The Neurofeedback Question

Outside an unassuming, stone-colored building in downtown Bethesda, Maryland, sandwiched between a sushi restaurant and a boutique clothing store, the mood is hectic. Pedestrians move hurriedly from work to lunch and back again. But inside, in a second-floor office, there’s calm. Soft, tan leather chairs with wicker footstools fill the space, decorated with small plants whose delicate branches and slender leaves stretch upward from eggshell-colored clay pots. Diminutive, round lamps cast a gentle glow against the office’s alabaster walls. If it weren’t for a handful of monitors, wires, and electrodes—all running through a black box labeled “NeuroAmp II”—you might think you’ve stumbled into a Japanese ryokan.

Psychiatrist Suruchi Chandra, who oversees all of this, won’t serve you tea or point you toward the nearest hot spring, but she does offer an experience of nourishment and healing at her “holistic and integrative” practice, which isn’t like most others. “Conventional medicine often starts and stops at symptom relief without getting to the why behind symptoms,” she explains. It’s why her office is often a last resort for therapy clients suffering from intractable forms of everything from anxiety to depression to trauma, from insomnia to migraines to back pain. They’ve tried everything, she says, to no avail—except for neurofeedback. And once they do try it, finally, they find relief.

Chandra first encountered neurofeedback 24 years ago during her graduate training, when a colleague told her how it had turned the tide for stuck clients, even those who’d seen top-tier therapists without getting better. “But I wasn’t convinced,” Chandra admits. Years later, finding that many of her therapy clients continued to struggle months into treatment, she decided to revisit neurofeedback and take a course on it. Once she tried it with her clients, “it immediately became clear,” she says. “I saw them get better in ways I hadn’t before.”

Today’s neurofeedback is the product of almost a century of research, beginning with the creation of the first electroencephalograph, or EEG, in 1924 by German psychiatrist Hans Berger. Berger’s device recorded electrical activity in the brain by placing electrodes on different points on the scalp. Decades later, in 1958, Joe Kamiya, later dubbed “the father of neurofeedback,” was using an EEG in his lab at the University of Chicago to conduct experiments on human consciousness when he discovered that the brain’s reward system could be leveraged to modify brain activity, specifically to treat insomnia and enhance meditative states. “People can be trained,” Kamiya later wrote, “to achieve a kind of mental relaxation or reduction in tension.”

This reward response became the cornerstone of neurofeedback, and in 1971 and 1975, researchers Barry Sterman and Joel Lubar began nudging neurofeedback toward the more therapeutic applications we recognize today. Taking Kamiya’s work a step further, they found that neurofeedback could successfully treat epileptic seizures, as well as attention-deficit and hyperactivity disorders. Sterman’s work was so highly acclaimed that he was eventually recruited by NASA to study whether the brain could be trained to develop a resistance to the toxic fumes of the lunar lander (spoiler alert: it could).

Despite decades of technological advancement, today’s neurofeedback doesn’t stray much from its origins: sticky, noninvasive electrodes are placed on the client’s head, over regions of the brain that correspond with certain functions, like emotions, memory, and impulsivity; and while focusing on a visual or auditory representation of their brain activity—say, a cartoon, puzzle, video game, or music—the client will try to calibrate that brain activity using relaxation techniques. Meanwhile, a neurofeedback practitioner sits nearby behind their own screen connected to a brain signal amplifier, which displays what Chandra calls a “brain map,” with more detail about the client’s brain activity and “what’s underneath their symptoms.” Then, the therapist gives prompts or feedback to help the client self-regulate.

Drawing from the principles of neuroplasticity and conditioning, the goal is to help the client “retrain” their brain through repeated experiences of brain wave regulation, so that they become more resilient and less easily triggered into states of hypo- or hyperarousal.

“Neurofeedback is for the child whose mother says, ‘My son can’t talk through their attention issues, but maybe rewiring the brain can help,’” Chandra explains. “Or for the person who feels like talk therapy isn’t enough, or who doesn’t want to try medication, or whose biology limits talk therapy’s effectiveness.”

