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.

I’ve recently spent some time looking at what the internet has to say about neurofeedback, and wow, what an eye-opener that has been. The marketing claims and misinformation are pretty amazing.

Let’s start to set the record straight, because as with most things, the truth is nuanced.

1.   Claim: Some kinds of neurofeedback are more cutting-edge than others.

Reality: Not exactly. When I started learning to do neurofeedback in the early 2000s, one of my excellent instructors had been doing neurofeedback as part of his psychology practice since the late 1970s. His equipment mostly original from the 1970s and was as big and bulky as you can imagine early technology to be. Despite that, he used his tool as one plays a fine musical instrument and got great results. He showed fellow students and me handwriting samples of some children whose ability to form letters transitioned from the large, clunky scrawl of someone just learning to write to legible penmanship of a typical elementary-school-aged person. It was amazing. He also introduced us to a middle-schooler who had improved his gait to the point that he was able to go from using a wheelchair to using a walker. Please understand that this remarkable achievement is NOT TYPICAL and almost no one in the field would make claims to help children walk or walk better.  I use it as an example to show that even very old, standard neurofeedback equipment operates on the same basic principle of measuring electrical brainwave activity and rewarding the brain for shifting itself.

I would argue that cutting-edge is more of a marketing term than a sign of better equipment. I have found that some start-up companies that make incredible claims about their cutting-edge technology, and it turns out to be based on faulty premises or feels ineffective.

That said, I think newer techniques and approaches to training are beneficial and important. Some of our older techniques are tried, true, reliable, and effective. Some of our newer techniques are based on new learning and are also reliable and effective. Sometimes, though, people can get stuck in old ways and fail to see that newer ways to train (called protocols) are faster and better in terms of results. This is where keeping up with colleagues and their findings is important.

In my practice, I use newer gear that is stable and reliable, and I rely on continuing my education to help know when, how, and where to conduct training sessions. Combining the proven and stable with the new and exciting seems to me to be a reasonable way to conduct brain training.

2. Claim: Neurofeedback is over-priced.

Reality: Again, not exactly. I AM aware of places that charge $20,000 for a week of spa-like services that include neurofeedback. I also know of a few places that charge around $700 per session. If there are people willing to pay those prices, great. I know I would not, and I bet that if you’re reading my blog, you would never do that either. Rest assured that those places are nowhere near the norm.

There is another side to the coin where instead of charging exorbitant fees, practitioners offer bargain rates. They could be training multiple people at once, so the service is not personal–and for neurofeedback, someone observing the session is usually important. Or, it could be that the practitioner is using a “plug and play” device that is more of a one-size fits all or an alleged brain-hacking device. Although the technology is moving closer and closer to the time when headbands and a power button are enough, I have not seen any device to date that I would consider the equivalent of plain old EEG neurofeedback. You really are getting what you pay for, and I don’t recommend going with cheap or one-size-fits-all brain training.

In between the exorbitant and the bargain is where most practitioners place themselves. Neurofeedback is a specialized skill and takes time to learn to do and use properly. Most people who offer neurofeedback as the main part of their work have spent years honing their craft or, if new, are working under the mentorship of a skilled practitioner. It is also a costly tool. Practitioners spend thousands on training, thousands on their devices, and countless hours in mentoring and keeping up with the latest trends. Like most fields, the learning never ends. It is reasonable to expect to pay for this expertise.

If you are interested in neurofeedback training but are concerned about the cost, please know that I am willing to work out interest-free payment plans. I also offer a 10% discount to active-duty members of the military or active-duty first-responders.

3. Claim: Neurofeedback can be done quickly.

Reality: That depends on what you want. Some practitioners operate under the model of doing as few sessions as possible, then expecting their clients to come back periodically for what they call tune-ups. I think they do this to try and accommodate the fact that most people are very busy and don’t want to dedicate much time to training their brains. The truth is that sometimes, such an approach requires more time, money, and effort in the long run.

Some people offer a few sessions because there are many published studies that attempt to show a shift or change, and the changes they find definitely happens in fewer than 20 sessions. Demonstrating efficacy is not the same as having changes stick over the long term.

I operate based on research done that shows more sessions lead to solid and long-lasting results. If you work with me or anyone who operates under my philosophy, you will—with a few exceptions that we can talk about during a consultation—do one round of neurofeedback training and be done, no tune-ups needed. I tell my clients to plan on 40 sessions, but like everything else I offer, the exact number of sessions depends upon the person sitting in the training chair. Some people can be done in as few as 20-25 sessions, most do take around 40 sessions, and a few require 50-60 sessions. In special circumstances, there are people who may need hundreds of sessions due to having truly stuck electrical brain patterns.

