically report with Neurofeedback training is improvement in sleep. Changes often include improvement in insomnia, bruxism (teeth grinding and clenching), poor sleep quality, difficulty waking, frequent waking, and nightmares.
Autism and Reactive Attachment Disorder (RAD)
Autism and RAD are of the fastest growing areas in Neurofeedback. The calming effects of Neurofeedback produce noticeable results quickly in these severely affected populations.
In a study soon to be published, Neurofeedback was compared with a successful twelve step program. The population was crack, cocaine, methamphetamine and heroin users. Sustained abstinence was five times greater with the group that got Neurofeedback training. This confirms previous published studies with equal results for alcoholics. Substance abuse is an obvious form of poor self-regulation and self-medication. 50% of this population is ADD/ADHD, and many have mood or sleep disorders.
Multiple peer-reviewed studies show a reduction in seizures that are non-responsive to medications—and that the training effect holds. A medical doctor recently reported on a seven-year-old patient experiencing up to a hundred seizures a day. He was uncontrolled on medication under supervision by Boston Children’s Hospital. With extensive Neurofeedback, he is now seizure free and off most medications.
Neurofeedback is not a treatment that fixes these problems. All of these problems, at least in part, relate to some type of brain dysregulation. Particularly since the 1990’a, neuroscience has identified brain problems—departures from the norm that can be seen in a qEEG (qualitative EEG), SPECT scans, or other types of brain map and underlie psychological problems. EEG training helps improve brain regulation, which usually helps reduce symptoms related to brain dysregulation.
How does the process work?
The clinician undertakes a comprehensive assessment of reported symptoms, often combined with standardized testing. Over thirty years models have been developed that correlate the assessment data with brain function. These are used to identify sites and frequencies at which to train. Additional information from a qEEG based brain map may also be useful in guiding EEG training, though it is not always necessary or cost effective. A qEEG brain map starts with a comprehensive clinical EEG. An in-depth computer analysis compares the EEG with a large normalized database and identifies deviations from the norm in brain function. This information can be used to help guide the training.
Sensors (electrodes) are placed over specific sites. Training may include increasing certain brainwave frequencies and/or decreasing others at specific sites. Auditory or video feedback rewards the client when they meet training goals (more or less of an EEG frequency). The clinician determines the training goals.
Training sessions are often twenty to thirty minutes in length. The therapist tracks client outcome and makes training adjustments accordingly. The training, which produces better brain regulation, is a generalized effect. That means the client does not think about the training to get the effect. Their brain simply responds better to demands when it is in a demanding situation.
What EEG frequencies are typically trained?
Beta frequencies (12-20 Hz) tend to be related to brain activation. Training these frequencies can assist in speech, organization, planning, elevating mood and reducing depression, in improved cognitive function and task performance, particularly when training over the frontal lobe. Training along the sensory motor strip can assist in calming the brain and can help with anger, stress related problems, decreasing over-arousal, improving inhibitory control, and impacting sleep regulation.
Originally, most training was done along the sensory motor strip. Neuroscience and brain imaging research have pointed to many other problem areas. As a result, Neurofeedback often includes training at the frontal and pre-frontal lobe, the anterior cingulated, and the temporal lobes. For example, alpha-theta training (8-11 Hz for alpha and 4-8 Hz for theta) uses Neurofeedback to guide people to their deepest levels of consciousness in order to facilitate and process psychological issues. This training is often used in transforming depression, addiction, anxiety, and PTSD. It also helps enhance creativity and promote deep states of relaxation. This training is done with eyes closed and is often enhanced with guided imagery. A double blind study on musical performance was just published by a noted university in London. Students at the Royal Conservancy of Music who did alpha-theta training were the only group of the five modalities studied that saw readily indefinable improvements in musical performance.
Healthy high alpha training (11-14 Hz) posteriorly (in the back of the head) is also being identified as an important contributor to better memory function. This EEG training has been labeled ‘brain brightening’ by Dr Tom Budzynski, a professor at the University of Washington.
Excessive theta and delta (slow wave activity) is inhibited during training. Theta waves (4-7 Hz) can be associated with distractibility, inability to focus. Delta waves (0-3 Hz) are often associated with sleep states, but in a waking state, can be associated with brain dysfunction. Excessive amounts of delta and theta will interfere with brain function (concentration, attention, etc.). Training is adjusted to reduce that activity. qEEG based brain maps can be used to help identify brain areas that are excessively slow or fast.
Certain frequencies of high beta can potentially stimulate attention. Other frequencies are associated with anxiety, tension, and trying too hard.
A brief history—How did science and cats discover SMR EEG training?
In 1968 Dr Barry Sterman, a neuroscientist at UCLA medical school proved that cats in his lab could be trained to make more EEG activity at 12-15 Hz frequencies using operant conditioning. He called it SMR (Sensory Motor Rhythm). Sterman then used the same cats for a NASA contract to investigate whether rocket fuel could cause seizure activity. The cats were exposed to a volatile fuel called hydrazine. Half the cats seized in a predictable dose response curve. The other half of the cats—those who had increased SMR brainwaves in the last experiment—had a dramatic reduction in seizures compared to the normal cats. It was a very unexpected outcome.
