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What is Neurofeedback?

Neurofeedback is biofeedback for the brain. Simply put, it exercises and helps “strengthen” the brain, calms it, and improves its 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 decrease excessive fast or slow
brainwaves that interfere with good function. Over time, the
result is a healthier and better regulated brain.

For example, if someone has excessive amounts of certain
EEG frequencies, (theta or alpha) in the frontal lobe, they
might experience depression or OCD (Obsessive/Compulsive
Disorder). By training the brain to reduce slower brainwaves
and increase fast 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 medications.
There are no known lasting side effects after 30 years of research

and clinical use. As the brain stabilizes, other modalities become
more effective.

HELPING BRAIN REGULATION

The brain helps regulate sleep, emotions, thinking, behavior,
and much more. The training doesn’t 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 subcortical brain structures. These functions are fundamental to brain regulation.

STATE FLEXIBILITY

We’ve 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 flexibility (being stuck in a particular state) causes problems—from impulsivity, to ADD, to anger, to OCD. Neurofeedback increases flexibility. EEG training also helps activate specific regions of the brain.

NEUROFEEDBACK IS NOT NEW

In the 1960s, when a lab taught cats to change their EEGs 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 1970s. But brain science during the 1990s advanced the field of EEG Nurofeedback, 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 is 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 CLINICIANS REPORT

A survey of psychologists and therapists who use this therapy report three common findings:
1. It is effective for use with mood disorders, depression, anxiety and ADD/ADHD;
2. Adding Neurofeedback improve outcomes significantly when compared to psychotherapy or medication alone;
3. Medications are often reduced.

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.

What professionals use Neurofeedback?

Over 2000 health professionals now use EEG Neurofeedback. The majority are licensed Psychologists, Neuropsychologists, Therapists, MFCCs, Counselors, and Social Workers. The majority are a growing number of MDs, 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 being addressed by clinicians with this tool are:

• ADD/ADHD

• Depression

• Anxiety Disorders

• Anger and Rage

• Learning Disabilities

• Bipolar Disorder

• Panic Attacks

• Conduct Disorder

• Cognitive Impairment (Traumatic Brain Injury, 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

Thearapists and MDs report that the frequency and intensity of migraines are often reduced- and sometimes eliminated. It appears the increased brain stability reduces the brain’s susceptibility to migraines. Clinicians report that improvements tend to holds, and medications can often be reduced. Chronic pain improvements (how the brain manages pain) are often significant, even in the most sever pain syndromes such as RSD.

• Sleep Dysregulation

One of the first changes clients typically report with Neurofeedback training is sleep. Changes often include improvement in insomnia, bruxism, poor sleep quality, difficulty waking, frequent waking, and nightmares.

• Autism, PDD, and Reactive Attachment Disorder

Autism, PDD, and RAD are the fastest growing areas of Neurofeedback. The calming effects of Nuerofeedback produce noticeable results quickly in these severely affected populations.

• Substance Abuse

In a study soon to be published, Neurofeedback was compared with a 12 step program. The population was a crack, cocaine, methamphetamine, and heroine users. Sustained abstinence was 5 times greater with the group that got Neurofeedback taining. 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, many have mood or sleep disorders.

• Epilepsy

Multiple peer-reviewed studies show a reduction in seizures that are non-responsive to medications- and that the training effect holds. An MD recently reported on a 7 year old patient experiencing up to 100 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 1990s, neuroscience has identified “brain problems”- departures from a normal population that can be seen in a qEEG, SPECT scan, or other types of brain map. EEG training helps improve brain regulation, which usually helps reduce symptoms related to brain dysregulation.

How does the process work?

ASSESSMENT: First, a clinician does a comprehensive assessment of reported symptoms, often combined with standardized testing. Over 30 years, models have been developed that correlate the assessment data with brain function. These are used to target sites and frequency to train. Additional information from a qEEG based brain map may also be helpful in guiding EEG training, though it’s 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 can help target the training.

Training: Sensors (electrodes) are then 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 20-30 minutes in length. The therapist tracks client outcomes and makes training adjustments accordingly. As the client improves, the effects are not a conscious effort- the client many not even be aware of the effect. The training- which produces better brain regulation, is a generalized effect. That means the client doesn’t “think about” the training to get the effect. Their brain simply responds better to demands when 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.




