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.
State flexibility
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:
1.It is effective for use with mood disorders, depression, anxiety, and
ADD/ADHD;
2.Adding Neurofeedback improves outcomes significantly when compared to
psychotherapy or medications 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 (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:
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.
Sleep deregulation
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.
Substance abuse
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.
Epilepsy
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?
Assessment
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.
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.
Click here for more information regarding our
current fees. No qEEG assessment is performed at our practice and the client is
referred to one of the Netcare Brain Resource Centers if a qEEG assessment is required. Their fees are available on request.
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.
Do medical aids reimburse
for Neurofeedback?
Some medical aids 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 up to the individual clinician and varies accordingly.
Some therapists bill Neurofeedback and
psychotherapy, which is more widely covered than other Biofeedback costs. They
report that it is often requested by their medical aid providers. Some
neuropsychologists feel that Neurofeedback is part of a cognitive rehab program
and bill it accordingly.
In our case, Neurofeedback is used as an adjunct to
psychotherapy. It is, therefore, billed under psychotherapy and the client is
reimbursed according to their scale of benefits.
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:
1.Find the best possible course;
2.After the course it is helpful for professionals to do ten or more EEG
training sessions on themselves first;
3.Train your family, friends, or colleagues (if there are not ethical
issues) to gain experiences. 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 Neurofeedback 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 experiences and knowledgeable tutor to help. The learning
curve on qEEG’s is significant.
Dr Opperman 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:
1.The most common are: Neurofeedback, EEG Biofeedback, EEG Neurofeedback.
2.You will also hear: Brainwave Training, Neurotherapy, Neurobiotherapy.
If you hear ‘Biofeedback’ it is usually NOT the
same thing. Biofeedback is more commonly known by professionals and the public
than 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.
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.
Yes. Therapists report many patients start
Neurofeedback while on one or more medications.