After additional research, EEG training was tried on a woman working in Sterman’s lab who suffered from uncontrolled seizures. She was trained at 12-15 Hz along the sensory motor strip. The training had the same inhibitory effect that it had on the cats and the woman now has a California driver’s license.
These events launched the field of Neurofeedback. Brain dysregulation—of which epilepsy is one of the most sever types—is reduced with EEG training. The research, particularly in epilepsy, is extensive.
Are there differences in Neurofeedback and Biofeedback?
Neurofeedback is EEG Biofeedback—it is just a specialized form of Biofeedback. Most health professionals are familiar with traditional Biofeedback methods such as EMG (muscle relaxation), GSR (galvanic skin response), temperature and respiration training. In the last few years, EEG Neurofeedback has become the fastest growing segment of the Biofeedback field. EEG Neurofeedback reduces stress and is relaxing—as does other modes of Biofeedback. But Neurofeedback provides a more direct and lasting impact on brain regulation along with central nervous system function.
How many training sessions does it take?
Noticeable results typically occur between the first and tenth sessions. In most cases therapists recommend a minimum of thirty to forty sessions. Certain situations can require many more sessions. The goal is to complete enough training to ensure consistent and lasting benefits. Like piano lessons, a lot of practice is needed for it to stick. The brain is learning a new pattern. You are looking for over-training for changes to become the dominant pattern. Sessions are usually about twenty to thirty minutes in length, though at times shorter sessions are useful. Initially, two to three sessions a week are recommended, thought it depends on the individual. Running up to two sessions a day can be done for accelerated training.
How long does the effect of training last?
Do the benefits of training hold long after training is completed? In general, therapists report that it does, if the client has done enough training and the right type of training. However, there are many sites to train on the brain and many different frequencies to choose from. Results may vary depending on the expertise or skill of the professional—just as medical doctors vary in their success of using medications.
Some long term studies have been undertaken by Dr Joel Lubar at the University of Tennessee and a few others showing sustained carryover of improvement. Published research on epilepsy shows the effects on epilepsy holds well even twelve months and longer post-training. However, much more research in this area still needs to be performed. Clinicians commonly report long lasting—and often permanent—changes.
Certain individuals may experience a relapse at some point. The trigger could be an injury, trauma, or extreme stress. There may be underlying neurological issues, or genetic vulnerabilities, or other factors. It varies by client—some will hold and never need maintenance sessions. For others, ongoing training may be appropriate. Once someone has gone through intensive training occasional maintenance sessions can be sufficient to get them back on track. The intensive training is seldom needed again—occasional ‘tune-ups’ can work quite well. It is as if once the brain has gotten it, it does not take much to get back to that place. The brain is devoted to its own regulation. Once it learns how to do so, it tends to retain the information.
Certain problems—such as brain injury, autism, Tourette’s, cerebral palsy, or other neurological problems—may require constant ongoing treatment to maintain improvements. For degenerative problems, including Multiple Sclerosis, Parkinson’s, or Alzheimer’s, reports suggest Neurofeedback helps stabilize the problem, or seems to slow the symptomatic progression. Reports indicate it may help optimize brain function with whatever resources still exist. Neurofeedback may be more of a quality of life training than an attempt to remediate the problem.
Can Neurofeedback training be used while a patient is on medication?
Yes. Therapists report many patients start Neurofeedback while on one or more medications.
After a number of Neurofeedback sessions, a reduction in medications is not unusual. It is very important that the client’s doctor be alerted if signs of overmedication occur. If that doctor is not open to reducing dosages when presented with signs of overmedication, then training may need to be discontinued.
For example, a 42-year-old female was being seen by a therapist. She had been on four medications for five years to treat depression. After forty sessions she was only using one medication at a reduced dosage with improved mood and affect.
How do these changes occur? It is well known that EEG changes with medication. The EEG also changes during Neurofeedback, so it is not surprising that changes in medication may be necessary. The theory is that as the brain becomes more activated during training (increased blood flow), the brain works more effectively. A regulated brain uses all substances more efficiently.
Not every patient’s medications are affected. For some patients, Neurofeedback seems to act synergistically with medications, allowing the medication to achieve a better response or stabilizing the use of medications. Neurofeedback is complementary to other treatment approaches, and may help them be more effective.
When does Neurofeedback not work?
This is a complex question that involves many factors. Just as medical doctors and psychologists vary in effectiveness based on training and knowledge, the same thing is true of Neurofeedback practitioners. In addition, client compliance also plays a big role. Lack of consistency in training will often cause treatment failures. There are many sites to train on the brain and many different frequencies to choose from. Training each can require a mix of skill, knowledge, and discernment to identify responsiveness. If the wrong protocol (frequency and site) is used, little or not effect may be noted.
Many therapists are finding that doing Neurofeedback without addressing underlying family system problems can also reduce the effectiveness of using Neurofeedback. Combining therapy for both appears to be a more effective approach.