In general, I advise people to plan on 40 twice-weekly sessions, but my goal is never to more sessions than a person needs or less than is needed to avoid doing so-called tune-ups.

4. Claim: Neurofeedback is covered by insurance.

Reality: Most insurers do not see neurofeedback as a health or mental health tool and thus do not cover it. Some practitioners, trying to be helpful, will mis-code their sessions so that their clients can get coverage. This is well-meaning, but it is also insurance fraud. However, some insurance companies, in some states, have begun to provide some limited coverage for neurofeedback. This coverage is usually quite restricted in the number of sessions and is usually for specific diagnoses. I am aware that here in Virginia, a couple of companies cover some sessions if there is an autism diagnosis, and a few others will cover some sessions for ADHD. If you think you have one of those golden plans that will help you pay for sessions, it is your responsibility to communicate with your insurance company.

I do not accept insurance, and insurance does not cover my services. My philosophy is not to use neurofeedback as a medical or mental health treatment.

5. Claim: Only MY way of doing neurofeedback works well.

Reality: Nope. Not true. My approach to neurofeedback training includes what I think of as the best of all world: collecting objective data for optimal brain performance along with subjective information about your life and what you’d like to train. The reality is, though, that some practitioners only ask about symptoms or problems, then surmise where to train based on that interview, with no measurements of what’s actually happening in the brain. This approach can work just fine. In fact, I use this with young children who are not yet ready to sit still for a full Trainers’ QEEG that measures 20 locations on the scalp to create a brain map. Other practitioners measure 19 spots on the scalp and compare that to normative databases that show how many standard deviations away from “normal” any one person’s brain might be. As much as I am opposed to the idea of a normal brain and trying to train to make everyone more normal, I agree that this approach can work, too.

If you are working with an experienced and skilled clinician who has invested the time and energy to learn to do neurofeedback well; who customizes your training to your brain and needs; and who works with you one-on-one rather than hiring staff who slap on electrodes, then leave, you are likely to get good results from your neurofeedback training.

Anyone who says that only their approach works is dissembling.

These are some of the key myths that I stumbled across in my browsing. I may write more on this subject another, but if in the meantime you have questions or ran across another piece of information that puzzles you, please feel free to contact me.

When people come to me for consultations, I talk about how neurofeedback works and show them a sample of what training looks like on the computer. Sometimes, children and teens want to see what their own brainwaves look like on a screen, so I will connect one channel for them to watch the squiggly lines on the screen. Sometimes, people want the history of neurofeedback to fill in the question of why they only recently heard of it. Sometimes, people have done enough research online that they are only in my office to meet me and schedule their brain map. Always, always, though, the question that is foremost, even if not always asked or if phrased differently, is what neurofeedback can do for them.

The most accurate answer to the question of “what can it do for me?” begins with an explanation of how neurofeedback works. In short, neurofeedback provides feedback to the autonomic nervous system so that it can learn and adjust. But, that’s not really plain English. A more understandable, though incomplete, explanation is that one part of our body’s nervous system is under our conscious control and one part is not directly accessible; neurofeedback works with the part we don’t normally think of as being under our control. For example, if we want to raise one arm over our head, we consciously control a big part of that movement, but if we want to adjust how the neurons are working in our brain, we cannot just squint our eyes and will it to happen.  Neurofeedback gets at the brain in ways we cannot, despite our best efforts.

Using just that short explanation of the mechanics of neurofeedback, it can seem that the ability to tweak some aspects of how our brainwaves are working may make the outcomes almost limitless. I wish that were true, but neurofeedback is not a magic wand.

If you are looking to calm down your nervous system, chances are that neurofeedback can do great things for you. This is especially true if you are eating well, getting out in nature and/or moving your body, and at least attempting to get regular sleep (knowing that often, sleep is part of the problem). This is true because the most significant benefit of neurofeedback is to calm the autonomic nervous system, and calming leads to a cascade of other good things:  a calm brain can sleep better, process better, get through the work or school day better, react to life better, etc.

Exactly how great the results will be also depends in part on your lifestyle and environment. If you are in a toxic work environment with endless, unreasonable deadlines; your relationships are abusive or non-existent; and you’re punishing your body in some way, getting results may be a bigger challenge. This is true because although neurofeedback can dial back the way you over-respond to the world around you, it cannot change your crazy world.

Then, for some people, their brains are stuck—perhaps due to epigenetics, a bad gut, a health diagnosis (think PANS/PANDAS, autism, Lyme) etc. Such people may also get good results, but it takes more time to make them happen.

