| This example
shows several EEG frequencies which are used by the therapist to set goals
for each client.
Originally, most training was done along the
sensory motor strip. Neuroscience and brain imaging research has pointed
to many other problem areas. As a result, Neurofeedback often includes
training at the frontal and pre-frontal lobe, the anterior cingulated,
and the temporal lobes. For example, research indicated that excessive
EEG slowing at the cingulate can be related to ADD, Depression, and
OCD.
Alpha-theta
training (8-11 or 8-12 HZ for alpha and 4-8 HZ for theta) uses Neurofeedback
to guide people to their deepest levels of consciousness, in order to
facilitate and process psychological issues. This training is often
used in transforming depression, addiction, anxiety, and PTSD. It also
helps enhance creativity and promote deep states of relaxation. This
training is done with eyes closed and is often enhanced with guided
imagery. A double blind study on musical performance was just published
by a noted university in London. Students of the Royal Conservatory
of Music who did alpha-theta training were the only group of the five
modalities studied that saw readily identifiable improvements in musical
performance. Healthy high alpha training (11-14) posteriorly (in the
back of the head) is also being identified as an important contributor
to better memory function. This EEG training has been labeled “brain
brightening” by Dr. Tom Budzynski, a professor at the University
of Washington.
Excessive
theta and delta (slow wave activity) is inhibited during training. Theta
waves (4-7_ can be associated with distractibility, not focusing. Delta
waves (0-3) are often associated with sleep states, but in waking state,
can be associated with brain dysfunction. Excessive amounts of delta
and theta will interfere with brain function (concentration, attention,
etc). Training is adjusted to reduce that activity. qEEG based brain
maps can be used to help identify brain areas that are excessively slow
or fast.
High Beta. Certain frequencies of high beta can potentially stimulate
attention. Other frequencies are associated with anxiety, tension, and
trying too hard.
A brief history- how did science and cats discover SMR EEG training?
In 1968,
Dr. Barry Sterman, a neuroscientist at UCLA medical center, proved that
cats in his lab could be trained to make more EEG activity at 12-15
HZ frequencies, using operant conditioning. He called it SMR- Sensory
Motor Rhythm. Sterman then used the same cats for a NASA contract to
investigate whether rocket fuel could cause seizure activity. The cats
were exposed to a volatile fuel called hydrazine. Half the cats seized
in a predictable dose response curve. The other half of the cats- those
who had increased SMR brainwaves in the last experiment, had a dramatic
reduction in seizure threshold vs. the normal cats. It was a very unexpected
outcome.
After additional
research, EEG training frequency was tried on a woman who worked in
Sterman’s lab with uncontrolled seizures (using 12-15 frequency
training along the sensory motor strip). The training had the same inhibitory
effect that it did on the cats (the woman now has a California driver’s
license).
These events
launched the field of Neurofeedback. Brain dysregulation (of which epilepsy
is one of the most severe types) is reduced with EEG training. The research,
particularly in epilepsy, is extensive.
Are there
differences in Nuerofeedback and biofeedback?
Nueorfeedback
if EEG biofeedback- it’s just a specialized form of biofeedback.
Most health professionals are familiar with traditional biofeedback
methods such as EMG/muscle relaxation, GSR/galvanic skin response, temperature
and respiration training. In the last few years, EEG Nuerofeedback has
become the fastest growing segment of biofeedback field. EEG Neurofeedback
reduces stress and is relaxing- as does other modes of biofeedback.
But Nurofeedback provides a more direct impact on brain regulation along
with central nervous system function.
How many
training sessions does it take?
Noticeable
results typically occur between the first and tenth session. In most
cases therapists recommend a minimum of 30-40 sessions. Certain situations
can require many more sessions. The goal is to complete enough training
to ensure consistent and lasting benefits. Like piano lessons, a lot
of practice is needed for it to stick. The brain is learning a new pattern.
You are looking for over- training for changes to become the dominant
pattern. Session are usually about 20-30 minutes in length, though at
times shorter sessions are useful. Initially, two to three sessions
a week are recommended, though it depends on the individual. Running
up to two sessions a day can be done for accelerated training.
How long
does the effect of training last?