Proponents say neurofeedback is a jack-of-all-trades: it can be used with children and adults, and treat virtually any mental health problem. It can even improve cognitive and motor function in stroke patients, they say, as well as in athletes and combat veterans who’ve suffered traumatic brain injuries. It’s noninvasive, painless, provides therapists with valuable information in real time, and gives clients an immediate sense of mastery over improving their mental health. Plus, it’s gamified! If that wasn’t enough, neurofeedback also has enthusiastic endorsements from several high-profile psychotherapists.

“Neurofeedback as a direct approach to changing behavioral patterns of the brain is one worth putting your money on,” says DBT creator Marsha Linehan. And trauma expert Bessel van der Kolk devoted an entire chapter to the practice in his bestseller The Body Keeps the Score. Neurofeedback, he writes, has “a marked effect on executive functioning, the capacity to plan activities, to anticipate the consequences of one’s actions, to move easily between one task and another, and to feel in control over one’s emotions. To my knowledge,” he continues, “no other treatment has achieved such marked improvement in executive functioning, which predicts how well a person will function in relationships, in school performance, and at work.”

But if neurofeedback has such a long, rich history, and is so useful and beloved by therapists and clients, then why isn’t it more popular? Why isn’t every therapist peeking into their client’s brain?

A Ship with No Captain

Any method or modality is bound to branch out over time, but that seems to be truer for neurofeedback than for others—and not necessarily for the better. Over its century-long history, the practice has suffered from a sort of doppler effect, ballooning out, splitting into factions, and suffering from a lack of regulation. Today, it’s not just therapists and psychiatrists who use neurofeedback, but non-clinicians too, like chiropractors and massage therapists.

That’s a problem, says Chandra, who strongly believes that neurofeedback should only be practiced by licensed mental health professionals. “You’re not only helping people regulate their emotions,” she explains, “but you may be working with trauma, where going into a calm state can trigger memories and thoughts. You need someone who’s trained to manage that and knows how to create a safe space if that happens.”

Even if a clinic is managed by a licensed clinician, it’s quite possible they won’t be the one doing your neurofeedback assessment. Many neurofeedback technicians aren’t licensed therapists, and only operate under their supervision, meaning that unlike clinicians, they’re not authorized to do any therapeutic processing in real time.

It’s not a stretch to say that no two neurofeedback practices look the same. There are different approaches to doing neurofeedback. Some, for instance, only examine certain brain activity, like low-frequency brain waves, or certain parts of the brain, like the frontal lobe. Some practitioners will track other biometrics in addition to brain activity, like respiration, heart rate, and muscle responses.

“Before you see a neurofeedback practitioner, it’s helpful to ask which approach they use,” Chandra advises. “There are a number of different schools, and just because you had a friend who really benefitted from neurofeedback doesn’t mean you’ll be getting the same treatment.”

On top of these discrepancies, the cost of a single neurofeedback session can vary widely, ranging from $50 to $200 on average, with a full course of treatment sometimes surpassing $10,000. There doesn’t seem to be a consensus on the duration of treatment, either. Some providers say it’s not uncommon for clients to see changes in as little as two to three sessions. Others say it can take upwards of 100 sessions before any noticeable change occurs.

Of course, there have been attempts to create guidelines and a vetting system for practicing neurofeedback, through a host of associations and membership organizations with names like the International Society for Neurofeedback and Research, the National Neuroregulation Network, and the Biofeedback Certification International Alliance, all of which offer some combination of certification programs, provider directories, and other resources. But they don’t recognize all forms of neurofeedback, which some practitioners have reported leaves them feeling adrift. And notably, they don’t have the same authority as, say, state licensing boards do over therapists.

I ask Chandra whether the average Joe could leave home today, buy some monitors and electrodes, take a two-week training, and call himself a neurofeedback practitioner. “Unfortunately, yes,” she replies. “These organizations give certificates saying you’re trained, but you don’t need to have a certificate to open a neurofeedback clinic. And because neurofeedback isn’t regulated, some of the device companies sell equipment that isn’t FDA-approved, or sell to unlicensed practitioners.”