This example shows several EEG frequencies which are used by the therapist to set goals for each client.

Originally, most training was done along the sensory motor strip. Neuroscience and brain imaging research has 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, research indicated that excessive EEG slowing at the cingulate can be related to ADD, Depression, and OCD.

Alpha-theta training (8-11 or 8-12 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 of the Royal Conservatory of Music who did alpha-theta training were the only group of the five modalities studied that saw readily identifiable improvements in musical performance. Healthy high alpha training (11-14) 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_ can be associated with distractibility, not focusing. Delta waves (0-3) are often associated with sleep states, but in 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.
High Beta. 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 center, 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 seizure threshold vs. the normal cats. It was a very unexpected outcome.

After additional research, EEG training frequency was tried on a woman who worked in Sterman’s lab with uncontrolled seizures (using 12-15 frequency training along the sensory motor strip). The training had the same inhibitory effect that it did on the cats (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 severe types) is reduced with EEG training. The research, particularly in epilepsy, is extensive.

Are there differences in Nuerofeedback and biofeedback?

Nueorfeedback if EEG biofeedback- it’s 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 Nuerofeedback has become the fastest growing segment of biofeedback field. EEG Neurofeedback reduces stress and is relaxing- as does other modes of biofeedback. But Nurofeedback provides a more direct 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 session. In most cases therapists recommend a minimum of 30-40 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. Session are usually about 20-30 minutes in length, though at times shorter sessions are useful. Initially, two to three sessions a week are recommended, though 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 they do, 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 MDs 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 12 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 of symptoms 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’s as if, once the brain has “gotten it”, it doesn’t take much to get back to that place. It may require a tune-up once a month, or once every 3-6 months. It’s client dependent/

Certain problems, such as brain injury, autism, Tourette’s cerebral palsy, or other neurological problems, may require consistent ongoing treatment to maintain improvements. For degenerative problems, including MS, Parkinson’s or Alzheimers, reports suggest nuerofeedback help stabilize the problem- or seem to slow the process. Reports indicate it may help optimize brain function with whatever resources still exist. It’s 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’s 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.
An 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 40 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 the EEG changes with medication. The EEG also changes during Neurofeedback, so it’s not surprising that changes in medications may be necessary. The theory is that as the brain becomes more activated during training (increased blood flow), the brain works more efficiently. The medication has a stronger effect on a more efficient brain.

Not every patient’s medications are affected. For some patients, neurofeedback seems to act synergistically with medications, allowing the medications to achieve a better response, or stabilizing the use of meds. Neurofeedback is complementary to other treatment approaches, and may help them be more effective.

When doesn’t Neurofeedback work?

This is a complex question that involves many factors. Just as MDs and psychologists vary in effectiveness based on training and knowledge, this same thing is true of neurofeedback practitioners. In addition, client compliance also plays a big role. N Lack of consistency in training often will cause treatment failures

There are many sites to train on the brain, and many different frequencies to choose from. Training each can have a different effect on the client. Choosing the right one – (like choosing the right medication) can require a mix of skill, knowledge and patience to identify responsiveness. If the wrong protocol (frequency and site) is used, little or no effect may be noted.

Therapists report 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 solution.

Defining “benefit” is also a challenge. Does it require 100% symptom resolution of the presenting problem? Is partial symptom resolution a success? It’s 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 aren’t seen quickly. Some clients are poor self-reports and don’t identify changes when they do occur.

A good therapist uses Neurofeedback as an integral modality to therapy – and it’s 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 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 – 1) training to normalize the EEG; and 2) training to improve symptoms – produce client benefit. Many therapists combine a symptom – based approach with qEEG (EEG based brain map) which can help guide some of the clinical decisions based on the EEG map.

How does training transfer to everyday situations?

In everyday situations the client is no longer sitting 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 a 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, or they are less angry or anxious, they don’t 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 qualifications of the provider, the market, etc.

Intake: An initial clinical assessment varies widely. This includes 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 neuropsych tests, others don’t. 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, the equipment used, and other factors.