Do the benefits
of training hold long after training is completed? In general, therapists
report that they do, if the client has done enough training, and the
right type of training. However, there are many sites to train on the
brain, and many different frequencies to choose from. Results may vary
depending on the expertise or skill of the professional- just as MDs
vary in their success of using medications.
Some long
term studies have been undertaken by Dr. Joel Lubar at the University
of Tennessee and a few others, showing sustained carryover of improvement.
Published research on epilepsy shows the effects on epilepsy holds well
even 12 months and longer post training. However, much more research
in this area still needs to be performed. Clinicians commonly report
long lasting- and often permanent changes.
Certain
individuals may experience a relapse of symptoms at some point. The
trigger could be an injury, trauma, or extreme stress. There may be
underlying neurological issues or genetic vulnerabilities, or other
factors. It varies by client- some will hold and never need “maintenance”
sessions. For others, ongoing training may be appropriate. Once someone
has gone through intensive training, occasional “maintenance”
Sessions can be sufficient to get them back on track. The intensive
training is seldom needed again- occasional “tune-ups” can
work quite well. It’s as if, once the brain has “gotten
it”, it doesn’t take much to get back to that place. It
may require a tune-up once a month, or once every 3-6 months. It’s
client dependent/
Certain
problems, such as brain injury, autism, Tourette’s cerebral palsy,
or other neurological problems, may require consistent ongoing treatment
to maintain improvements. For degenerative problems, including MS, Parkinson’s
or Alzheimers, reports suggest nuerofeedback help stabilize the problem-
or seem to slow the process. Reports indicate it may help optimize brain
function with whatever resources still exist. It’s more of a “quality
of life” training than an attempt to remediate the problem.
Can Neurofeedback
training be used while a patient is on medication?
Yes. Therapists
report many patients start Neurofeedback while on one or more medications.
After a
number of Neurofeedback sessions, a reduction in medications is not
unusual. It’s very important that the client’s doctor be
alerted if signs of overmedication occur. If that doctor is not open
to reducing dosages when presented with signs of overmedication, then
training may need to be discontinued.
An example: a 42-year-old female was being seen by a therapist. She
had been on four medications for five years to treat depression. After
40 sessions, she was only using one medication at a reduced dosage,
with improved mood and affect.
How do these
changes occur? It is well known that the EEG changes with medication.
The EEG also changes during Neurofeedback, so it’s not surprising
that changes in medications may be necessary. The theory is that as
the brain becomes more activated during training (increased blood flow),
the brain works more efficiently. The medication has a stronger effect
on a more efficient brain.
Not every
patient’s medications are affected. For some patients, neurofeedback
seems to act synergistically with medications, allowing the medications
to achieve a better response, or stabilizing the use of meds. Neurofeedback
is complementary to other treatment approaches, and may help them be
more effective.
When doesn’t
Neurofeedback work?
This is
a complex question that involves many factors. Just as MDs and psychologists
vary in effectiveness based on training and knowledge, this same thing
is true of neurofeedback practitioners. In addition, client compliance
also plays a big role. N Lack of consistency in training often will
cause treatment failures
There are
many sites to train on the brain, and many different frequencies to
choose from. Training each can have a different effect on the client.
Choosing the right one – (like choosing the right medication)
can require a mix of skill, knowledge and patience to identify responsiveness.
If the wrong protocol (frequency and site) is used, little or no effect
may be noted.
Therapists
report that doing Neurofeedback without addressing underlying family
system problems can also reduce the effectiveness of using Neurofeedback.
Combining therapy for both appears to be a more effective solution.
Defining
“benefit” is also a challenge. Does it require 100% symptom
resolution of the presenting problem? Is partial symptom resolution
a success? It’s important to set expectations with clients before
they start training, and discuss the expectations on an ongoing basis.
Some clients may perceive failure if remediation is not achieved. Some
clients are impatient, and may stop training if dramatic improvements
aren’t seen quickly. Some clients are poor self-reports and don’t
identify changes when they do occur.
A good therapist
uses Neurofeedback as an integral modality to therapy – and it’s
the combination that makes for maximum effectiveness.
