When people first discover neurofeedback and start exploring whether they want to try it for themselves, one of the smart and key questions they ask is what the science says.
I find the “It treats ADHD, Anxiety, Depression, PTSD, other Trauma, and More!” response that I see all too often to be disingenuous and incomplete. The fuller truth requires nuance, a bit of history, and a little patience to sort through.
Neuroscience Origins
Neurofeedback, also sometimes called neurotherapy or neuro biofeedback, emerged from a UCLA neuroscience laboratory in the late 1960s. Dr. Barry Sterman was experimenting on his laboratory cats, trying to teach them to create a relaxed but alert brainwave pattern, when he got involved with a NASA project to explore the toxicity of rocket fuel for humans. In a move that would be controversial today, he injected his laboratory cats with the rocket fuel. As you’d expect, all the cats had seizures and some died. For a few of the cats, the seizure onset was delayed, and Dr. Sterman realized that the cats that survived with delayed seizures were the ones he’d been teaching to relax using rewards for shifting brainwaves.
One of his graduate assistants suffered from epilepsy, and together with Dr. Sterman decided to experiment and see whether what they had accidentally done with cats would work in humans. To make a long story short, she saw good results.
From there, Dr. Margaret Ayers, a Hollywood psychologist, convinced Dr. Sterman to let her try to use this new tool in her practice. One of her clients was a troubled young man with attention, focus, impulsivity, and other problems. The neurotherapy worked well enough for him that his parents—a school teacher and a physicist—brought what is now known as neurofeedback into the broader world.
Its acceptance was slow, in part because hippie culture adopted a type of neurofeedback called alpha training to help with their meditation and spiritual practices. That discredited it among many people.
Another impediment was that computers in the 1970s were enormous and expensive.
By the late 1990s, both impediments had faded. Personal computers that operated quickly enough to provide real-time rewards emerged into the consumer market. Spiritual/meditative uses persisted, but more quietly.
Since then, neurofeedback has slowly morphed into a tool that is used by home users, mental health providers, and medical professionals. It’s gaining popularity and, despite its solid foundation in neuroscience, a lot of mythology, over-promises, and falsehoods are emerging.
What the FDA Says
The FDA recognizes neurofeedback as safe and cites five purposes:
- General Relaxation
- Relaxation for Stress Management
- Muscle Relaxation
- Muscle Relaxation for Pain Management
- Quality of Life Management.
Because the FDA considers it so safe, neurofeedback devices do not certification or registration through 510 (k) requirements (view at fda.gov for further information) It IS possible to register a device, but it is not necessary.
Although neurofeedback is safe and requires neither FDA approval nor registration to use, some companies go through the process of hiring an attorney and jumping through the hoops to achieve registration for their neurofeedback gear. Why? In my opinion, it’s mostly marketing. Calling a device medical grade can make it seem to be more credible in the eyes of those who do not know that the registered device is essentially the same as unregistered devices, just with an advertising pedigree.
You, or your practitioner, are paying a premium for something that is utterly unnecessary except to one-up a competitor or charge higher prices to unwitting practitioners. (This isn’t to say that there are no differences among different neurofeedback devices, but regardless of whether someone’s device cost $1000 or $15,000, the insides of those devices are largely alike in all the most important ways.)
Learning Theory
The theory behind how neurofeedback works is that it’s basic operant conditioning: you give a reward when you get the desired behavior to increase the frequency of that behavior. In this case, the rewards from neurofeedback systems gently teach the brain to shift its energy patterns.
People change their brains, both intentionally and unintentionally, every day. Every time you practice something, learn something new, or are exposed to something novel, you are changing your brain. Even things as simple as listening to a song you haven’t heard before changes the brain. In the case of neurofeedback, its focused teaching offers gentle rewards for shifting brainwaves rather than, say, memorizing a new song. It’s learning.
Researchers argue whether it’s truly operant conditioning at work or something else, but over the past 50-plus years, there has never been a published study showing any long-term harm from neurofeedback. It’s safe, based on decades of practice. The FDA has not disagreed.
