I have once again heard from potential clients that they are looking for practitioners who have cutting-edge gear, thinking that these people will be the “best” practitioners. Despite the fact that most of my gear is new and pretty fancy, I’d argue that cutting-edge is just a marketing gimmick and not a way in which to choose a practitioner. Here’s why.

Some manufacturing companies market their neurofeedback gear to practitioners (and sometimes, the public at large) as the most scientific and cutting-edge. It’s mostly marketing hype, and I suspect that there are practitioners—especially those looking for a low-effort way to get in to the field—fall for this marketing fluff. That, in turn, makes me wonder what people who are potentially wanting to give neurofeedback a try might think when practitioners pass along this “latest and greatest” mindset to them.

The truth is that the basic equipment gets better and better all the time, but there really haven’t been seismic shifts in what’s available for training.

Neurofeedback is based on measuring the electrical brainwave patterns at different sites on the head, then providing feedback to the body based on those measurements. The electrical signal is picked up by electrodes, and they display on almost all neurofeedback software via an oscilloscope. Basically, all oscilloscopes, regardless of whether a person is measuring electricity from brainwaves or building wiring, show the same thing. Some may have fancier graphics (on one of my pieces of software, I have the ability to change the size of the display, the graphic display of the signal, and even the colors in which it appears), but they all perform the same basic function.

The same is true of what we call amplifiers. The brain’s electrical signal is quite faint, because it has to make it through the bones of the skull, and the signal may include non-brainwave information (called artifact) that needs to be filtered out. The amplifier literally amplifies, or boosts, the signal, and the software filters the signal to help get as clean of a measurement as possible. Amplifiers are more sophisticated than they were in the 1970s, but again, they all perform the same basic task. Some can train one channel—site on the brain—at a time, some can train two, some can train four, and a very few can train eight (though eight-channel systems are rare and not always reliable or helpful). Some come in colorful boxes. Some are bigger in size than others. But, amplifiers all basically do the same thing.

Software makes a much bigger difference than hardware. Some software is marketed as plug-and-play to practitioners, so the devices are set up to be easy for anyone to learn to use quickly. Such devices work when they work, but practitioners are left with little vision to see what’s really happening, and they do not receive a good education on what is happening to any one client, or why, because it’s all happening in a proprietary black box.

I am not a fan of dumbed-down devices and find myself often frustrated with lofty claims of superiority that are more fluff than substance.

Other types of software are more solid, but users frequently don’t receive information on how measurements of brainwave activity get translated in to how to train the brain, where, etc. It’s much simpler to say, “Do THIS,” than to explain why, and when/how to vary from that original plan.

So, if neither software nor hardware are game changers in the “this is cutting-edge” arena, it means that the greatest weakness, and biggest diversifier, in the world of neurofeedback is the education of the practitioner. I don’t mean whether a person has a master’s or a doctorate, or any degree at all, because most graduate programs in mental health do little more than mention that neurofeedback is a tool that exists. Non mental-health professions, such as chiropractic, physical or occupational therapy, or school teaching, receive even less information in their programs about neurofeedback than those in counseling or psychology programs. No degree in anything confers expertise in neurofeedback, it is training in neurofeedback that confers expertise.

As a result, it’s still a bit of a Wild West situation for practitioners, and the buyer must beware. Most learning happens in hotel conference rooms and at conferences. There is great education out there, but whew, it is a challenge to discern, and it is still incumbent upon the client/customer to know to ask about education and not the technology itself (for the most part, anyhow; some one-size-fits-all devices aren’t that helpful even for those with a solid education). There are basic, introductory classes which last about a week in most cases, but they are not enough to really understand what one is doing. Neurofeedback has a steep learning curve, and it requires dedicated effort from each practitioner who is truly trying to master it and not just take shortcuts.

Since I raise this subject, I’ll also share my own background. I started with a week-long program through a company called EEGer. Then, I studied under a psychologist in private practice who took on a few local psychotherapists as students. After that, I took another week-long class with a company called Brain Trainer International. Because I wanted to work for certification, I did a 500-hour apprenticeship with a local practitioner. I’m not quite at 20 years of experience yet, but I continue to study and learn what is happening in the field, and I help mentor future practitioners.

My equipment is new, and I have pieces of software in my toolkit that are brand new to the market this year. Despite all the shiny newness of gear, I would argue that my competitive edge is almost two decades of experience based on solid education. I base this not only on myself, but on someone I studied with who used and got great results from gear that was from the late 1970s. Like that wise teacher, I’ll put my training and experience up against anyone advertising a new kind of hardware any day.

Dutch researcher and neurofeedback practitioner Dr. Martijn Arns is well-respected internationally for his work on creating more methodologically sound examinations of the efficacy of neurofeedback. As long ago as 2009, he published an analysis indicating that neurofeedback benefits those who have focus and attention problems. He and his co-authors wrote: “we conclude that neurofeedback treatment for ADHD can be considered “Efficacious and Specific” (Level 5) with a large ES for inattention and impulsivity and a medium ES for hyperactivity.”

