What Practitioners Are Saying
From clinical practices to forward operating bases in Afghanistan, the Protocol Guide is the roadmap for the most effective work in neurofeedback. Here's what practitioners are saying..
In my practice of neuropsychiatric integrative medicine I have evaluated various techniques for brain training. The approach that clearly stands out as the most intuitive, accessible, and effective is the Othmer Method. I have used it to help people with a wide variety of diagnoses, including seizure disorders, brain injury, and autistic spectrum disorders. The Protocol Guide is one of the most valuable tools in my clinical toolbox.
Doreen McMahon, MD - Family Practice
With the growth of our neurofeedback services, our general outpatient clinical psychology practice has grown beyond our walls to include an inpatient substance abuse program, a wellness center, and a university's athletic team. TheProtocol Guide has become an integral part of how we treat - an indispensable reference. It's our neurofeedback "google."
Rick Harris, PsyD - Clinical Psychologist
I cannot imagine doing my work without neurofeedback. It has been the most reliable and rapid intervention for long term remediation of the most debilitating PTSD symptoms. What I have witnessed with increased selfregulation in hundreds of cases is revolutionary. The Protocol Guide is a thorough, concise map of brain functioning and healing. I loved reading it, and I rely on it in my work.
Anna Benson, PhD - Clinical Psychologist / PTSD specialists
Synchrony and Alpha-Theta neurofeedback
Copyright © 2017 by EEG Info
This Sixth Edition of the Protocol Guide reflects our current approach, including infra-low frequency, Alpha-Theta and Synchrony neurofeedback. The infra-low training frequencies discussed in this 2017 edition of the Protocol Guide apply only when using the 1 or 2 channel infra-low frequency HD application in Cygnet.
We have continually refined our neurofeedback training and assessment methods based on optimization of clinical effects. This has led us to a better understanding of electrode placement options and to increased training frequency range and specificity. Beginning in 1989 with standard beta and SMR frequency ranges, we gradually extended to lower training frequencies over a number of years, as we sought more calming effects with highly aroused nervous systems. In 2006 this took us into the infra-low frequency range of the EEG, below 0.1 Hz.
Since 2006 we have continued to extend the range down to lower training frequencies. And we have continued to optimize the hardware and software to function in this infra-low frequency range. With our new lower frequency range, we are now achieving consistently stronger training effects, especially for severe and chronic conditions.
The Protocol Guide includes material presented in live and online neurofeedback courses for professionals by EEG Info.
Content copyright © 2017 by EEG Info
No reproduction of content is allowed except by permission from EEG Info.
For more information
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GOALS OF NEUROFEEDBACK
- Physiological self-regulation
- Psychological resolution
- Reduced symptoms
- Improved function
- Increased well-being and quality of life
With neurofeedback we are enhancing awareness of internal states by allowing the brain to witness its own EEG activity. This promotes self-regulation, which supports better function. We are not diagnosing or treating disorders and we are not correcting brainwave patterns. Our nervous systems strive to keep us alive and functioning optimally, but we often get stuck in dysfunctional modes of behavior. Our goal is to allow the nervous system to calm down and reset itself onto a better path.
Infra-low frequency training allows better physiological self-regulation and Alpha-Theta training allows psychological resolution,while Synchrony neurofeedback promotes resilience and well-being. All together they provide powerful tools for improving health and well-being. Some clients come to reduce uncomfortable symptoms. Others come to improve performance. The usual outcome is reduced symptoms and improved function for both groups.
In this guide we will focus first on neurofeedback assessment – how we understand patterns of dysregulation which map to our training options, and how we develop an overall treatment plan. Then we will consider neurofeedback training – how we implement that plan, guiding our changes in electrode placement and training frequency according to response to training.
- Understanding categories of dysregulation
- Symptoms as indicators of dysregulation
- Developing a treatment plan
- Understanding of individual client that guides process and clarifies over time
Diagnoses are not really helpful in understanding how to best train an individual. We are more interested in categories of physiological dysregulation that relate to our neurofeedback options of electrode placement and training frequency. Our categories of dysregulation include physiological arousal regulation, instabilities, disinhibition, localized dysfunctions, and learned fears and habits. We use specific symptoms as indicators of modes of dysregulation. So we are not really treating symptoms with neurofeedback, but rather using symptoms to help us understand how the nervous system is dysregulated.