Does EEG
training make permanent changes to brainwave patterns?
Identifiable
abnormalities in the EEG are seen in epilepsy, with head injury, or
from a variety of other causes. With improved brain regulation through
Neurofeedback training, you often see a reduction or elimination of
those EEG abnormalities. There are also certain profiles of ADD, anxiety
and depression in which reductions in excess amplitudes can be anticipated
with the training.
However,
there is still debate in the field. At times, you do not see a permanent
change in EEG but rather a change in the regulatory function of the
brain – resulting in improved outcome. Some suggest that a good
measure of improved regulatory change does not yet exist. Other clinicians
and scientists believe that “normalization” of the EEG is
the primary goal. More research is needed here, but both approaches
– 1) training to normalize the EEG; and 2) training to improve
symptoms – produce client benefit. Many therapists combine a symptom
– based approach with qEEG (EEG based brain map) which can help
guide some of the clinical decisions based on the EEG map.
How does
training transfer to everyday situations?
In everyday
situations the client is no longer sitting in a treatment session, receiving
the feedback. Do they have to remember the effect of the training to
experience it? No, that is clearly not the mechanism in place. Instead,
the effects tend to generalize. It takes a form of increased stability
under demand, greater resilience, and more appropriate state flexibility.
The brain is being trained for better self – regulation, which
may be most noticeable by an “absence of ” problems.
When an
individual notes their attention has improved, or they are less angry
or anxious, they don’t have to remember what they did in Neurofeedback.
The training generalizes, and the brain – under a high demand
situation – seems to have learned to manage itself better.
What is
the cost to the client?
Client fees
vary, depending on qualifications of the provider, the market, etc.
Intake:
An initial clinical assessment varies widely. This includes the expertise
and credentials of the provider, and the time of intake (from 45 minutes
to several hours). Some psychologists and neuropsychologists will do
a battery of neuropsych tests, others don’t. If a quantitative
EEG (qEEG based brain map) is added to the intake, it can significantly
increase the cost of the testing. Costs of the qEEG vary by the level
of expertise in interpretation, the type of provider, the equipment
used, and other factors.
Session
costs typically are similar to the pre –session cost that a professional
charges for other services. Some practitioners offer a discount if multiple
sessions are pre – paid, since it reduces paperwork and collection
time for the practitioner, and encourages the client to come consistently.
What is
the cost to the clinician?
Equipment
costs, quality and capabilities range widely. Courses and clinical supervision
costs vary widely both in cost and quality, and there are no requirements
for the amount of training a professional receives before they start
practicing. We highly recommend that clinicians budget for ongoing training
and supervision. The learning curve is significant.
Do insurance
companies reimburse for Neurofeedback?
Some insurance
companies will pay directly for biofeedback. Many will not. Many professionals
charge clients out – of – pocket for Neurofeedback, and
provide the billing for the client to file with their own insurance.
But this is up to the individual clinician, and varies accordingly.
Neurofeedback uses the same CPT billing as biofeedback – 90901.
Some therapists
bill Neurofeedback as psychotherapy, which is more widely covered than
other biofeedback codes. They report that it is requested often by their
insurance providers. There are other codes – 90875 and 90867 –
that provide billing for psychotherapy combined with neurophysiological
training (including Nuerofeedback). These codes are not as widely accepted
as psychotherapy by insurance companies, though their use is growing.
Some nueropsychologists feel Neurofeedback is part of a cognitive rehab
program, and bill it accordingly. Some health professionals have reported
insurance success with other codes for patients at times.
How much practice is needed before working with patients?
There are
psychologists and MDs who have started training clients within two weeks
of their first course. Others practice for several months before they
charge clients. There are no required standards.
Knowledgeable
professionals suggest: 1) Find the best possible course. 2) After the
course, it’s helpful for professionals to do ten or more EEG training
sessions on themselves first. This helps the clinician to better understand
the process. 3) Train your family, friends or colleagues (if there not
ethical issues) to gain experience. There are a variety of protocols
that must be learned, which consist of specific brain sites and frequencies,
both of which must be chosen appropriately. 4) Consult with a clinician
experienced in nuerofeedback to shorten the learning curve. 5) If you
decide to use qEEG data (EEG brain map) as a tool to guide the training,
find a very experienced and knowledgeable tutor to help. The learning
curve on qEEG is significant without ongoing help.