Defining ‘benefit’ is also a challenge. Does it require 100% symptom resolution of the presenting problem? Is partial symptom resolution a success? It is important to set expectations with clients before they start training and discuss the expectations on an ongoing basis. Some clients may perceive failure if remediation is not achieved. Some clients are impatient and may stop training if dramatic improvements are not seen quickly. Some clients are poor self-reporters and do not identify changes when they do occur.
A good therapist uses Neurofeedback as an integral modality to therapy—and it is the combination that makes for maximum effectiveness.
Does EEG training make permanent changes to brainwave patterns?
Identifiable abnormalities in the EEG are seen in epilepsy, with head injury, or from a variety of other causes. With improved brain regulation through Neurofeedback training you often see a reduction or elimination of those EEG abnormalities. There are also certain profiles of ADD, anxiety, and depression in which reductions in excess amplitudes can be anticipated with the training.
However, there is still debate in the field. At times you do not see a permanent change in the EEG, but rather a change in the regulatory function of the brain—resulting in improved outcome. Some suggest that a good measure of improved regulatory change does not yet exist. Other clinicians and scientists believe that ‘normalization’ of the EEG is the primary goal. More research is needed here. But both approaches—training to normalize EEG and training to improve symptoms—produce client benefit. Many therapists combine a symptom-based approach with the use of a qEEG brain map to help guide their clinic decisions.
How does training transfer to everyday situations?
In everyday situations the client is no longer in a treatment session, receiving the feedback. Do they have to remember the effect of the training to experience it? No, that is clearly not the mechanism in place. Instead, the effects tend to generalize. It takes the form of increased stability under demand, greater resilience and more appropriate state flexibility. The brain is being trained for better self-regulation, which may be most noticeable by an absence of problems.
When an individual notes their attention has improved, if they are less angry or anxious, they do not have to remember what they did in Neurofeedback. The training generalizes and the brain—under a high demand situation—seems to have learned to manage itself better.
What is the cost to the client?
Client fees vary depending on the qualifications of the provider, the market, etc.
An initial clinical assessment varies widely. These include the expertise and credentials of the provider and the time of intake (from 45 minutes to several hours). Some psychologists and neuropsychologists will do a battery of neuropsychological tests, others do not. If a quantitative EEG (qEEG based brain map) is added to the intake, it can significantly increase the cost of the testing. Costs of the qEEG vary by the level of expertise in interpretation, the type of provider, they equipment used, and other factors.
Session costs are typically similar to the per session cost that a professional charges for other services.
What is the cost to the clinician?
Equipment costs, quality, and capabilities vary widely. Courses and clinical supervision costs vary widely, both in cost and quality and there are no requirements for the amount of training a professional receives before they start practicing. We highly recommend that clinicians budget for ongoing training and supervision. The learning curve is significant.
How much practice is needed before working with patients?
There are psychologists and medical doctors who have started training clients within two weeks of their first course. Others practice for several months before they charge clients. There are no required standards.
Knowledgeable professionals suggest:
Dr Kadiri is well versed and has many hours of experience in the use of Neurofeedback.
Are there adverse effects from Neurofeedback?
In the thirty years of the field with hundreds of thousands of training sessions by clinicians, there has never been a lawsuit for adverse effects of Neurofeedback training. It is, after all, just self-regulation training.
That having been said, recognize that anything that has the power to change things for the better could potentially have adverse effects. That is why good professional training is critical. This tool can help improve sleep—it can also make sleep worse. It can improve depression—or could make it worse. However, it is hard to make things worse for long. Initially, the effects wear off quickly and the appropriate changes can be made. Effects of training can be reversed by changing protocols. Monitoring change and shifting training protocols is part of the responsibility of a trained professional. Like titrating medications, short-term effects provide information useful in adjusting the client’s training. Negative responses wear off. So, negative effects from going in the wrong direction can be rapidly changed.
Is Biofeedback certification required to provide Neurofeedback?
Biofeedback is a natural tool for mental health professionals and is covered under the American Psychological Association’s guidelines for psychologists.
Certification programs for Neurofeedback and Biofeedback have been created by the Biofeedback Certification Institute of America (BCIA), a peer reviewed organization that has set standards for this field. They provide two kinds of certification. There is BCIA for General Biofeedback—EMG (muscle activity), GSR (galvanic skin response), breathing rate, and other peripheral measures. A separate BCIA certification exists for EEG Biofeedback (Neurofeedback).
The EEG Biofeedback certification is still in the early stages of gaining acceptance and currently no states require EEG BCIA certification as a requirement to provide Neurofeedback. States accept that if the clinician is a licensed health professional, licensure is sufficient.
EEG Neurofeedback equipment should be FDA approved. FDA approved equipment is legally sold to licensed clinicians. Some ‘low end’ consumer oriented equipment is sometimes purchased by individuals, but is not recommended because they lack the expertise to apply it properly.
What is the right name—Neurofeedback or EEG Biofeedback?
No-one in the field has agreed to a single name. Any of the following names can be used:
If you hear ‘Biofeedback’ it is usually NOT the same thing. Biofeedback is more commonly known by professionals and the public than is Neurofeedback.
- Extracted from “Neurofeedback in a Clinical Practice” by EEG Spectrum International.
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