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"In my opinion, if any medication had demonstrated such a wide spectrum of efficacy,
it would be universally accepted and widely used." (p. v).
 "It is a field to be taken seriously by all." (p. vii).

Frank H. Duffy, M.D., Professor and Pediatric Neurologist,
Harvard Medical School, Journal of Clinical Electroencephalography
(January 2000 editorial)


What is EEG Biofeedback (Neurofeedback)?

The body has a limited capacity to sense information coming from inside itself. However, if you monitor any biological process, amplify it, and feed it back to the brain, your brain can change it. Neurofeedback provides a way for your brain to change your body. We observe your brain in action from moment to moment by monitoring your brainwaves. We show you your brain activity, and we help you to change it by rewarding shifts toward a more appropriate and stable brain state. It is a gradual learning process.

On a deeper level, Neurofeedback relies on two empirical realities that relate to health and growth:

  • Energy flow is the foundation of physiological functioning.  Energy affects a person’s sleep, mood, attention, thinking, perception, behavior, and basic body processes, that is, virtually every aspect of individual human life.
  • Animals and people naturally “work” (or perform behaviors) for that which will provide to them what is pleasant and rewarding.  Typically we will also perform under duress; however we generally will not continue to do so if the unpleasant inducement is removed. Thus, if something pleasant can be gained for our effort or a desired behavior is rewarded immediately following its occurrence, the effort will be repeated, and the behavior will increase. This is so regardless of whether the activity is consciously intended or it is unconscious and reflexive.  Energy patterns in the brain (brainwaves) also repeat when there are rewards, even though we do not consciously produce them

We see in problem states that brainwaves (which are a reflection of brain energy) are deviant and lacking in consistent regulation. By setting behavioral boundaries and goals for a person’s brainwaves, we challenge them to stay within normal limits.  More regulated function is consistent with no symptoms, or, in the case of organic disease, with ones that are significantly more mild and less frequent than previously.

How Exactly Does Neurofeedback Work?

The training begins with use of the electroencephalogram (EEG).  EEG is another name for brainwave recordings.  Neurofeedback is based on the EEG and works like a mind mirror.  It shows you how your brain is functioning and tells you if you are on the right track.  By encouraging a correction of abnormal brainwave patterns, we assist the brain to function better. Eventually, your brainwave activity is “shaped” toward more desirable, more regulated performance.  You are both the agent and, eventually, the proof (reflected in your physical and psychological functioning) of the positive change.

What is the Physiology that Underlies this Brain Training?

Neurofeedback is concerned with the brain's internal regulatory networks—in other words—its bioelectrical functioning.  Brain chemistry is intimately involved with the bioelectrical functioning of the brain as well.  Consider what occurs when we take in nutrients, medications and toxins:  as additional chemicals are introduced into the central nervous system (CNS), they alter the electrical potential surrounding and within each nerve cell.  Changes in electrical potential result in changes in the frequency and quantity of molecules flowing into and out of these nerve cells across the neuronal membrane.  These changes in molecular flow affect nerve cell activities.  Activity alterations change various energy states that in turn impact moods, perceptual sensitivities, and the functioning of other parts and processes of the body outside the central nervous system (CNS). 

In summary, with Neurofeedback the capacity of the brain to function differently is challenged through the mechanism of provision and delay of reward.  This stimulates the brain’s learning to alter energy states that support naturally consistent regulation rather than forcing brain regulation "top down” through metabolism of externally introduced chemicals.  Since meeting challenges that are rewarded is pleasurable to the individual, so long as rewards continue to appear on a consistent basis, the new behaviors and activities temporally connected to them will continue. With a sufficient number of learning trials (brain training), new patterns will be remembered, and the more healthful states they induce will perpetuate themselves.

What can Neurofeedback help?

By promoting more reliable regulation, Neurofeedback improves mental performance, emotional control and physiological stability.  The conditions that respond well to this improvement include

  • the anxiety-depression spectrum
  • attention deficits
  • behavior disorders
  • sleep disorders
  • headaches and migraines
  • PMS and emotional disturbances

Neurofeedback is additionally useful for

  • organic brain conditions such as seizures,
  • the autism spectrum,
  • traumatic brain injury
  • perception and perceptual anomalies (vision, hearing, taste, touch, smell)
  • sensory integration
  • cerebral palsy, Parkinson's, ALS, MS
  • tics and movement problems
  • neuropathies
  • other less common clinical entities, including some genetic disorders

Does Neurofeedback cure symptoms or conditions?

