What is Neurofeedback?

Neurofeedback is the direct training of brain function, through which the brain learns to function better and more efficiently. Self-regulation is the brain's core skill. During development, the brain learns self-regulation by way of feedback on its interaction with the world. We can now augment that process by allowing the brain to see itself in action from moment to moment through its own brainwave activity, the EEG. The brain effectively gets to watch its own dance of self-regulation in real time. This suffices to allow the brain to improve its self-regulatory competence. This is a gradual learning process. We refer to this kind of neurofeedback process as Endogenous Neuromodulation.

Most mental dysfunctions and disorders can be understood as disregulations, the failure of the brain to coordinate properly in the domain of timing and frequency—its dynamics. (We use the term disregulation when we're just dealing with such dysfunctions. The medical term dysregulation is appropriate where underlying organic factors play a key role.) Most brain-based dysfunctions are accessible to us by way of our brain training strategy. The training particularizes in terms of sensor placement and specific training frequency, depending on the issues. Also, training self-regulation is a moving target. That is why a skilled clinician needs to be in charge of the process.

Brain disregulation is a problem for all of us at some level. We've all taken our knocks, from the birth process on, and in the course of life we come to accept our limitations. It can now be said that no one knows the inherent functional competence of their own brain unless it has had a chance to train self-regulation. Historically, this has consisted of the usual techniques that encompass meditation, mindfulness, physical fitness, martial arts, playing musical instruments, etc. The process can now be aided significantly by way of instrumental support that takes advantage of what we have learned about functional neuroanatomy (the connectome) and brain function in the bio-electrical domain (dynamic connectivity).

All sustained benefits derived from neurofeedback ultimately trace back to learning that has taken place in the brain. We are merely facilitating and potentiating the process. Our organization has played a lead role in the evolution of the clinical application of these methods over the course of the last 38 years. Nearly two million people have already benefited from our particular approach, at the hands of over 10,000 clinicians in over forty countries. The method is well established, and it is well represented in the scientific literature.

Our intellectual abilities and emotional resources can be considerably enhanced with neurofeedback training.

Siegfried Othmer Ph.D.

How Does it Work?

We apply sensors to the scalp to detect the brainwave activity. (Nothing goes into the brain. This is not a brain stimulation technique.) The tiny brain signal is amplified, and then by way of signal processing the activity at certain key brainwave frequencies is extracted. This signal stream is then reflected back to the trainee's brain by way of a video game display, auditory feedback, and tactile feedback. The trainee is engaged by the game while the brain learns from the information imbedded in the signal. The trainee can even be watching a movie while the brain learns. Cognitive engagement with the signal is not required.

The clinician chooses what sensor placement to use, and what frequency range to work in. This choice is based on the totality of client complaints, which are evaluated in the context of personal and family history. Interpretation is in terms of the key failure modes of cerebral regulation, which then specify the appropriate protocols. The clinician optimizes the training parameters on the basis of the reaction to the training. Other protocols are then added to target remaining patterns of disregulation.

This is an improvement over an earlier day, when neurofeedback depended on the volitional engagement with the training signal. That is no longer necessary. In consequence, the training has become more efficient as well as more impactful. The older process (which is also still in common use) depends on our understanding, because we place ourselves in charge of how the brain is to be trained. We set the goals to be achieved. Then the feedback 'rewards' the trainee as these specific EEG-based training goals are approached. This technique is known as operant conditioning, and such reward-based training still has its place, even in our own work.

The new approach, which has largely taken over our practice, exploits the brain's wisdom to direct the training. Here's the crucial distinction: For the trainee and for the clinician, the signal is an observation. Even trainees cannot really 'relate' to their own EEG in the general case. For the trainee's brain, however, the encounter with the signal is an experience. It is awareness of the context that gives meaning to the signal, and the brain is in sole possession of that awareness.

This new approach is appropriately termed Endogenous Neuromodulation. It operates entirely on the basis of the brain's endogenous (i.e., self-generated) neural activity, and the neuromodulatory response is entirely initiated by the brain. There are no external nudges or rewards.

In this kind of training, the brain has to recognize itself in the signal in first instance, or the process does not move forward. Once such recognition occurs, however, the brain will naturally exploit the signal for its own benefit. We have a feedback loop. The brain bootstraps the information on its own activity to alter its instantaneous state in a manner determined entirely by the brain itself. This is an iterative process, with the change in brain state reflected in the signal, effecting yet another brain response. The process is a continuous one. All this can readily occur beneath consciousness. This is referred to as 'covert' neurofeedback. Over time, this process eventuates in improved functionality—when performed under appropriate conditions.

It may surprise us that we are talking about the brain being in charge just as if it were a person. This is called 'anthropomorphizing the brain,' and it has been frowned upon by scientists because it implies the existence of a 'decider' that is doing the deciding. In this case, however, it is entirely appropriate. The only entity that 'gets' what is going on here is the brain that produced the signal in the first place. So we have placed the brain in charge of the actual process. This makes the process context-sensitive, as indeed it needs to be, in a manner that is not possible any other way. That, in turn, makes the training more efficient and more effective.