This lack of standardization is also partially responsible for one of neurofeedback’s biggest headaches: a shortage of rigorous, double-blind clinical trials that tend to give other methods credibility. Even Bessel van der Kolk admits this is one of neurofeedback’s weak spots. It “needs more work,” he recently told Big Think, “because it’s never been supported by federal funding.”

Many studies do exist, but they’re often discredited for their lack of control and placebo groups and small sample sizes—and undermined, predictably, by disagreements about which variation of neurofeedback works best. Everyone tries to advocate for their method, which isn’t very objective,” Chandra explains, “so the studies haven’t been able to tell us what approach works best with which symptoms.” It’s hard to say whether Joe Kimaya would even recognize his creation today. Before he passed away in 2021 at age 95, he’d been almost singularly devoted to studying how neurofeedback could treat insomnia, not a laundry list of other psychological and physical issues.

For some therapists and clients, neurofeedback feels like a silver bullet. But has all this excitement turned it into a runaway train? How might neurofeedback be regarded if the field had managed to establish a consensus on things like treatment cost and duration, or what neurofeedback can and can’t treat, or what brain waves practitioners should be examining, or how clinical studies should be conducted? What if it had a well-known, charismatic leader? What if its governing bodies had teeth, holding practitioners and equipment salespeople to strict standards?

Who knows? Maybe neurofeedback could be the closest thing we have to a silver bullet, if only it didn’t feel like the wild west out there.

Changing the Narrative

Despite the chaos surrounding neurofeedback, practitioners like Chandra aren’t deterred. Like so many, they’re continuing to do the work because they’ve seen it help—and often, they’ve experienced it making a difference in their own lives.

Roxana Sasu, a Romanian physician, is one of these practitioners. She’s the executive director of the Neurofeedback Advocacy Project, an Oregon-based nonprofit organization whose mission is to make neurofeedback more accessible to vulnerable and underserved populations across the United States. In addition to seeing clients in her practice in Los Angeles, Sasu teaches neurofeedback to clinicians in public agencies and private practices in the country and abroad.

Before she began doing neurofeedback 16 years ago, Sasu suffered from debilitating migraines. Medication only helped so much. “I just thought this was going to be my life,” she says. Like Chandra, she had her doubts when she heard about neurofeedback’s incredible outcomes. But after giving it a try, she became a believer. “When I went home afterward, I had one of the best nights of sleep in my life,” she says. “And I woke up clear-headed, with no migraine. I knew right then that there was something to this.”

Soon, Sasu began practicing neurofeedback, and witnessed other miraculous transformations in her clients, like the time a nonverbal, six-year-old-boy on the autism spectrum, whose family was bilingual, went through a course of six neurofeedback sessions and suddenly began using English and Spanish words. Another client, a nine-year-old boy, had been experiencing difficulties with motor control and seizures, but after 40 sessions, he was able to ride a bicycle—and his seizures largely subsided.

Sasu is quick to add that these are exceptional cases, and that neurofeedback can be a long process. “It isn’t a quick fix or a magic pill,” she explains. “The brain needs time to learn how to function differently.”

But Sasu says she shares these stories because they instill hope at a time when people desperately need it. Unfortunately, she says, too many people stumble upon neurofeedback late in their treatment journey, after lots of suffering. For her, the biggest question isn’t how to unify the field, but how to get through to these clients, and fellow therapists interested in neurofeedback, to ensure that it’s being used not as a last resort, but early on in treatment.

Of course, there are impediments. Chandra says that not only do few clinicians learn about neurofeedback in graduate school, since a shortage of prominent research studies means it’s less likely to be taught, but there are plenty of misconceptions about how the practice actually works. Some would-be clients, she says, believe that neurofeedback is invasive, or that it’s a form of mind control. Some hear words like electrodes and think it involves shocking the brain. Others worry that neurofeedback might change them in ways they don’t like, or have potentially harmful side effects. Of course, Chandra says, none of these things are true.