Our assessment leads to an overall neurofeedback treatment plan. We want to know as much as possible about the client's function and dysfunction, from which we develop an understanding and expectation of what specific modes of training might be most helpful for that individual. Later we will implement this plan as we are guided each step of the way by the observed and reported effects of training. Beginning by optimizing a starting electrode placement and training frequency, we then add basic sites, other sites, Alpha-Theta and Synchrony as needed.
THE CLINICAL MODEL
- How to think about brain function
- Regulation and dysregulation
- How to think about neurofeedback
- Model for understanding results of training
- Model based on clinical experience
Neurofeedback produces strong and specific effects. It makes a significant difference where we put electrodes and what frequencies we feed back to the brain. We need a model of brain function and dysfunction that will allow us to think about how to train and how to understand the specific effects of training. This working model will support our decision making throughout the neurofeedback process. The model is shaped by our clinical experience over many years, as our ideas are tested daily in clinical practice.
The Central Nervous System
The central nervous system (CNS) is an incredibly complicated network of billions of neurons plus other supporting cells. It includes many different functional levels from the cerebral cortex at the top down through subcortical structures, brainstem and spinal cord. We put our electrodes on the scalp, where they pick up electrical activity from groups of neurons in the cortex. These neurons are aligned in a way that allows their electrical potentials to add together so that they can be measured at the scalp. Our EEG signal comes from the cortex, but we understand that training on the cortical EEG impacts broader brain circuits involving subcortical and brainstem areas as well.
It is helpful to have a simplified model of the brain to help us understand brain function and dysfunction and how we might best target the neurofeedback training.
Central Nervous System Building Blocks
- Subcortical nuclei
- Spinal cord
How do they work together?
Input / Output
- Slower actions based on cognitive appraisal and goals
- Fast reactions for survival
- Learned fears and habits
- Vital body functions and orientation to environment
- Body sensation and movement
Input and output functions are organized at each level of the central nervous system such that input comes into the back and output goes out from the front. Understanding both the type of information and how it is being processed at these different levels can help us understand where and how dysfunction is occurring.
At a spinal cord level input comes from our bodies, which may be sent to higher levels for processing and response. Output from the spinal cord allows us to move our bodies reflexively or according to instructions from higher levels of the central nervous system. There is also local coordination of sensory input and motor output. Dysfunction at a spinal cord level is far from our scalp electrodes, but can still be influenced by changing top-down influence on spinal cord function.
The brainstem is involved in processing sensory input and controlling motor output to orient us to the environment. It regulates vital functions essential for life – breathing, sleep/wake cycle, body temperature, etc. Brainstem dysfunction with a traumatic brain injury, for example, can have a severe impact on basic life-supporting functions. Neurofeedback can be helpful in reorganizing and recovering these brainstem functions.
Subcortical nuclei are involved in rapid assessment of danger and opportunity and rapid response to keep us safe and well. These survival responses are more rapid than the detailed analysis and response at a cortical level. They constantly shape our perception and behavior below our conscious awareness or control. This will be a frequent target for neurofeedback to reestablish some balance between automatic life-preserving reactions and deliberate conscious actions.
The cortex mediates detailed analysis of sensory input and the selection and control of behavioral output. Good cortical function allows us to carefully consider options and deliberately control our actions. The verbal narrative of our conscious experience occurs at a cortical level.
Input and output functions are not sequential, but rather simultaneous. Perception guides action, and action also guides perception. Our needs and desires guide both. Back and front areas of the central nervous system work together. Parietal and frontal cortical areas, for example, work together to guide movement, while prefrontal areas hold the plan, and limbic areas set priorities. Perception, then, should be seen as a directed, purposeful process that is driven by the brain's needs and expectations. This realization is central to our understanding of the process of neurofeedback.
Physiological Arousal and Activation
- Physiological arousal = overall tone
- Activation of specific brain areas supports specific brain functions
How does the brain select and organize its input and output functions? How does it control its readiness to attend and respond? And how does it activate areas needed for the function at hand?
This brings us to regulation of brain states. How are the brain's resources managed to achieve the current goals? Physiological arousal and activation are key contributors to this brain state regulation. First the brainstem manages physiological arousal level – the general tone of the central nervous system. Subcortical nuclei are then involved in more specific control of activation. Specific brain areas are activated to allow specific functions, preparing for specific perception and response.
