Twice a week, Stephanie, a 37-year-old artist based in Boston, meets with her therapist to work on improving symptoms associated with post-traumatic stress disorder, which include flashbacks, bad dreams and suicidal thoughts.
“I was having nightmares where I was yelling out so loudly that my partner could actually hear and transcribe what I was saying on another floor of the house,” said Stephanie, who asked to withhold her last name because of the stigma surrounding mental health.
Her sessions, however, are not your average armchair therapy. At some point during each meeting, her therapist, Ainat Rogel, places Stephanie in front of a computer, attaches several electrodes to her skull and instructs her to control a video that appears onscreen — using just her thoughts.
The treatment is known as neurofeedback, a therapy some say can improve our attention, moods, sleeping habits and even our athletic ability by measuring brain activity and showing it to us — either on a screen or through headphones — in real time. A practitioner places electrodes on a patient’s head that detects (but does not stimulate) brain activity. This is then analyzed by a computer that sends it back to the patient as images or sounds. As the patient completes tasks, the computer encourages healthy patterns of brain activity.
People suffering from anxiety, for instance, may lessen their symptoms by repeatedly being guided to generate brain patterns correlated with a calmer state of mind. Just as we learn to ride a bike by doing it repeatedly, the theory goes, our brains can learn to be less depressed, more focused and better primed for a good night’s sleep.
In Stephanie’s case, Dr. Rogel sets a video to play at full screen when sensors detect brain activity corresponding to a reduction in her PTSD symptoms. The video shrinks and becomes more difficult to view when the electrodes detect unhealthy patterns.
Stephanie said she isn’t entirely sure what she does to make the video play at full screen. “Sometimes I’ll put a thought into my mind or focus on something I need to work on,” she said. “Sometimes I’ll focus on a memory.”
The important part, said Dr. Rogel, who founded the neurofeedback clinic Boston Neurodynamics, is repeated exposure to beneficial brain activity. If done often enough, she said, exercises like these can help patients retrain their brains into healthier patterns.
“This is the only thing I’ve tried that’s given me any relief,” Stephanie said, adding that her symptoms have steadily improved since her first week of treatment this past May.
Over the last decade, neurofeedback has entered mainstream culture. Tobias Harris of the Philadelphia 76ers uses it to improve his focus. Motivational speaker Tony Robbins credits neurofeedback for increasing his ability to multitask. Well-heeled investors, including the former secretary of education, Betsy DeVos, continue to pour millions into neurofeedback companies that promise dramatic improvements to the ways our brains function.
However, neurofeedback is still not accepted as a mainstream treatment within mental health circles — and the most robust research into the intervention so far suggests it is no more effective than a placebo.
So… Does it work?
Neurofeedback is a type of biofeedback, which uses sensors to record and provide feedback about a range of biological processes like breathing, heart rate or muscle tension. Those suffering from panic attacks, for instance, might use a device that tracks the respiratory system and promotes measured breathing.
Practitioners across the country use neurofeedback to treat conditions like attention deficit hyperactivity disorder, major depressive disorder, anxiety disorder, epilepsy and traumatic brain injuries. The Food and Drug Administration has cleared a wide range of neurofeedback devices to treat these and other conditions, and the Centers for Disease Control and Prevention list it as an option in cases of ADHD in children, though they stop short of endorsing it.
But a 2020 meta-analysis of 17 neurofeedback studies examining its impact on disorders like depression and anxiety was less inspiring. It suggested it is possible to coax our brains into producing certain patterns through repetitive feedback, but the impact on mood disorders was relatively small.
“It’s one thing to be able to say, ‘Hey, we can change the brain,’ and another to show that inducing these changes is actually going to impact symptoms,” said David Dodell-Feder, an assistant psychology and neuroscience professor at the University of Rochester and an author of the study.
Robert Thibault, a postdoctoral scholar at the Meta-Research Innovation Center at Stanford University, is also skeptical. He said neurofeedback advocates point to peer-reviewed research that have “impressive results,” but most are not rigorous double-blind, placebo-controlled trials. Of the dozen or so such trials, he said, “all but one concluded that fake neurofeedback works just as well as real neurofeedback.”