“We’re simply reading the brain waves,” she says. “We’re receiving information and providing real-time feedback, so that the brain can better regulate itself. I tell my clients it’s a little like having a personal trainer who helps you learn to lift weights or improve your form; we’re helping you learn to retrain your brain.”

In an effort to dispel the myths and misconceptions surrounding neurofeedback, Sasu is changing the language around it—“staying away from labels,” she says. Rather than saying neurofeedback can treat anxiety and depression and fibromyalgia and restless leg syndrome and a host of other problems, she keeps it simple. “We’re helping the brain rewire,” she explains, “reinforcing new pathways that it can use to self-regulate better.” And the data that shows up on her screen? “It’s just information,” Sasu says. “It’s not good or bad. It’s just information. And as long as the brain receives this information, it will start using it. Can neurofeedback treat anxiety? Sure. But anxiety has many faces.”

There’s another point Sasu wants to get across to people about why neurofeedback works: simply put, it’s fun.

“The fact that neurofeedback is fun makes it appealing to just about anyone,” she says. “It doesn’t feel like you’re in a doctor’s office, or in a therapist’s office, for that matter. I make sure the experience is as inviting and comfortable and peaceful as possible. You’re sitting in a comfy chair. You’re playing a game or watching a movie. You’re holding a stuffed animal that vibrates when your brain lights up. And the whole time, your brain is seeing its own activity, like it’s looking in a mirror.”

Therapy on its own, she adds, is inherently more serious business. “It’s not easy when clients—especially kids—are expected to talk about all the bad things that happened to them. When the work is playful, they’re much more open to talking about difficult things, and it’s easier for the therapist to build rapport.” But the beauty in neurofeedback, she continues, “is you don’t need talk about things like your trauma. Your brain handles it at a very core level, and helps you move from emergency mode to normal mode. Then, once you’re feeling safe, the therapist can help you process things on a conscious level.”

A Bold Prediction

A century after the creation of neurofeedback, there are still plenty of organizational kinks that need to be worked out. But that shouldn’t discount the fact that neurofeedback has helped plenty of people turn their lives around—or that it could still become a household name. At least that’s what Bernhard Wandernoth thinks.

Wandernoth, a self-described “tech geek” since childhood, says he’s always “aimed to make the impossible possible.” And helping neurofeedback reach its full potential is no exception. After graduating as an electronics engineer specializing in signal processing and information theory, he worked in research and development in the aerospace industry.

When he first got wind of neurofeedback 20 years ago, he was intrigued. If only 10 percent of the claims in this field are true, he thought, I want to be a part of it. Wandernoth took a neurofeedback class, bought some equipment, and tried neurofeedback on a few people. And when he found it worked, he was so taken with it that he decided to switch professional gears, signing on to help design neurofeedback equipment—including the NeuroAmp technology found in Chandra’s Bethesda office—and working with organizations sponsoring neurofeedback studies and pilot projects, including Sasu’s Neurofeedback Advocacy Project.

“The claims about neurofeedback sound too good to be true,” Wandernoth says. “But quite honestly, many of them are true. It simply improves all symptoms that can be attributed to a lack of self-regulation.” The advantages for therapists are “immense,” he continues. “It augments clinical skills and empowers the clinician.”

So why aren’t more therapists and clients using it?

“Innovations take time to catch on,” he says. “That’s universally the case. The space technologies I contributed to took more than 25 years from initial concept to commercial launch.” He compares neurofeedback’s trajectory to public attitudes 120 years ago, “when people developed incredible visions of what could be done with electricity. It simply took another four or five generations before many of them could come true. Nobody could have dreamed that every cell phone today would have chips with 10 billion switching elements. I’ve dealt extensively with technology road maps. Many things will be possible with neurofeedback, but probably not for another 50 to 100 years.”

In short, Wandernoth says, there’s nothing wrong with a little excitement and lofty visions, even if it results in some measure of disorganization. In time, he says, neurofeedback will get the recognition it deserves.

In the meantime, Chandra, Sasu, and Wandernoth recommend that any therapists on the fence about neurofeedback give it a shot for themselves. To a large extent, they say, taking that first leap of faith—believing that the impossible can be possible—is the hardest part.