[Please note: those with unstable brains and have significant mental illness such as psychosis are not good candidates for neurofeedback.]
Treating Diseases and Disorders
Did you notice that that FDA list of recognized uses does not include treating mental health disorders or migraines or tinnitus or any of the myriad of other things that many practitioners claim to treat?
If a person has a license for a specific occupation—in the world of neurofeedback, it’s usually counselors, social workers, psychologists, a few physicians (usually psychiatrists), chiropractors, and occupational therapists—that person is empowered to use tools to help achieve their treatment goals. As long as the use is within the parameters of what their license allows them to do, called scope of practice, it is perfectly okay to make claims about how they use neurofeedback. It doesn’t mean that the FDA recognizes it, but it is okay.
One example of using tools for treatment is when a therapist teaches mindfulness to a client. Mindfulness is used for many things, but in the hands of a therapist, it’s a treatment. In the hand of someone at home, it’s a relaxation/spiritual practice. That doesn’t make the home practitioner any less qualified to help their own anxiety using mindfulness or meditation.
Despite not really being useful as a diagnostic tool at this time, the field of psychology is striving to make neurofeedback into a harder science that can be used to detect mental health disorders. Some are collecting brain maps and putting them into databases that they are then using to try and connect certain patterns to specific issues. The effort is admirable but still hit and miss. For instance, one neurofeedback client who wanted to do brain training to improve his sports performance was told instead that he had a learning disability, based on comparing his qEEG to database information. This person had no disabilities and was shocked and upset by the results. Perhaps there are times when such predictions are accurate, but we just aren’t “there” yet when it comes to tying specific brainwaves to specific disorders.
Research is Tied to Disorders
This brings us back to the issue of research. For our purposes now, let’s stick with mental health disorders.
All practitioners in the United States who have authority to diagnose mental health conditions rely upon a document called the Diagnostic and Statistical Manual of Mental Disorders, or DSM-V. Now in its fifth edition, the document provides the foundation for our current construct of mental illness. A committee of renowned psychiatrists hash out what is and is not a disorder, and what behaviors should or should not be included in the diagnosis.
In short, the DSM is a committee-created document that is a checklist of behaviors for a practitioner to observe or receive reporting about in order to diagnose as accurately as possible.
The DSM serves us well in many ways, but it has a bit of a notorious history and is sometimes grounded more in culture than science. At one point, both hysteria and homosexuality were included as mental health disorders. In recent years, the committee has worked hard to create a more scientifically founded manual.
The trouble, as psychiatrist Dr. Daniel Amen has repeated pointed out, psychiatry is the only field in which doctors don’t examine the organ in which they specialize in treating. This means that diagnoses do not align with electrical patterns in the brain, nor do they align especially well with chemical patterns in the brain.
The State of Neurofeedback Research
Diagnoses based on behaviors are helpful when it comes to things like understanding each other in conversation or acquiring IEPs for students, but it makes neurofeedback research especially challenging.
That’s because it’s only been in the past few years that clinicians have been trying to tie diagnoses to brainwave patterns. It works a little bit, but as you can imagine, a checklist of behaviors doesn’t necessarily equate to a diagnosis.
If someone goes to a neurofeedback practitioner and says they have trouble focusing, it could be related to any one of a dozen or more different brainwave patterns. For example, certain places in the brain could have electrical patterns that are too fast, or too slow, or out of proportion to the mirror side of the brain (called the homologous region). They could have connectivity issues (called coherence) that run too high or too low. It’s not as simple as saying that a person has ADHD and so should do neurofeedback in one particular way.
I think this reliance on diagnostic language that isn’t pinned to our brain’s energy patterns is one reason that people go to practitioners and do not receive the results they hoped to receive.
A second impediment to good neurofeedback research is that people can often tell when they receive fake, or sham, neurofeedback. That makes it challenging to create a placebo group in studies.
A third impediment to solid research is that there are multiple approaches to providing feedback to the brain. Some approaches really don’t include feedback as others recognize it. Some approaches use tools that have such precision that they lose meaning (kind of like saying that the room you are in is 72.34897 degrees—it may be an accurate measurement, but is it helpful to you?). Other approaches only attach electrodes at one or two sites on the scalp and claim that it affects the whole brain. Almost all approaches work at least some of the time, but differentiating among them for research purposes is fraught.