When it comes to problems of dysregulation without organic, genetic, immunological, or toxic roots, we would say that there is not a disease to be cured.  In these circumstances, self-regulation may very well be a complete remedy.  In the case of organic brain disorders, it is a matter of getting the brain to function better and improving symptoms rather than curing the condition.

Who can benefit from Neurofeedback?

Individuals of any age can benefit from EEG training:

  • Neurofeedback can help a variety of childhood problems such as bedwetting, certain adaptive social problems, rigid personality traits, and tantrums.
  • Neurofeedback can assist adolescents challenged with the commonly experienced depression of adolescence that is more often seen as a behavioral disorder or as an excessively irritable and angry mood than the expectable adult depressive symptoms.
  • For adults (and others), Neurofeedback can alleviate symptoms of physical and emotional problems such as migraines or PTSD. It is a critical piece in the effective treatment of addictions to various harmful substances. 

Simply by detecting the brain's going off track through EEG information that is available to you in a pleasantly translated format, each person can become the agent for incrementally shaping his or her own brain activity toward enhanced stability and improved, more consistent energy patterns. This improvement process is both healthful and natural!

Neurofeedback can assist in maintaining good brain function during normal aging, as well as during organic decline.  Furthermore, all ages and levels of peak performers use EEG training to enhance their abilities in sports, business and the arts.  In these very different applications, the specific brainwave frequencies we reward and the sites on the scalp from which we select the information that we utilize are unique to each individual’s needs and goals.  This is where our professional knowledge of outcomes research and clinical experience become most important.

How is Neurofeedback done?

Sensors are attached to the scalp with EEG paste. The sensors conduct energy signals (brainwaves) detectable beneath the skull to the Neurofeedback hardware. Application of the sensors is painless and is entirely non-invasive.  There is absolutely no use of any voltage or current to the brain.

A computer receiving the brainwave information translates it to make its various characteristics available for the Neurofeedback process.  Software then allows us to see amounts and functional categories of brain energy that we may choose to reward or inhibit to varying degrees based upon your needs and our clinical expertise. It also reveals the same characteristics to you, but in a translated format, one that shows you the ebb and flow of your brainwaves as features of a video game, DVD, or piece of enjoyable music.

With minimal instruction from us, you quickly find that you can learn how to keep a video moving along or a game playing with consistent volume and contrast by using only your brainwaves (everyone can do it!!). It is because of the attraction of the format that you want to see, play or listen to that your brain actually figures out what to do in order to accommodate to the thresholds and limitations that we set individually for you. 

What if the Neurofeedback client is taking medications?

Initially, there is no conflict between Neurofeedback and a medication that is working.  However with successful Neurofeedback training, as the brain takes over the role of regulating itself, it may become evident that previously prescribed medications may be needed in lower dosages or may not be needed any longer. 

It is important for clients to communicate with their prescribing physicians regarding their medications and the use of Neurofeedback or provide consent to us so we may do so.

Duration of Training

Gains achieved in the Neurofeedback treatment process tend to be permanent. There is no set training span, because several factors that differ for each person will affect the length of a training sequence.  Just as with any type of learning, these important factors include the level of competence of the provider, the type of disorder or symptom/behavior cluster for which Neurofeedback is sought initially; accurate and consistent feedback from the client; good communication from any outside reporter or observer who spends a lot of time with the individual; and unique aspects of the client’s temperament and physiology, including how fast the individual’s brain learns new patterns of functioning.

When clients collaborate optimally in the training process and the obstructive behaviors of the ones who are impaired reduce, its span is efficient and as brief as possible for that client. If there are frequent or lengthy interruptions in a series of sessions due to illness, vacations, and other lapses in training regularity, gains will be somewhat slower. This is true for any education. Longterm memory consolidation requires repetition of information, best spaced at relatively frequent, manageable intervals.

Clinician Requirements

The ideal background for a Neurofeedback provider would include specialized knowledge of psychology; psychotherapy (both individual and family systems); psychophysiological processes; learning theory; electroencephalography; general and preventive individual and public health practices; biomedical interventions; psychological; neuropsychological, and educational assessment; Western and Eastern medicine: and knowledge of the technical characteristics of the equipment being used. A license to practice in at least one of the health fields mentioned should be held by the provider who performs or closely supervises the training by a technician.