Finally, if you are someone who has very slow brainwaves dominant while awake, it can be more of a challenge to get that brain moving faster. Slowing down is, in my opinion, an easier task that trying to fire up a slow brain. It CAN be done, it just takes awhile.

This is a long-winded way of saying that almost everyone can benefit to some degree from brain-training using neurofeedback. It isn’t a cure-all—in fact, no one should consider neurofeedback as a cure for anything—but it does help optimize how you’re functioning in much the same way that going to a gym boosts physical performance. The difference is that once you’ve finished a round of neurofeedback, your brain holds on to those gains in ways that training muscles does not.

So…what exactly CAN neurofeedback do for you? It can move your brain toward more optimal functioning, however that looks for you.

Most people who choose to pursue brain training using neurofeedback really just want to know if it works and, more specifically, whether neurofeedback will work for them or their family member. Usually the answer is yes, but the unknown is how much it will change a person’s life. Some people experience extraordinary, life-changing events. Most get satisfactory change. A small number experience mild changes (this is especially true for people with “stuck” brains such as those with an autism diagnosis). A tiny minority experience no change at all—in my practice, I’ve had fewer than five people with no change; these were frustrating experiences for everyone involved. For those with no change, a few were overscheduled teenagers whose family structure and school/extracurricular commitments meant that they never got good sleep, which is the foundation for any body change. Only once has the lack of shift been a bit of a mystery, and that was for a healthy adult whose brain map did not match her lived experience. We stopped sessions before too much time and effort was wasted, and her situation will probably sit with me for the rest of my career.

Every now and then, though, the question that those who are considering neurofeedback want answered is whether it’s scientifically proven. That is a fraught question, so I’ll unpack it a bit here.

First, neurofeedback has been around since the late 1960s. During the Apollo era, NASA scientists approached a neuroscience researcher at UCLA who was doing an early version of brain training on cats and asked him to explore rocket fuel toxicity, because people were falling ill, and they suspected it was from rocket fuel. In testing that now is famous among all well-trained neurofeedback practitioners, the UCLA researcher injected his cats with the rocket fuel. Half the cats had seizures and died within two hours. The other half had seizures at the 5-6-hour mark, yet survived. It turned out that the ones who survived all had been part of the researcher’s brain-training experiments. Later, a graduate assistant from the lab who suffered from epilepsy decided to try brain training on herself. It worked, and neurofeedback has evolved from there. Unfortunately, the UCLA researchers did not write up the graduate assistant’s experiment as a case study, so there is nothing in peer-reviewed literature about the dramatic reduction in seizures she experienced. This means that very few neurologists are aware of neurofeedback as an intervention for seizures and most discount the process as invalid.

Nonetheless, the past almost-60 years have seen a steady flow of research into neurofeedback. Most of the studies are small and use DSM diagnoses as a baseline for interventions. Unfortunately, the Diagnostic Statistical Manual of Mental Disorders categories, which encode the criteria for identifying and labeling mental health conditions, are committee-created and bear very little relationship with electrical brainwave patterns. This makes research difficult on many levels. If, for example, one gathers 50 people with a diagnosis of ADHD, their brains are not likely to all look alike.

Another hindrance to scientific studies is that it is quite a challenge to do sham neurofeedback so that one can have a control population. Quite often, those experiencing fake neurofeedback figure out quite quickly that they are not receiving the real thing. However, in my opinion—an opinion shared by others—neurofeedback research should not be following a pharmaceutical model of double-blind, placebo-controlled studies anyway. A more apt comparison would be the way that surgical advances are achieved—practitioners discover new and better ways to implement good surgical outcomes, then share their results with other practitioners. Indeed, this is how most of the advances in neurofeedback approaches and protocols occur—from practitioners to researchers for validation rather than from researchers to practitioners.

Finally, there is the pathology model of neurofeedback research, which aims to treat or control disorders. I fundamentally disagree with this and do not do brain training to treat disorders (especially because of my views of the DSM). Instead, I believe in brainwave optimization. I train the brain that presents in front of me to optimize performance, because unless one has a physical/structural problem in the brain, each of us has a perfect brain. It has evolved over time to respond to our environment and keep us alive and safe.  The trick of neurofeedback is to work with what’s there and improve its performance. I like using a gym analogy. Just as someone joins a gym for better fitness, my clients work with me to work out their brains.  The difference is that once one stops working out, body fitness fades, but with brain training, that growth and learning lasts long-term. How wonderful is that!

For those who are interested in seeing the body of scientific literature on neurofeedback, there is an annotated bibliography that members of the International Society for Neuroregulation and Research have compiled. It is available here.