Dr. Thibault said neurofeedback therapy success stories are likely caused by the placebo effect and not the treatment. He suggested that the therapy’s success may have something to do with the “healing environment” that practitioners create in their clinics or the allure of using sophisticated brain-monitoring technology.
Though Dr. Rogel said she has personally witnessed the positive impact of neurofeedback on her patients, she would still “welcome the chance” to demonstrate neurofeedback’s effectiveness through double-blind, placebo-controlled trials. “I can say, well, this one client benefited from neurofeedback, and this is great,” she said. But she also wants to see more exhaustive studies that would back up the success she sees in her clinic each day.
An ill-defined industry
Neurofeedback practitioners vary widely in their training, background and the services they provide — contributing to confusion within the industry as to who should be administering the therapy and what it entails.
“There are so many practitioners out there that, quite frankly, have no business doing neurofeedback,” said Rhonda Potter, an associate executive director of the Biofeedback Certification International Alliance, which offers a neurofeedback certificate program. To date, B.C.I.A. has certified 1,300 neurofeedback practitioners, mostly in North America. Ms. Potter guessed there are “many thousands” more operating across the country, however, that have not sought out certification.
She said a formal background in mental health is not a prerequisite to becoming a neurofeedback provider. In many instances, an online course is all that is needed to earn the certificate required to operate one of the dozens of neurofeedback devices on the market.
Some companies skip the practitioner entirely by selling pricey neurofeedback devices directly to consumers. Though unlikely to do much harm, Ms. Potter said she would be skeptical of any person or product “claiming you can simply take a piece of equipment out of a box, apply some sensors and say we’re doing neurofeedback.”
Even among seasoned practitioners, the therapy varies widely. Some insist on creating a baseline “brain map” before a patient’s first neurofeedback session — applying sensors to the skull for two hours to observe and document brain activity. Others say such maps are optional or unnecessary.
Through its accreditation program, B.C.I.A. is attempting to provide stricter standards for the industry, Ms. Potter said. To earn the group’s credentials, practitioners must have a degree in a relevant health care field, take coursework in neuroscience, complete a training program and pass an exam. However, the certificate program, the only one of its kind, is voluntary.
Before you try it
While its effectiveness is still debated, neurofeedback is generally thought to be safe. Even critics admit there are few side effects or downsides for those who have the time and money. So if you have read the studies, understand the criticisms, and still want to try your hand (or head) at neurofeedback — here are some things to keep in mind.
Know the costs — and find out if your insurance will cover it.
The costs of neurofeedback therapy can be prohibitive, and few insurance plans will cover it. A single session costs $100 to $300, but most practitioners say patients need at least 10 exposures, and often many more, to benefit. A brain map and analysis, which some practitioners use to set a baseline for future sessions, can cost $1,000 or more.
Neurofeedback practitioners said costs are similar to what you might pay for traditional talk therapy — and potentially less, depending on how many sessions you undergo. Some insurers do cover it, so call your provider to learn about their policies. Many neurofeedback clinics offer work sheets with talking points and questions to help you advocate for coverage.
Choose your practitioner carefully.
Ms. Potter of B.C.I.A. pointed to a searchable database on the organization’s website as a good place to find a practitioner, though she added there are also plenty of practitioners who lack these credentials and still do good work. She suggested interviewing several practitioners before making a decision — and to prepare questions in advance.
“Find out exactly what training they’ve had, and what type of machinery they are trained to use,” she said. “If there’s a specific disorder you’re looking to have treated, make sure they have experience treating that disorder.”
Explore all recommended treatment options.
Though there are no known side effects to neurofeedback, it could still pose a danger to those who pursue the therapy to the exclusion of other treatment options recommended by health professionals.
“One of the biggest issues is delaying proper treatment that’s evidenced to actually work,” said Dr. Thibault. “If you have a learning disorder, and you’re pursuing neurofeedback in place of accepted therapies that would help you correct your learning disorder, then you’re doing yourself harm.”