PHOTO BY TOM CROKE
Lawrence M. Hirshberg, Ph.D., BCN, said neurofeedback is almost never the first treatment for mental health problems. Hirschberg is director of the NeuroDevelopment Center in Cambridge, Mass. and Providence, R.I., and a Brown University faculty member.
The brain could be considered the communication center of the body, sending messages to every cell and keeping all systems running properly. But psychological or physical trauma can disrupt those signals. Researchers are finding that neurofeedback can repair broken connections and help restore functioning.
A traumatic brain injury involves the tearing of white matter connections in the brain that cause the whole system to be “out of whack,” according to Diane Roberts-Stoler, Ed.D., owner of Dr. Diane Brain Health in North Andover, Massachusetts.
She speaks from first-hand experience. In 1990, she suffered a stroke while driving, resulting in a head-on collision; fourteen years later she had a mini-stroke. Subsequently, two other separate accidents left her with concussions and traumatic brain injuries. During routine CAT scans and MRIs, doctors discovered a brain tumor and diagnosed permanent brain damage.
Today, thanks to neurofeedback, Roberts-Stoler has proliferated in her work as a psychologist, speaker and author who focuses on brain, health, sports and performing arts psychology.
“During a neurofeedback session, the clinician maps 19 points on the brain,” she explained. “The waves give the clinician a snapshot of the asymmetry, phase and cohesion in the brain. Neuroplasticity in the brain allows us to make new connections.”
In her practice, Roberts-Stoler uses different types of neurofeedback, including a Low Energy Neurofeedback System (LENS) and quantitative electroencephalogram (QEEG) to confirm a diagnosis and then attempts to find the cause of the “disconnect.”
Laurence M. Hirshberg, Ph.D., BCN, director of the NeuroDevelopment Center, located in Cambridge, Mass. and Providence, R.I., and faculty in the department of psychiatry and human behavior at Brown University, explained that neurofeedback records changes in brain function shown through EEG and functional magnetic resonance imaging (fMRI).
When a patient presents, Hirshberg reviews previous therapies, because in most cases, neurofeedback is almost never the first approach to a mental health problem.
“Ninety percent of patients have experienced multiple treatment failures/insufficiencies. Neurofeedback is only the first treatment in kids with ADHD whose parents choose not to use medication,” he said.
Prior to initiating treatment, Hirshberg evaluates the patient’s diagnosis, existing research on how to achieve an effective pattern of functioning for the diagnosis and conducts a QEEG that he compares to a database showing normal brain activity to establish a baseline. He solicits the patient’s observations both before and after a session, which help to fine-tune the settings.
According to Hirshberg, the neurofeedback protocol comprises two components: where to acquire the EEG signal, i.e., where to place the electrodes and what frequency to use.
Before beginning treatment, Hirshberg instructs the client to be calm and patient.
“There will be moments when the brain is not getting it. Those moments are as important as when things are happening,” he said. “It’s not volitional or intentional. It’s a different kind of learning.”
He noted that the patient views a grid on the computer screen. Recordings are taken every half-second; when a goal is met one section of the grid fills in. “When targets are met, a version of thumbs up is given to the patient. Think of it as behavior reinforcement,” he added.
Hirshberg reported that follow-up studies show neurofeedback to be effective across a spectrum of mental illnesses, including ADHD; PTSD; depression; generalized anxiety disorder; traumatic brain injuries and concussions; autism; sleep difficulties; attachment disorder; chronic fatigue and pain; and bipolar disorder.
However results are unique to each patient. “When treating a patient, there are individual outcomes. In some cases, we might reduce sessions from two times a week to once per week to see if the symptoms decrease in between. Some patients come back for a booster if they have severe trouble. Some patients train at home,” he said.
Neurofeedback causes no lasting adverse effects, according to Hirshberg, although there may be short-term issues. “For instance, in children with ADHD, neurofeedback can lead to difficulty falling asleep the night of the session. In such a case, we would adjust the dose and activation,” he said.
“One other side effect has been tics when training for ADHD. We had to stop treatment for a couple of patients.”
On its own neurofeedback can be helpful, but in some cases, patients engage in other therapies simultaneously.
“We like to initiate neurofeedback with a level playing ground. We ask the patient if he intends to do another therapy or take medications,” Hirshberg said. “We don’t want too many variables starting at the same time. Approximately 60 percent are on medication during neurofeedback.”
Mark Gapen, Ph.D., BCN, internship director at Community Services Institute, Inc. in Springfield, Mass., equates neurofeedback to “gym for the brain.” He sees the therapy as a way to access unconscious processes that are difficult to address through talk therapy. He pointed out though that “psychotherapy synergistically interacts with neurofeedback.”
Training to use neurofeedback involves four days of didactic instruction as well as firsthand experience, Gapen reported.
“As part of the certification process, you have to demonstrate that you have done 10 sessions on yourself,” he said. “I advise clinicians to start practicing right after completing the training. You will never master it, but you don’t want to lose what you’ve learned.”
Unfortunately, insurers currently don’t reimburse specifically for neurofeedback, said Gapen. “I would like to see insurance companies reimburse on an integrated psychotherapy and biofeedback CPT code at a decent level. This would allow more clinicians to accept insurance for this work,” he said.
Gapen also advocates for more neurofeedback-related education in professional psychology schools.
“We won’t expand neurofeedback unless we integrate it into the curriculum. Few graduate programs provide training in neurofeedback. We need more institutional presence and younger clinicians in the field,” he said.
Hirshberg reported that although some studies have demonstrated positive outcomes, a lot of work remains to be done. “There have been lots of claims of what neurofeedback can help, which are not always substantiated,” he said.
Hirshberg designed and coordinated a study funded by the National Institute of Mental Health, which should provide more solid information on whether changes are connected to the EEG feedback procedure.
By Phyllis Hanlon