Neurofeedback Therapy: A Promising Approach for Trauma

There is increasing recognition that unresolved trauma underpins many mental health problems.

A range of treatments have flourished to promote healing from trauma, with talk therapy and medication being well known.

However, there is another type of therapy that requires no pharmacological drugs and no need to revisit painful memories.

In this article, we will explore neurofeedback, also called neurotherapy, as a promising approach to trauma healing.

We examine how it works, look at a typical session, then review the evidence and criticisms of the approach. We also take a brief look at training options and neurotherapy books well worth reading.

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Neurofeedback Therapy: How Does It Work?

Biofeedback therapy is a complementary therapy that is used to treat a range of conditions like chronic pain, urinary incontinence, and high blood pressure (Marzbani et al., 2016).

Biofeedback involves monitoring physiological markers of autonomic nervous system activity, including temperature, pulse, blood pressure, or any type of biological process over which we have no conscious control. The idea is that by becoming more vigilant of these processes, we can learn how to self-regulate (Onagawa et al., 2023).

Neurofeedback therapy has its roots in biofeedback (Marzbani et al., 2016). It takes biofeedback a step further, where neurofeedback for trauma tracks brain wave activity to regulate a dysregulated nervous system.

Trauma is characterized by disrupted brain wave patterns that correlate with unpleasant symptoms like anxiety, brain fog, hypervigilance, or low mood. In turn, these symptoms can lead to dysfunctional behaviors that are often misdirected attempts to self soothe, including substance abuse and other forms of self-harm (Shaw et al., 2023).

Neurofeedback therapy retrains the brain and nervous system to self-regulate, thereby easing symptoms of trauma and other conditions (Shaw et al., 2023).

During treatment, neurofeedback therapists track brain wave activity using EEG sensors in response to a pleasurable audio-visual stimulus. It can be a favorite movie, music video, or video game. Brain wave activity is monitored by software that mediates the stimulus, making it lighter, darker, more or less colorful, and louder or quieter in response to brain activity (Onagawa et al., 2023).

As the brain recognizes it is witnessing its own “neurological dance” on the screen, it stimulates the brain reward cascade and release of dopamine (Fisher, 2014). The result is pleasure and enjoyment. However, all of this happens without conscious control.

Gradually, because of the neuroplasticity of the brain responding to the neurofeedback loop, which drives an operant conditioning process, the brain learns that regulating its own activity (and thereby nervous system) is intrinsically pleasurable (Fisher, 2014).

The benefits of neurofeedback

The short-term benefits of neurofeedback therapy include that it’s not physiologically invasive like pharmacological treatments, and it doesn’t involve talking about painful experiences, which may trigger traumatic memories and intensify symptoms.

The long-term benefit is a reconditioning of brain activity, resulting in the regulation of a previously dysregulated nervous system.

For a short and simple explanation that’s suitable for sharing with clients, look at the short Brain Centre video below.

Is Neurofeedback Evidence-Based?

This article is a short introduction to neurofeedback and has limited space to explore the range of studies available. It’s also important when reviewing research articles and meta-analyses of treatment efficacy to identify who funded the research and any potential conflicts of interest. Assessing the state of the evidence is therefore a time-consuming and arduous process.

However, the episode of SciShow Psych below provides a critical summary of what it claims is the body of evidence available.

You can read the comments underneath the video on YouTube for criticisms of the presentation by those who claim they’ve benefitted from neurofeedback therapy.

In brief, currently, the evidence base for the effectiveness of neurofeedback therapy is mixed, mostly because of the lack of randomized control trials (RCTs) with suitable control groups (Marzbani et al., 2016).

RCTs are the gold standard for research studies aiming to establish treatment efficacy and are required to bring new medications to market. Such studies require a great deal of financial investment that is often difficult to procure unless there are substantial commercial interests involved, as there are in drug trials, for example.

If higher-quality research studies found that neurofeedback was an effective treatment for trauma, brain injury, and other mental health problems, it could pose a financial threat to big pharmaceutical companies by undermining the market for their products.

This needs to be considered when examining the state of the evidence for any non-pharmacological alternative to medication. The funding of poorly designed studies that discredit non-pharmacological treatments should always be identified. This is beyond the scope of this modest introductory article.

6 Criticisms of Neurotherapy

The following are the criticisms most often lodged at neurotherapy by skeptics and those invested in other treatment options.