The next question is what states of arousal and activation are needed. How does the brain choose a state of readiness and specific functions to activate? This brings us to drives and emotions and the limbic system.
Drives and Emotions
- Assess danger and rewards
- Priorities and motivation
- Control brainstem arousal and activation,
also immune, endocrine and autonomic regulation
- Conscious goals and top-down regulation
- Subconscious fears and habits
- Emotional tone
The limbic system manages drives and emotions, which in turn motivate our perception, behavior and physiological regulation. We engage with the world seeking safety and rewards. Limbic function allows us to judge dangers and opportunities, and motivates behaviors that will maximize our wellbeing.
We will focus on subcortical and subconscious limbic areas that play a significant role in rapidly assessing internal and external danger and rewards, and then motivating reactions that keep us alive. We understand that drives and emotions are also distributed functions that involve brainstem control of emotional tone, and cortical management of conscious plans and goals. Cortical limbic areas also provide top-down regulation of immune, endocrine and autonomic functions.
Limbic function is critically important for our ongoing survival, but it can become a problem when out of balance. In life-threatening situations we learn life-preserving behaviors, which sometimes continue after the danger has passed. Those with Post Traumatic Stress Disorder (PTSD), for example, continue to react to their environments in a way that is no longer appropriate. They are unable to inhibit the subconscious reaction even though they understand consciously that it is no longer needed. With neurofeedback for PTSD we calm the agitation and hyper-vigilance with infralow frequency training and then allow resolution of traumatic memories with Alpha-Theta training.
Top-Down Inhibitory Control
- Inhibits subcortical reactions
- Allowing considered action
- Calms brainstem arousal
Inhibitory control is another important factor in how different levels of the central nervous system work together. Cortical areas have inhibitory control over lower brain regions and their automatic reactions. This allows time for detailed sensory analysis and consideration of priorities and possible consequences before selecting and executing a response. The prefrontal cortex is the highest level, with inhibitory control over all lower areas of the central nervous system. Good prefrontal function is essential for self-control and mature behavior.
- Automatic regulation of brain states
- Below conscious awareness and control
- Good self-regulation means flexibility and stability
- Neurofeedback promotes self-regulation
- Impacts symptoms of dysregulation
- Improves health and well-being
- Not the same as self-control or will power
Self-regulation is an important concept in thinking about neurofeedback. We will use the term selfregulation to refer to automatic, unconscious regulation of physiological functions. Good selfregulation underlies efficient and effective functioning of brain and body. Neurofeedback can be understood as a process that promotes good self-regulation, enhancing flexibility and stability of state. It thereby improves health and well-being, and also reduces dysregulation and suffering.
We will use the term self-control to refer to the ability to withhold automatic reactions, allowing time for consideration of options and possible consequences. This leads to more mature functioning reflecting good top-down regulation by the prefrontal cortex. Neurofeedback promotes calming and prefrontal self-control, which reduces the need for conscious will power in our daily lives. Will power is a limited resource that is easily exhausted when we rely on it to manage our dysregulated nervous systems.
Understanding Patterns of Dysregulation
- 1. Physiological arousal
- 2. Instabilities
- 3. Disinhibition
- 4. Localized dysfunctions
- 5. Learned fears and habits
- Not about diagnosis
We can now use this simplified model of central nervous system building blocks and interactions to understand basic categories of brain regulation and dysregulation. These basic categories correlate with how and where we need to train with infra-low frequency and Alpha-Theta neurofeedback. And these modes of dysregulation form the basis for the rest of the Protocol Guide. They are key to assessment and to understanding the effects of training, and for decision making throughout the neurofeedback process.
- Indicators of physiological arousal help us understand the effect of training frequency on arousal level for each individual. During training we expect to use symptoms related to shifts in arousal level to adjust training frequency.
- Instabilities result in paroxysmal symptoms as the brain loses control with migraines, panic, seizures, etc. The presence of instabilities at any time in a person's life suggests that we include inter-hemispheric stabilization with a T3-T4 placement.
- Disinhibition relates to loss of prefrontal self-control with stress or boredom, as with tics or impulsivity. This calls for training with placements for calming agitation and also increasing prefrontal inhibitory control.