Fourth, neurofeedback research lacks significant funding. Pharmaceutical companies have deep pockets and can run studies on 10,000 people at a time. So far, none of the universities conducting research into neurofeedback have been able to run such large studies. Small studies have value, but are held in less high regard when compared to studies with big numbers of participants.
Finally, doctors without information about how neurofeedback really works often pooh-pooh it as ineffective snake oil. The mother of one of my former clients whom I referred to a neurologist reported to me that the neurologist laughed at her when she said the child was doing neurofeedback—that sort of derisiveness without information is unhelpful. Worse, stories abound of pharmaceutical companies trying to impede research into and acceptance of neurofeedback.
What this Means for Consumers
Despite the noisy, messy soup that is the field of neurofeedback, we continue to make solid progress. At the university level, researchers do their best to standardize what they are testing and measuring. They are making progress. Right now, we can look not only to a few universities in the US, but to prominent researchers in Germany, Israel, the Netherlands, and Turkey. It’s a worldwide effort to move us forward.
Peer-reviewed literature. If you wish to delve into individual studies, there is a fairly significant body of literature, albeit usually with a small number of subjects in each study. If you wish to peruse the literature directly, Dr. Cynthia Kerson produced a bibliography for Applied Psychophysiology Education. The International Society for Neuroregulation and Research also has a bibliography that is sorted by mental disorder. I also have a few studies, as well as several books, available on my resources tab.
Peer-to-peer knowledge. Please be aware that practitioners themselves are a key source of expanded knowledge in the field of neurofeedback. Some will experiment and discover new protocols (a plan for what and where to train) that they then share with others. This path to knowledge of what and how to do things resembles the way doctors create surgical advances more than how drugs are tested. One person explores a new way to approach brain training, tells others, then those others experiment to try and replicate results. This has happened and continues to happen in particular with creating beneficial training for those who have an autism diagnosis, for example. At times, this information is shared via informal conversation with colleagues and mentoring new practitioners. Some is shared in online webinars and member groups. Some is shared at conferences. Some comes via publication in peer-reviewed journals.
The bottom line is that neurofeedback is a powerful learning tool. It is part science, part intuitive art. It has many proponents who wish to claim that it is dangerous unless in the hands of their occupation, yet the FDA finds it so safe that there are no regulations limiting its application. It has an army of dedicated researchers worldwide who work to understand the brain and how neurofeedback can affect brain function without pharmaceutical intervention. An increasing number of mental health practitioners are enthusiastic in using neurofeedback to help their clients and patients. Parents, usually moms, use neurofeedback at home for their children and foster children. Brain hackers also love to experiment from home.
What does this mean for you?
Neurofeedback is safe for most people and backed by 60 years of use.
It’s backed by neuroscience yet also involves the art of intuition and practical experience.
There are things to know if you want neurofeedback for yourself or a loved one:
If you’re going to search for a practitioner, know that most universities do not teach neurofeedback (though thankfully, the number is increasing). This means that no credential, not even MD, confers the ability to do neurofeedback and do it well. Moreover, there is no license or degree in neurofeedback at this time. People learn largely from private companies and individual practitioners.
Instead of looking for specific degrees or certifications, look to the experience and education of the practitioner. Ask them questions about how they work, why, and how. If they cannot answer those questions well or, worse, try to undermine you for asking, move on and find someone else. Some new to the field have dug in deeply and are highly competent, while some who have dabbled in neurofeedback for years haven’t invested time in deep learning and still don’t quite understand why they do what they do.
Neurofeedback is also something you can learn to do for yourself if you’re dedicated. There is a learning curve, and it’s fairly steep. If you’re going to go down this path, beware of the lure of most of the plug-and-play gadgets coming on to the market these days. They are usually too simplistic to meet all your or your clients’ needs.
Whatever way you go, this is an exciting time to be a part of the world of neurofeedback.