1. There is no definitive proof of which brain wave patterns conform to which type of disorder, so it’s unclear if a disorder has been treated successfully just by observing changes in brain wave patterns (Newson & Thiagarajan, 2019).
2. Brain wave patterns differ from one individual to the next, and so “normal” brain wave patterns also vary (Berenguer-Sanchez et al., 2012).
3. When we understand 1 and 2, trying to recondition the brain to a proposed normal brain wave pattern as a treatment for a disorder may not make sense given the variation in brain wave patterns in healthy individuals (Newson & Thiagarajan, 2019).
4. The equipment required to conduct neurotherapy is expensive and the length of treatment is time consuming (Marzbani et al., 2016).
5. Evidence of the effectiveness of neurotherapy is not of a high enough standard, study sizes are small, and there are very few randomized control trials with suitable controls to establish the effects of neurotherapy in the medium and long term (Sharawy, 2021).
6. Side effects are unknown and undocumented because of the lack of RCT studies on treatment effectiveness (Sharawy, 2021).

Neurofeedback vs. Biofeedback

Biofeedback tracks the metabolic processes of the entire human organism, with the aim of regulating the mind–body connection and reaching a deep state of relaxation associated with homeostasis (Fisher, 2014).

It is used to treat a range of health problems that may be worsened by stress triggers of sympathetic nervous system activity, also known as the fight-or-flight response. Stress is now understood to be a causal factor in the etiology of many diseases (Nicholson et al., 2020).

Neurofeedback is sometimes called EEG biofeedback because it uses EEG equipment to monitor brain activity. Neurofeedback focuses only on regulating brain activity to treat trauma symptoms resulting from a dysregulated nervous system and poor executive function (Nicholson et al., 2020).

Meditation has very similar effects on brain function to neurofeedback when practiced regularly but requires self-discipline and motivation to practice. Meanwhile, neurofeedback is a passive process of reconditioning that has been called “meditation with handrails” (Othmer, 2014). However, unlike meditation, it actually takes no conscious effort at all.

The relationship between biofeedback and neurofeedback is explained in Trish Leigh’s video below, where she describes how reconditioning of neurophysiological mechanisms works using both treatment modalities.

Practical Applications for Neurofeedback

The title of this article refers to neurofeedback as a promising treatment for trauma. During my research, I came across a Salvation Army Bell Shelter in Los Angeles that offers neurofeedback to residents experiencing homelessness and trauma. As I worked with people with mental health and addiction problems experiencing homelessness for several years in London, I have some experience and insight into this client group.

Firstly, homelessness is a traumatic experience because one of our basic survival needs — the need for shelter from the elements and safety from predators — is not being met. Life on the streets is highly dangerous (Crisis UK, 2023).

In addition, the events that lead to homelessness are always traumatic, be it mental health problems, addictions with roots in traumatic childhood experiences, or a need to flee abusive relationships or domestic violence (FEANTSA, 2017).

Ex-convicts and veterans suffering from addictions, post-traumatic stress disorder (PTSD), and additional mental health problems like depression are also at high risk of ending up on the streets. It’s fair to say that homeless people are traumatized people, often in multiple ways (FEANTSA, 2017).

Below is a case study example of a practical application of neurofeedback with a deeply traumatized client group: people experiencing homelessness. In this short video, but the Bell Shelter service users describe their life experiences leading up to homelessness, which you may find disturbing.

The video above is not a research study but a documentation of lived experience. One founder of the Bell Shelter project is Homecoming for Veterans, which offers neurofeedback to veterans with PTSD for free through a network of clinicians across the United States. It’s also running a large long-term research project into the effectiveness of neurofeedback for trauma led by Siegfried Othmer.

You can find a large repository of research articles on practical applications of EEG-based neurofeedback for trauma at Othmer’s EEG Institute website.

However, although these studies are all peer reviewed, many have been excluded from the body of evidence referred to in the SciShow Psych video above because they have been conducted in centers that also have a commercial interest in developing the neurofeedback equipment used.

Neurofeedback seems to be a promising approach to healing trauma and other practical applications including addictions (White & Richards, 2023), attention deficit hyperactivity disorder (Arns et al., 2009), autism (Coben & Padolsky, 2007), learning disabilities (Dehghani Firouzabadi et al., 2021), obsessive-compulsive disorder (Hammond, 2003), and many other conditions.

Training and Certification in Neurofeedback

Neurofeedback certification was introduced as a voluntary self-regulation process to set professional standards of care and to satisfy health care insurance providers.

Internationally recognized certification for those with a licensed health care practitioner degree (international) or 3,000 hours of equivalent patient experience (United States only) is offered by the Biofeedback Certification International Alliance (BCIA) headquartered in the United States.

BCIA has offered certification programs in neurofeedback since 1981. Professional certification stipulates standards of competence and clinical practice. In addition, the BCIA recertification program ensures that each certificate holder follow a code of ethics, take part in continuing education, and maintain agreed standards of clinical practice.

