Donald C.E. Ferguson, Ph.D., MPH
Research Professor, Department of Psychiatry
Uniformed Services University
Bethesda, Maryland
Health Care and/or Medical Interventions

Elsie L. Ferguson, Ph.D.
Medical Psychologist - Clinical Psychophysiologist - Private Practice
Chevy Chase, MD

HYPERLINK "mailto:dferguson@usuhs.mil"
dferguson@usuhs.mil

or HYPERLINK "mailto:pairofdocs@starpower.net"
pairofdocs@starpower.net

What is Neurofeedback?

Neurofeedback is a biofeedback treatment modality that has been in clinical use for roughly three decades. Limited numbers of health professionals in the United States and elsewhere are trained in and experienced in its use. Professionals trained and experienced in neurofeedback, also called neurotherapy, may be found in medical centers and in teaching hospitals. Office based practitioners of neurotherapy may also be found in many major metropolitan cities in North America, though they are not numerous.

Neurotherapy practitioners are health practitioners initially trained in one of several health or medical disciplines, but who have also had additional training in neurotherapy as a subspecialty or specialty. Electroencephalographic (EEG) equipment plus additional electronic equipment which can do a variety of mathematical signal processing of brain wave data, and which has the capability to display and rapidly feed back information to the patient or client about many types of ongoing brain wave patterns is required.

Not only EEG equipment is needed, but additional biofeedback equipment and several types of purpose-designed, specialized software as well. Practitioners, skilled in the therapeutic use of this equipment, in dealing with a variety of conditions, and in interpretation of its output in coaching and guiding the patient or client require additional training.

Neurotherapy is based on physiological monitoring of brain activity, and in training, guiding and coaching the patient in neurological self regulation learning with the objective of modifying underlying patterns of neurological (brain wave) activity in health facilitating and/or rehabilitative directions.

A simplified analogy to facilitate understanding: A thermostat controls the heating and cooling in your home. The temperature of your home is regulated by the setting of the thermostat. The thermostat controls the furnace and air conditioner. If you change the setting of the thermostat, the ongoing ambient temperature of your home changes and your comfort level is altered.

In a similar manner the brain acts as a kind of thermostat for physiological processes such as breathing, heart rate, body temperature and the like. These processes operate automatically, and for the most part out of our awareness. With brain wave changes, our heart rate, respiration and body temperature will change.

There is a complex of underlying, ongoing brain wave activity that is completely out of conscious awareness, which controls our physiological functions. These brain wave complexes are modifiable, and ongoing patterns can be retrained using available neurofeedback technology and neurotherapy treatment methods.

In many medical conditions usual brain wave activity and patterns have been modified in a dysfunctional manner. Neurotherapy is a treatment modality which can be utilized to retrain and modify these standing patterns back to patterns associated with more healthful and normal patterns.

When this is done, similar to the situation which occurs when you reset your thermostat in your home if it is too hot or too cold, underlying physiological processes can be modified in a health inducing or corrective manner. Your physiological "temperature" is changed. Though this is remarkable, it is an objectively demonstrable and not a theoretical outcome.

Neurotherapy is Not Psychotherapy

It should be evident from the foregoing discussion that neurotherapy is not a form of psychotherapy. It is not a "talking therapy." It is based on measuring, monitoring, processing, and feeding back in both visual and aural (hearable) form, selective, direct, real-time information on what is happening in the brain and is directed towards retraining and coaching, through monitoring, those dysfunctional patterns in a more healthful, health inducing or therapeutic direction. To oversimplify, where the brain goes (much) physiology follows.

Indications for the Use of Neurotherapy

Neurotherapy is increasingly used in treatment of Attention Deficit Disorder (ADD), Attention Deficit Hyperactivity Disorder (ADHD), in rehabilitation of traumatic brain injury, obsessive compulsive disorders (OCD), and in a growing number of biological states in which autonomic nervous system (ANS) hyper-arousal or hypo-arousal contributes in a negative manner to underlying medical conditions and illnesses. Conditions in which hyper arousal plays a dysfunctional role are many. Stress related disorders in our culture are nearly of epidemic proportions given often conflicting demands, pace, complexity, and rate of change demanded of those living in industrial and post-industrial societies.

ANS hyper arousal or hypo-arousal can be "modified" with medication. However, medication is often palliative only. Stop taking the medication, and the problems return. With some medications there also may be a compensatory "overshoot" or "rebound" when medications are stopped, and functional, though not physiological addiction to the medication may result requiring continuous and chronic use of the medication.

Neurotherapy in such situations is directed towards resetting brain "thermostats" which control the level of brain (and physiological) arousal. The data shows that once accomplished, this "resetting" is both robust and long-lasting. An additional benefit of neurotherapy is that (properly administered) there are no negative or adverse side effects, which is seldom the case with a number of medications and pharmacologic agents.

It is very common to use both medication and neurotherapy simultaneously. In many, if not most cases the need for side effect inducing medications can be gradually reduced, and in many cases eliminated entirely over time using this method. Such treatment is ordinarily done in conjunction with a referring physician or medical specialist since few physicians are trained, or willing to invest the time, capital, or effort in acquiring  needed training, and continuing education involved in a new specialty themselves. This field is burgeoning new uses and indications for neurotherapy are being discovered each year.