Certificates for attendance at biofeedback courses and even certification by the Biofeedback Certification Institute of America are not necessarily sufficient to constitute appropriate credentials for competent utilization of EEG biofeedback techniques. 

You may check the credentials of any health care provider by going to the website of the California Department of Consumer Affairs and entering the name of any prospective clinician into the database of the board appropriate to that individual’s representation of having a license or registration legally on file.
 
Client Requirements

It is essential for the client to be an active and willing communicator of his/her own experience.  A symptom and performance tracking process that relies on client ratings and other feedback is an important element for obtaining the most effective results from Neurofeedback.  

Just as a psychiatrist or physician cannot monitor medication and other treatment effects without client reports giving information about possible changes in symptoms and behavior, the Neurofeedback provider cannot make appropriately targeted decisions without accurate communication and some measurements upon which to base such decisions.  Thus, certain neuropsychological tests are given at the outset of training; then after every biofeedback session, the client and/or parent is asked for detailed information in written form about the effects of the training experience in relation to various aspects of life functioning. These include patterns and changes in sleep, mood, outlook, behavior, activity level, thinking, motivation, and physical well-being. 

In addition, the clinician periodically measures cognitive and behavioral changes with objective, normed testing instruments to demonstrate gains. Both kinds of information (subjective and objective) are used to make clinical decisions throughout the course of treatment.

Neurofeedback Outcomes

Effects of a single session of Neurofeedback generally last between a few minutes to about a day. New learning from a series of sessions will be detectable in improvements in the individual’s cognitive, emotional, and physical functioning over a longer term and will be noticed by the client and/or by others. Differences usually will also be reflected in changed aspects of neuropsychological testing and brain imaging such as raw EEG tracings, brainmapping, Neurospect scans, fMRI scans, LORETA scans, PET scans and infrared photography that may have been performed prior to training.

It bears re-emphasizing that the parent’s/client’s cooperation and observational skills critically affect the duration and outcome of biofeedback training. If client observation and documentation are haphazardly completed, training pace and overall effectiveness will be compromised.  Neurofeedback works with passive patients (which is why brain-injured infants and some individuals in coma states receive benefit), but its best outcomes emerge from a collaboration of the client, any caretakers involved, and the practitioner.

Adverse Effects from Neurofeedback

So-called wrong training effects from Neurofeedback rarely occur, particularly in the hands of a competent clinician. Examples of wrong training effects might be a temporary change in sleep (greater difficulty in falling asleep or awakening), a discernible change in arousal (e.g., feeling unusually lethargic or overly speeded up), a mood effect (more placidity or reactivity than usual), or an unusual physical feeling (for example, increased or decreased muscle tension). However, when reported within the session, such temporary state changes that appear to be due to EEG biofeedback, if unwanted, can be reversed almost immediately. If not reported, they typically “wear off” within a few hours. Minor fatigue generally abates within an hour or so; minor sleep disruptions will not occur for more than a day or two after a session.

For some clients (notably those who are poor reporters, unaccustomed to paying attention to their own physical and emotional feelings, or who lack the capacity to give specific verbal feedback), it is necessary for involved observers to be attentive to the areas of behavior that Neurofeedback addresses and report them on the client’s behalf.

If it effectively deals with so many conditions, why is EEG Biofeedback not widely used?

Neurofeedback is a fairly new health training approach.  Its principles were incidentally discovered through research related to the effects of fuel compounds on NASA pilots in the 1970s.  Application of this advance relies on computer technology, which is in an ongoing state of development. 

Because there is a lag-time between the discovery of any new laboratory-based health techniques and their clinical deployment or the development of any improved equipment and its wide-scale frontline use, in the transition phase, the latest knowledge simply is not yet available to everyone who would otherwise be competent to apply it.   This becomes quite clear when one considers the field of surgery.  Here the very latest techniques are taught in medical schools long after they have become commonplace at the practice level, where they have already been presented clinically in hospital based trainings led by pioneering individual surgeons, small teams of collaborators, or surgical technicians representing companies who design and manufacture equipment. 

Similarly, in the field of medicine, the mechanisms of action of the very latest medical compounds usually are not introduced in medical school physiology courses.  Rather they are most commonly presented via the distribution channels of the manufacturers by pharmaceutical sales reps. Younger physicians, therefore, have much to learn about their fields of specialization after medical school. More seasoned physicians take their time in learning about advances, for they generally have already developed approaches to treatment that they upgrade after conferring with other physicians and attending professional gatherings. It is a lengthy process requiring 2+ years on the average to complete. Physicians often require large-scale clinical trials to establish legitimacy for them or the previous buy-in of other physicians rather than relying on their own scrutiny of well-documented scientific information, frequently because they lack sufficient time and opportunity to do so.  The typical approach is conservative as opposed to investigative and proactive.