While BCIA sets the prevailing international standards for certification, training options vary by region and country. We have listed some below.

1. United States – BCIA

Each candidate for neurofeedback professional entry-level certification is required to provide a portfolio of evidence to be considered for examination. The examination is then taken online using cameras and artificial intelligence to monitor exam security. No travel is required.

You can find out more about entry-level professional certification requirements from the BCIA.

2. Australia – ANSA (BCIA Australia)

The Applied Neuroscience Society of Australasia (ANSA) offers internationally recognized BCIA certification in neurofeedback through this range of training providers.

3. International BCIA training options

BCIA provides a list of international training providers located in various countries across the globe, including Canada, China, Egypt, France, Germany, Israel, Italy, Japan, Mexico, The Netherlands, Switzerland, and Taiwan. You can investigate further by following the country-specific links provided on the BCIA list here.

It’s important to remember that completing a training program is the first step, and certified neurofeedback practitioner status requires your participation and investment in lifelong learning. Practitioners need to remain abreast of evolving professional standards and technological developments in the field.

3 Neurotherapy Books Worth Reading

The following three books have been chosen for their mix of theory and practice, accessible language, and case study illustrations.

1. Neurofeedback 101: Rewiring the Brain for ADHD, Anxiety, Depression and Beyond (without medication) – Michael P. Cohen

Michael P. Cohen is the director of neurotechnology at the Center for Brain Training, one of the largest neurofeedback practices in south Florida. He has specialized in neurofeedback since 1996 and trains health professionals in neurofeedback for clinical practice.

Neurofeedback 101 is an introductory text on neurofeedback for laypeople and clinicians alike.

It may be especially useful for sharing with potential clients. The book explains what neurofeedback is in simple, clear language, how it works, and what it can achieve. It uses real-life examples to illustrate how neurofeedback helps both kids and adults with their symptoms.

Find the book on Amazon.

2. Neurofeedback in the Treatment of Developmental Trauma: Calming the Fear-Driven Brain – Sebern F. Fisher

International trauma expert Bessel van der Kolk wrote the foreword to this book by psychotherapist Sebern Fisher, calling her “an immensely experienced neurofeedback practitioner [and] the right person to teach us how to integrate it into clinical practice” (Fisher, 2014, xi).

Developmental trauma results from ruptures in a child’s ability to attach to a primary caregiver safely and can cause a range of complex symptoms, including emotional dysregulation, dissociation, self-harm, and social isolation, all underpinned by a bedrock of fear.

Fisher’s book explains how neurofeedback can help treat developmental trauma, including severe childhood abuse, neglect, and abandonment.

Theory and practice are combined to explain how neurofeedback can retrain the brain and regulate a traumatized nervous system. Fisher describes how neurofeedback can help stabilize attention, regulate emotion, and reduce fear over time.

The book also covers the clinical skills required to provide neurofeedback, including how to introduce it to clients, how to perform assessments, and how to combine neurofeedback sessions with traditional talking therapies.

Find the book on Amazon.

3. Neurotherapy and Neurofeedback – Theodore J. Chapin and Lori A. Russell-Chapin

In Neurotherapy and Neurofeedback, Lori Russell-Chapin and Theodore Chapin draw on their clinical and scholarly expertise to explain advances in neurobiology and neuropsychology and introduce the growing body of research in the field.

The book explores the neuroscience of the human brain and its ability to develop new neurons and neuronal pathways in response to fresh challenges across the lifespan, which amounts to the brain “rewiring” itself.

The authors describe how neurofeedback trains the brain to self-regulate, which is an intrinsically rewarding activity that enhances executive function.

Readers learn how brain dysregulation occurs and the kinds of interventions available when medication and talking therapies fail to alleviate psychological suffering.

Find the book on Amazon.

A Take-Home Message

Neurofeedback, or neurotherapy, is a non-pharmacological treatment for a range of conditions that result in unusual brain wave patterns and a dysregulated nervous system.

During treatment, a neurofeedback loop is established between the brain and the audio–visual stimulus on the screen that the brain gradually recognizes as its own activity. This feedback loop triggers the release of small amounts of dopamine in the brain and is inherently pleasurable. Therefore, the entire brain training cycle is self-reinforcing because it is intrinsically rewarding.

Further research is needed to establish treatment efficacy in large-scale RCTs that are properly controlled. These would also uncover any side effects that may be missed in small-scale studies.

At present, neurotherapy is offered to veterans with PTSD for free across the United States. Research shows it is an effective treatment for trauma that avoids the pitfalls of other treatments, such as medication compliance and side effects, and the triggering of traumatic memories in talking therapy.

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