Session costs typically are similar to the pre –session cost that a professional charges for other services. Some practitioners offer a discount if multiple sessions are pre – paid, since it reduces paperwork and collection time for the practitioner, and encourages the client to come consistently.

What is the cost to the clinician?

Equipment costs, quality and capabilities range 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.

Do insurance companies reimburse for Neurofeedback?

Some insurance companies will pay directly for biofeedback. Many will not. Many professionals charge clients out – of – pocket for Neurofeedback, and provide the billing for the client to file with their own insurance. But this is up to the individual clinician, and varies accordingly. Neurofeedback uses the same CPT billing as biofeedback – 90901.

Some therapists bill Neurofeedback as psychotherapy, which is more widely covered than other biofeedback codes. They report that it is requested often by their insurance providers. There are other codes – 90875 and 90867 – that provide billing for psychotherapy combined with neurophysiological training (including Nuerofeedback). These codes are not as widely accepted as psychotherapy by insurance companies, though their use is growing. Some nueropsychologists feel Neurofeedback is part of a cognitive rehab program, and bill it accordingly. Some health professionals have reported insurance success with other codes for patients at times.


How much practice is needed before working with patients?

There are psychologists and MDs 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: 1) Find the best possible course. 2) After the course, it’s helpful for professionals to do ten or more EEG training sessions on themselves first. This helps the clinician to better understand the process. 3) Train your family, friends or colleagues (if there not ethical issues) to gain experience. There are a variety of protocols that must be learned, which consist of specific brain sites and frequencies, both of which must be chosen appropriately. 4) Consult with a clinician experienced in nuerofeedback to shorten the learning curve. 5) If you decide to use qEEG data (EEG brain map) as a tool to guide the training, find a very experienced and knowledgeable tutor to help. The learning curve on qEEG is significant without ongoing help.

Are there adverse effects from Neurofeedback?

In the 30 – year history 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’s 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’s 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 trained professional. Like titrating medications, short – term effects provide information useful in adjusting the client’s training. Short – term symptoms 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 APA 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’s 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 Beiofeedback 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.

Is there sufficient research in the field of Neurofeedback?

There will probably be enough research. Research abstracts and some journal articles are available on the web. A medical journal published in January 2000, Clinical EEG and Neuroscience (not on the web), devoted a whole issue to reviewing scientific literature for Neurofeedback. This issue is a good overview of the research. Contact EEG Spectrum International to get a copy of this journal, or check your local medical library.

Over 1000 studies have been published related to this field. The majority of studies are in three areas: epilepsy, ADD, and substance abuse, as well as in basic research. The research is sufficient to encourage a growing number of licensed clinicians – including professors of respected universities and medical schools – to adopt Neurofeedback.
The challenge is that it takes a lot of reading to understand Neurofeedback. It includes the basic neuroscience of the EEG as well as many clinical studies. Dr. Barry Sterman, 1996 article, “Physiological Origins and Functional Correlates of EEG Rhythmic Activities: Implications for Self – Regulation” reviews some of the key research, while providing an in – depth discussion of some of the underlying mechanisms at work in the EEG as it relates to neurofeedback.

More outcome studies are clearly needed. But the literature that exists is substantial. Frank Duffy, a noted Harvard Neurologist, reviewed the literature and wrote an editorial for the Clinical EEG and Neuroscience Journal. After identifying some unresolved research issues, he added: “The literature, which lacks any negative study of substance, suggests that EBT (EEG Biofeedback Therapy) should play a major therapeutic role in many difficult areas. In my opinion, if any medication had demonstrated such a wide spectrum of efficacy it would be universally accepted and widely used.”

What’s the right name: Neurofeedback, EEG Biofeedback…?

No one in the field has agreed to a single name. Any of the following names can be used.
The most common are: Neurofeedback, EEG Biofeedback, or EEG Neurofeedback
You’ll also hear: Brainwave Training, Neurotherapy, or Neurobiofeedback

If you hear “Biofeedback” – it’s usually NOT the same thing. Biofeedback is more commonly known by professionals and the public than is Neurofeedback.

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