Information dissemination is no different in the fields of mental health and education.  Newer and more effective treatment approaches do not emerge directly from professional journals and graduate curricula but from innovations by individual clinicians and teachers who accumulate their best achievements and promote the broader use of these through writing, professional presentations, and public marketing.  It takes months to several years for this process to have broad effect. 

Although what is most therapeutic for the patient at any given time may not be the most popular in the field of health care delivery, in all fields, over time, with sufficient communication, eventually an aggregation of successes speaks for itself.  The word gets out in various ways, and a groundswell of demand from people wanting positive outcomes prompts training institutions to expand the numbers of those skilled in delivering solutions.

Progress in the field of EEG biofeedback

EEG-guided interventions have been employed by various U.S. government agencies for many years.  They are currently used in hundreds of schools in the United States, the United Kingdom, and other countries throughout the rest of the world.  The relative obscurity of Neurofeedback practice within the U.S. health care community is due to the reality that the EEG biofeedback field is simply not yet sufficiently established to be widely researched.  Yet smaller studies and pilot research that have already been published do show impressive and incontrovertibly positive outcomes (see Research section below.)  Some universities have taken up the banner and are now mounting well-designed research projects or have them underway already.  In the United States there are also training programs for EEG biofeedback providers at the graduate level (the University of North Texas, University of Tennessee, State University of New York, and others).

Because Neurofeedback is natural and carries very low risks (none either long lasting or life threatening, as with surgeries and some medications), it is destined to become one of a handful of first-line health treatments considered for a variety of unpleasant states and disorders.  Until this occurs, its availability will be limited to the range of the number of providers who have independently sought to add this powerful tool to their overall treatment repertoires in the quest to give the best to their clients.

Governmental Regulation of the Practice of Neurofeedback

Consumers must be aware that biofeedback is not presently specifically licensed as a professional specialty by the State of California Department of Consumer Affairs and that all Neurofeedback providers are not alike.

Even though the effects of Neurofeedback frequently are psychoemotional and cognitive, the State Board of Psychology does not regulate its application. Rather it is monitored by the California Medical Board, which is charged with oversight of  “complementary” health treatments and alternatives to traditional Western medical interventions. The plethora of activities that meet the definition of an alternative medical treatment makes comprehensive regulation and application of speedy sanctions for violations a practical impossibility for the Board.  Therefore even in some of the rare instances of blatant misrepresentations of credentials by persons who have gained access to equipment and are alleging training or licensing they do not have (both unethical and criminal) often do not get pursued or prosecuted when there are complaints. Thus, caveat emptor applies to choosing a sufficiently qualified Neurofeedback care provider.

Reimbursement

Insurance companies and HMOs vary in their reimbursement policies for Neurofeedback. Many do cover this treatment. We can assist in your researching your coverage by providing you with a questionnaire in the form of a comprehensive structured interview designed to help you sort through the relevant issues with your carrier. This includes service codes appropriate for what we do. If you have insurance that does pay part of your fees, your insurer may require a letter of referral for treatment from a psychological or medical professional and/or information regarding treatment goals and progress before treatment is begun. You will need to find out and follow your insurer’s policies in this respect.

Research

To keep abreast on the latest Neurofeedback research and articles, do visit the research links of the following organizations

EEG Institute

EEG Spectrum International

International Society for Neurofeedback and Research
The above website provides a frequently updated Comprehensive Bibliography of outcomes and evidence-based Neurofeedback research.

What is required to get started?

Setting an appointment for a diagnostic interview to become acquainted with the history and nature of the problem is the first step. In our center, the initial conversation or consultation is best managed with a comprehensive background of the client in hand; so we urge those wanting to inquire to complete our forms and submit this information to us in advance. In certain situations, based on this information, an appropriate medical referral is given before any Neurofeedback training is recommended.

Often a qEEG (quantitative EEG, or “brain map”) that compares individual brain activity to that of a “normal” brain will be called for as a diagnostic tool, or another imaging study may be requested to complete an evaluation. With children and those with traumatic or organic brain problems, a cognitive or neuropsychological assessment may be needed to establish baseline against which to measure change.

Collaboration with primary care providers and specialists is always desired and attempted.


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