Since then, of course, more work has been done to underscore neurofeedback’s benefits—including NIH-funded work—but Dr. Arns’s work continues to stand out. You may access the abstract here, and the entire text of the meta-analysis is available behind a paywall.

Neurofeedback is a challenge to learn to do and takes years to master, but its essence is straightforward: learn the sites on the scalp where training is conducted and what brain functions lie beneath each individual address, learn the software, then discern where and how to provide training for each individual.

It’s straightforward enough that dedicated people can learn to do neurofeedback at home for themselves or a loved one when, for whatever reason, coming to an office for training is not an option.

Here’s the funny thing, though: I’ve had people come to me for training after working with other providers, and they get different results when training with me. I’ve had home trainers who are perfectly smart and capable at brain training tell me they don’t get the same results at home as they do when coming to my office for a few sessions. (I see photos and videos of what they’re doing, so I KNOW it’s right.)

There shouldn’t be a difference. It’s the same or similar technology. The same spots on the scalp. The same set of rewards.

Yet, the outcomes are not the same.

The reason why eluded me for a while, but I think I understand now.

When in graduate school for counseling, one of the things I learned was that no matter what type of counseling was done under what theoretical umbrella, the key factor that led to client improvement was the client-therapist relationship. That doesn’t mean that theory and practice do not matter; of course they do. But, human connection is the common thread that leads to progress in psychotherapy.

Even though they are not the same, I suspect that the same thing is true for neurofeedback as it is for mental health counseling—relationships matter.

In theory, neurofeedback works based on holding an electronic mirror up to the brain, then allowing the brain to make adjustments based on what it “sees.” This involves attaching electrodes, using an EEG device to measure brainwaves, then using software to reward change. It all sounds mechanistic and without a human element.

Increasingly, I’m not so sure about that. I think the person doing the training matters. I think their connection and encouragement matters.

Why wouldn’t it, when human connection matters in most other aspects of life?

I don’t want to overstate the idea. It doesn’t mean that an unskilled practitioner will get good results just because you like them, and it doesn’t mean that a skilled practitioner won’t get good results simply because you don’t connect with them well. It’s that a good relationship can help optimize good brain training.

I mentioned this to a colleague recently, and her response was to share with me that she’s had people tell her that they start to feel better as soon as they sit down next to her.

She and I don’t have clinical studies to prove this, but it makes sense.  At a time when so many people in our society feel disconnected from each other, a little connection—the feeling that another person truly cares about you and your well-being—matters.

In the early 1990s, researchers in Australia were among the first to explore the question of how long neurofeedback training lasts. They assembled a group of 10-year-old boys with a diagnosis of ADHD and provided them with 40 sessions of neurofeedback. Pre- and post-training testing showed that all the boys made great strides in their ability to focus on tasks.

One year later, the researchers re-tested the boys to find out how much backsliding occurred over the course of a year. They were surprised to discover that after 12 months, every one of the boys not only held on to their gains, they performed even better on attention tests than they did in the immediate aftermath of their 40 sessions.

This led researchers and practitioners alike to believe that neurofeedback is a form of learning for the brain. For example, when one first learns to read, sight words are among the first words memorized:  rat, sat, mat, hat, cat. As one continues to practice reading, the reader does not forget those learned words and instead builds on the learning, figuring out more sight words, then two-syllable words, and so on. A typically developing reader makes progress; she does not forget those first words unless there is some kind of emergency that interferes with memory and continued learning.

We believe that it is similar for neurofeedback—people hold on to their gains once they have finished training.

Finish Training. Don’t Stop too Soon.

The assumption behind this, though, is that a person has finished training.

Researchers over the past decade or so has performed testing with fewer and fewer neurofeedback sessions, reporting back that after eight or ten sessions, some sort of change occurs. Unfortunately, that has led to a similar trend over time among practitioners who assert that a trainee can be finished with all neurofeedback training in just a few sessions. The problem with that is that these people have just begun to experience changes and have not necessarily fully integrated them. This means that they require what the field is calling “tune-ups” of 10-20 sessions to re-set the gains that were previously made.

I disagree with this approach. I believe that training should continue until the learning is entrenched and the person can hang on to their changes. As a general rule, I tell any prospective client to plan to work with me around 40 sessions. If it takes less than that, we will stop, because I do not believe that anyone should do more training than is necessary. My goal is to ensure that you don’t need to come back for additional training or “tune-ups” while also ensuring that my clients do not waste time and money by doing training for too long.

Does this work? Does a full course of training lead to a lifetime of benefits? The scientific literature is mostly silent on this, but in my almost 20 years of practice, I have only had a few people who needed to come back for additional training. Those individuals had significant issues, such as experimentation with street drugs, complications from surgical anesthesia, uncontrolled thyroid issues (stable thyroid conditions seem to be fine), and autism. I have also either contacted or been contacted by a few former clients. These individuals have all reported that they held on to the gains they made.

This does not mean that the effects of neurofeedback last forever. They might! But, no one really knows for sure how long results last, and anyone who asserts that they are permanent is missing the nuance that we just don’t know, because neurofeedback hasn’t been popularly used for that long.

What I can say for sure is that when one finishes a full course of neurofeedback, the results typically last for a very long time.