Are there
adverse effects from Neurofeedback?
In the 30
– year history of the field with hundreds of thousands of training
sessions by clinicians, there has never been a lawsuit for adverse effects
of Neurofeedback training. It is, after all, just self-regulation training.
That having
been said, recognize that anything that has the power to change things
for the better could potentially have adverse effects. That’s
why good professional training is critical. This tool can help improve
sleep – it can also make sleep worse. It can improve depression
– or could make it worse. However, it’s hard to make things
worse for long. Initially, the effects wear off quickly, and the appropriate
changes can be made. Effects of training can be reversed by changing
protocols. Monitoring change and shifting training protocols is part
of the responsibility of trained professional. Like titrating medications,
short – term effects provide information useful in adjusting the
client’s training. Short – term symptoms wear off. So, negative
effects from going in the wrong direction can be rapidly
changed.
Is
biofeedback certification required to provide Neurofeedback?
Biofeedback
is a natural tool for mental health professionals, and is covered under
the APA guidelines for psychologists.
Certification
programs for neurofeedback and biofeedback have been created by the
Biofeedback Certification Institute of America (BCIA), a peer reviewed
organization that has set standards for this field. They provide two
kinds of certification. There’s BCIA for general biofeedback –
EMG (muscle activity), GSR (galvanic skin response), breathing rate
and other peripheral measures. A separate BCIA certification exists
for EEG Biofeedback (Neurofeedback).
The EEG
Beiofeedback certification is still in the early stages of gaining acceptance,
and currently no states require EEG BCIA certification as a requirement
to provide Neurofeedback. States accept that if the clinician is a licensed
health professional, licensure is sufficient.
EEG Neurofeedback
equipment should be FDA approved. FDA approved equipment is legally
sold to licensed clinicians. Some “low end” consumer oriented
equipment is sometimes purchased by individuals, but is not recommended
because they lack the expertise to apply it properly.
Is there
sufficient research in the field of Neurofeedback?
There will
probably be enough research. Research abstracts and some journal articles
are available on the web. A medical journal published in January 2000,
Clinical EEG and Neuroscience (not on the web), devoted a whole issue
to reviewing scientific literature for Neurofeedback. This issue is
a good overview of the research. Contact EEG Spectrum International
to get a copy of this journal, or check your local medical library.
Over 1000
studies have been published related to this field. The majority of studies
are in three areas: epilepsy, ADD, and substance abuse, as well as in
basic research. The research is sufficient to encourage a growing number
of licensed clinicians – including professors of respected universities
and medical schools – to adopt Neurofeedback.
The challenge is that it takes a lot of reading to understand Neurofeedback.
It includes the basic neuroscience of the EEG as well as many clinical
studies. Dr. Barry Sterman, 1996 article, “Physiological Origins
and Functional Correlates of EEG Rhythmic Activities: Implications for
Self – Regulation” reviews some of the key research, while
providing an in – depth discussion of some of the underlying mechanisms
at work in the EEG as it relates to neurofeedback.
More outcome
studies are clearly needed. But the literature that exists is substantial.
Frank Duffy, a noted Harvard Neurologist, reviewed the literature and
wrote an editorial for the Clinical EEG and Neuroscience Journal. After
identifying some unresolved research issues, he added: “The literature,
which lacks any negative study of substance, suggests that EBT (EEG
Biofeedback Therapy) should play a major therapeutic role in many difficult
areas. In my opinion, if any medication had demonstrated such a wide
spectrum of efficacy it would be universally accepted and widely used.”
What’s
the right name: Neurofeedback, EEG Biofeedback…?
No one in
the field has agreed to a single name. Any of the following names can
be used.
The most common are: Neurofeedback, EEG Biofeedback, or EEG Neurofeedback
You’ll also hear: Brainwave Training, Neurotherapy, or Neurobiofeedback
If you hear
“Biofeedback” – it’s usually NOT the same thing.
Biofeedback is more commonly known by professionals and the public than
is Neurofeedback.
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