The clinician remains in charge of the steering—determining the parameters under which the training takes place. That in turn calls for great professional skill, as it is a matter of turning the trainee reports on the changes being experienced into refinements of the training protocols. The training process combines the 'first-person' perspective of the trainee with the 'third-person' perspective of the clinician. This is somewhat analogous to what happens in psychotherapy, but the focus here is on what happens at the neurophysiological level rather than in the realm of psychodynamics.

Even though the person training may be distracted by a movie, this does not mean the trainee is merely a passive participant in the process. On the contrary, the clinician is dependent on good reporting from trainees on their experience of the training. Noticeable shift in physiological state can occur—and routinely does occur—in a matter of minutes. The reports on such state shifts, as well as on change in symptoms, indicate to the clinician how to adjust the training parameters for best outcome. In the case of someone who cannot report, we depend on family members or other caregivers, and the clinician watches for changes that occur from session to session.

Now the question remains: If there is no decider, how is the deciding getting done? The brain is a self-organizing system, and it has a problem. By the time it finds out what is happening out in the world it has already happened. There are signal processing delays. And it takes time for the brain to organize a response. So, in order for the brain to act in the world in real time (like, for example, hitting a baseball), it has to project the information it has forward in time. It is always operating on a prediction model. (We don't know how that is organized either.)

In any event, the same thing holds for issues of state regulation. The brain projects the signal forward it time, and then tries to bring closure between the unfolding reality and the prediction. The decision-making is not an event, but rather a continuous process, one that involves the whole brain. This is what the brain is organized to do, because the prime directive for the nervous system is the organization of movement.

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Who Provides Neurofeedback?

Neurofeedback (EEG Biofeedback) is typically provided by mental health professionals such as psychologists, family therapists, and counselors. The training may also be provided by nurses, clinical social workers, and rehabilitation specialists. These professions usually work with clients one-on-one. Neurologists and other MDs also provide the service, but will usually have the training supervised by a qualified staff person.

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Is Neurofeedback a Cure?

Neurofeedback targets brain disregulation, to which the disease model generally does not apply. So, the word cure is not applicable. On the other hand, with respect to disregulation, full remediation is often a realistic possibility, as in ADHD, where normal function may be readily achieved, and in the case of migraines, where freedom from migraine is an achievable goal. Many other examples could be given.

Sometimes a disease process is involved, as in Parkinson Disease. Here patients may well not only make a substantial functional recovery in motor and other symptoms, but the deterioration of function may also be significantly delayed. The same is observed in the dementias. In addition to some initial functional recovery, there may be a favorable impingement on the progression of the disease process.

In the case of organic brain disorders such as seizure disorder or stroke, it can likewise only be a matter of getting the brain to function better rather than of curing the condition. Even if no more seizures are observed after the training, the seizure focus presumptively still exists and a vulnerability to seizure likely remains.

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What Conditions Can it Help?

At the top level, our neurofeedback helps with conditions that are of concern to nearly everyone: stress reactivity, quality of sleep, alertness, energy level, mood regulation, appetite regulation, attention, and cognitive function more generally. Our neurofeedback is training in optimum functioning. That is to say, the method is inherently function-focused rather than dysfunction-focused.

The neurofeedback is also expected to be helpful with the anxiety-depression spectrum, with attentional deficits and related behavioral issues in childhood and adolescence, with headaches and migraines, PMS and mood swings. These are of concern to substantial fractions of our population. These conditions are so commonplace that they are frequently regarded as a part of life that one simply has to accept. That is not the case. It is not natural to have recurring headaches, or attentional deficits, or PMS that interferes with your life. These conditions have specific causes, and they are largely remediable.

While we work with all age groups effectively, we are especially concerned with the more "intractable" brain-based problems of childhood for which there are few good alternatives. Children have their entire lives ahead of them, and parents typically put their children's needs ahead of their own. Many children have sleep problems that can be helped such as bed wetting, sleep walking, sleep talking, teeth grinding, nightmares, and night terrors. We can help with the disruptive behavior disorders such as oppositionality and conduct disorder, as well as pediatric bipolar disorder. We can also work with organic brain conditions such as the autistic spectrum and pervasive developmental delay. The list includes asthma, panic, substance dependency, glucose regulation in Type II diabetes, as well as medically uncontrolled seizure activity and Tourette Syndrome.

The training can be worthwhile with cerebral palsy, and it can be helpful with the severe eating disorders. Vision problems can often be helped, along with other learning disabilities. The training is indicated in cases of acquired brain injury, birth trauma, and it is the key to remediating developmental trauma.