Biofeedback and Neurofeedback are Not Identities

Most neurotherapists have a background in clinical biofeedback or psychophysiology. However, in relation to biofeedback, neurofeedback and neurotherapy are added clinical psychophysiology subspecialties which require additional training and experience much in the manner analogous to gastroenterology training which is a type of subspecialty training which adds to, but follows an internal medicine residency.   Additional training, experience, supervision, plus continuing education and a substantial financial investment in additional EEG equipment, hardware, computer software and display devices are needed to add neurofeedback to the clinician's armamentarium. 

Regular continuing education for neurofeedback specialists is especially important since developments in research findings, constantly improved technology, equipment, software, innovations in treatment protocols and methodologies have all been changing rapidly, with improved efficacy plus a growing number of illness conditions are being demonstrated to receive benefit from neurofeedback interventions.

Essentially most neurotherapists are also skilled in clinical biofeedback and psychophysiology and their application to disorders such as migraine, tension headache, Raynaud's, hypertension, and stress related disorders.

A considerable number of neurotherapists, but not all, are trained, qualified psychotherapists as well. This depends on the original discipline in which a neurotherapist was trained. If his/her initial training was in physiology or medicine, very few will have been trained as psychotherapists as well. If, however, a neurotherapist came from a clinical or medical psychology, or psychiatry background, or specialized in behavioral medicine or health psychology, or in clinical social work, it is probable they were specifically trained mental health practitioners and thus psychotherapists as well. 

Many medical conditions lead to psychological problems (and may be thought of as somatopsychic conditions). The reverse is also true, and these are often considered psychosomatic illnesses. It can be useful for many patients/clients to be treated by professionals skilled in both neurofeedback, biofeedback, and a mental health discipline.

Once again, to reiterate, neurotherapy itself is not psychotherapy, it is a physiological not a psychological intervention. It is not behavior therapy. It is not cognitive therapy. It is not "talking therapy." A number of neurotherapists are not mental health practitioners, and deal either primarily or entirely with medical conditions, often on referral from knowledgeable physicians who continue to follow these patients and manage their usual ongoing clinical care. Cooperative, collegial relations with  patient's primary care physicians are the norm since medication dosages often need to be adjusted downwards as treatment progresses reflecting changes and to mitigate side effect problems. 

Since neurotherapy is not an invasive procedure, neurotheraists need not be (and seldom are) physicians. This may be somewhat confusing to staff and claims processors in many health insurance companies until they have either self educated, are taught or come to understand the distinctions involved, and gain experience with conditions for which neurotherapy makes a significant and economic difference in outcome. It is early days for insurance companies in this regard.

Since neurotherapy is a "relatively new kid on the block" few health insurance companies or third party payers will reimburse for it. Most of the rapidly growing number of parents with ADD or ADHD children are more than happy nonetheless to have an effective, durable alternative to medications whose long term effects (Ritalin and methylphenidates) appear to be less than happy ones, and willingly fund this treatment for benefits they have seen others obtain from it.

Research Foundations

Neurofeedback and neurotherapy are evidence based treatment modalities. Active research into new and additional uses for this treatment modality are under exploration and ongoing at universities, medical centers, and medical schools throughout North America and abroad. A stream of promising and proven uses for this approach has been forthcoming over the past five years.

Using search engines on the World Wide Web (and using neurofeedback as the search term) will lead the interested reader to much useful information about this topic.

Other Resources to Augment Understanding of Neurotherapy

There are a number of professional biofeedback associations in North America at State and Regional levels, but two national associations which have World Wide Web sites may be of interest to readers interested in learning more. They are as follows:

The International Society for Neuronal Regulation (ISNR): a professional membership organization is comprised of several hundred professionals involved in neurofeedback training and in research. Today, EEG biofeedback or neurofeedback is not the most commonly used form of neuronal regulation, but is often used in conjunction with other forms of biofeedback or with other interventions such as medication. SNR maintains a listing of member practitioners in the United States at its Web site (www.isnr-jnt.org/index.htm). Scientific articles and other material of interest may be found at this Web site. The SNR publishes a scientific journal (The Journal of Neurotherapy). 

The Association for Applied Psychophysiology and Biofeedback (AAPB), first founded in 1969 (as the Biofeedback Research Society, and later known as the Biofeedback Society of America), currently numbers over 1,900 professionals. The organization is interdisciplinary and includes professionals from the fields of psychology, psychiatry, physical rehabilitation, physical therapy, dentistry, nursing, education, and others. Interests of the membership include both basic and applied aspects of clinical practice and research. (www.aapb.org). AAPB publishes a journal which may be found in most medical school and graduate school libraries with a doctoral program in clinical or health psychology. 

A number of states and U.S. regions have biofeedback societies, many of these societies have web sites, and a Google search www.google.com using search terms such as "neurofeedback", "biofeedback" will provide added information. A listing of state society Web sites (but which is not entirely up to date) is found at www.biofeedback.net and some society web sites list provider directories, and at very least Contact addresses for their officers.

There are basic science journals such as Psychophysiology which are actively and regularly published, but beyond the scope of this article. Contact the ISNR, the AAPB, or a MASBBM Society Officer for further information using addresses given at each of the Web sites to obtain additional information resources.