We can also be helpful with many of the problems of adolescence, including drug abuse and suicidal behavior. We can also help to maintain good brain function as people get older. The good news is that almost any brain, regardless of its level of function, can be trained to function better.

Is Training Unique?

Over the years, certain neurofeedback (EEG Biofeedback) training protocols have been developed that are helpful with certain classes of problems such as attention, anxiety and depression, seizures and migraines, as well as cognitive function. There are a number of assessment tools we use to help us decide which protocols to use. These are simple neurodiagnostic and neuropsychological tests.

Do Training Effects Last?

If the problem being addressed is one of brain disregulation, then the answer is generally yes, we expect the benefits of training to be retained. That covers a lot of ground. Neurofeedback involves a learning process, and if that brings order out of disorder, the brain will continue to utilize its new capabilities and thus reinforce them over the course of life going forward. It is not unlikely that the basis may have been laid for further improvements even after the course of training is finished.

If the training effects fall off over time, either there hasn't been sufficient training to consolidate the gains at the outset, or there may be external constraints at issue. A child living in a toxic environment (in either the physical or the environmental and psychological sense) will have more difficulty retaining good function.

Matters are different when we are dealing with degenerative conditions like Parkinson's or the dementias, or when we are working against continuing insults to the system, as may be the case in the autism spectrum. In such cases the training needs to be continued at some level over time, or for as long as the training seems useful. Allergic susceptibilities and food intolerances make it more difficult to hold the gains. Poor digestive function will pose a problem, as does poor nutrition, by way of the gut-brain interaction.

In sum, it is expected that the effects of training should last. When they don't, the cause should be looked for.

What is the Success Rate?

Through our thirty-eight years of experience with neurofeedback, we have reached the point of having very high expectations for success in training with a wide variety of conditions. When such success is not forthcoming, or if the gains cannot hold, then there is usually a reason for that which needs to be pursued. In the normal course of events, neurofeedback ought to work with everybody. That is to say, nearly everyone should make gains that they themselves would judge to be worthwhile.

Our brains are made for learning and skill-acquisition. On the other hand, we are working with many families whose expectations have been lowered by their past experience. And they need to see progress before they will share our optimism. We understand that.

It turns out that among the vast majority of clients (>95% in one clinician's experience) the actual outcome exceeds the prior expectations. Against such low expectations, the changes that can be produced with neurofeedback may even appear miraculous. One neurofeedback office has a sign on its front desk: "We expect miracles. If none occur, something has gone wrong." What appears miraculous in all of this is really nothing more than the incredible capacity of our brains to recover function when given the opportunity.

As a practical matter, in a clinical setting the success rate is much more under our control than it would be in the case of a research study. If someone makes no progress early on for reasons known or unknown, the training doesn't go forward. With 'non-responders' dropping out early, a high percentage of success (in the eyes of the trainee) is more or less guaranteed. Of course, success is not a black-or-white issue. Success here is defined as meeting or exceeding the initial expectations for the training. (Such expectations should be documented if a formal comparison is of interest, because it is commonly observed that expectations tend to escalate over the course of the training.)

What About Medications?

With successful neurofeedback training, the medications targeting brain function may very well no longer be needed, or they may be needed at lower dosages, as the brain takes over more of the role of regulating itself. This decrease in medications is particularly striking when the medications play a supportive role in any event, as is often the case for the more severe disorders that we are targeting with our work. A case in point: One Vietnam veteran came to the training with a list of 23 medications that had been prescribed for him. After the training he was down to one—insulin for his diabetes. His severely dysregulated state at the outset was testimony that all these medications weren't really resolving his problems.

Most children and adolescents coming for ADHD will likely no longer need the support of stimulant medication after the training. Those who have been on sleep medications for a long time may well wean off of them with the training. Anti-convulsant medication for epilepsy is likely to be retained, but dosage may well be reduced. Those on several anti-convulsant medications may well be able to cut back to just one. Sufficient progress should ordinarily be made in migraine susceptibility so as to eliminate the problem of medication over-use (which exacerbates migraine incidence).

It is important for clients to communicate with their prescribing physician regarding neurofeedback and medications. In the case of blood pressure medication, for example, a quick reduction in medication dosage may be called for.

Is it Covered by Insurance?

There is an insurance code for biofeedback, under which neurofeedback is covered. And there are codes for combining psychotherapy with biofeedback / neurofeedback. It may also be a matter of whether biofeedback is provided for in a particular policy. However, coverage for chronic mental health concerns is rarely adequate in the United States, so parents and others may have to advocate strongly with their insurance company for reimbursement, with the support of their provider. Initial rejection of claims is commonplace, typically on the basis that biofeedback and neurofeedback remain investigational. The biofeedback code is over forty years old. Biofeedback and neurofeedback are no longer at the investigational frontier. Innovation continues, but that is just a matter of building on solidly established prior work. Presently, nearly half a percent of all publications in mental health relate to neurofeedback, and the rate is rising substantially.