- Localized dysfunctions might be indicated by report of symptoms, or by testing or brain imaging. This information suggests potentially useful training sites.
- Learned fears and habits that interfere with good behavioral control and well-being indicate that Alpha-Theta might be an important part of a total neurofeedback program. Subcortical survival or reward strategies can continue to shape behavior in ways that outlive their usefulness. After physiological calming and stabilizing with infra-low frequency neurofeedback, Alpha-Theta training can then allow needed processing and resolution of traumatic experiences.
These are our basic categories for assessment and for understanding responses to training. We will look at these five categories in more detail since they are fundamental to our understanding of neurofeedback.
Physiological arousal is our first category of central nervous system regulation and dysregulation. It is the most basic component of brain state regulation. Arousal is managed by brainstem nuclei that project widely throughout the central nervous system. This is part of the Reticular Activating System that manages wakefulness and alertness. Wherever we place electrodes on the scalp we will be impacting this arousal system, so it is always an issue in training.
- Regulation of brain states
- Physiological arousal = tone
We think of physiological arousal as being under brainstem control. The brainstem sets the tone of the whole central nervous system. The brainstem component is rather nonspecific – just how awake the person is. How people actually experience a shift in arousal level will be individually specific. It might affect attention, mood, physical tension, thinking, etc., which involve other more specific brain functions. For the sake of neurofeedback training, we are interested in shifts in core physiological arousal level as a guide to finding the optimal training frequency for each individual.
Arousal and Performance Curve
Arousal level has a strong impact on our overall level of functioning. We each live on our own individual arousal and performance curve. We move up and down this curve over the course of the day. With a well-regulated nervous system there is a good middle range of normal function. This allows us to use our higher cognitive abilities to manage our daily lives. At the end of the day we should be tired and drift off to sleep through low arousal. And, at the high end of the arousal curve, we should be able to respond quickly to emergencies without freezing, and without taking time to stop and consciously analyze the situation.
Good self-regulation means both flexibility and stability of state. High arousal is useful in emergencies, but getting stuck there can lead to significant problems. In emergency mode we hyper-focus on the emergency and ignore our bodies and our future plans. Low arousal states are essential for rest and sleep, but can interfere with good alert functioning during the day. Our goal with neurofeedback is to improve flexibility and stability of state regulation, not just to move the person's arousal level.
Neurofeedback and Arousal
We can map this same performance curve with training frequency rather than arousal level on the x axis. Adjusting the training frequency up or down has the effect of shifting arousal level up or down. It is our job clinically to read the signs of arousal shifts and use that information to optimize the effect of training. The optimal training frequency is individually specific, so we need to find the training frequency that works best for each person. This process of observing and interpreting training effects related to training frequency is a key component of effective neurofeedback training.
Arousal and Activation
- Activation of specific brain areas
- Controlled by subcortical nuclei
- Disregulated activation of specific circuits may relate to useful training sites
- Neurofeedback impacts arousal and activation
Arousal and Reward Deficits
- Reward deficiency – limbic issue - not low arousal
- Anticipation of reward motivates action
- Rewards satisfy drives
- To achieve pleasure or safety
- To escape pain or misery
- Thrill seeking for reward not for arousal
- Neurofeedback also impacts limbic function
Another important distinction for the sake of neurofeedback is that between arousal and reward deficits. Reward deficits relate to deficiencies in interest, pleasure and engagement, while arousal relates to core wakefulness. Reward deficiency is not the same as low arousal.
Those with reward deficiency might lack interest and engagement in normal activities, presenting as depression. Or they might escalate to thrill-seeking behavior in order to feel alive, seeking reward rather than wakefulness. We all need rewards to stay alive. Rewards satisfy drives, either to achieve pleasure or to escape from suffering, or both. Those who experience unrelenting misery and lack feelings of pleasure, safety or self-worth will take great risks for moments of peace, security or pleasure. Those with reward deficiency are vulnerable to addictive substances and behaviors, which turn on their reward systems that were not responding to more normal stimuli.
For reward deficits we want to target limbic function, not just brainstem arousal. We target limbic function most directly with temporal lobe and prefrontal placements. There are left and right brain aspects of the reward system. We might target the right hemisphere when rewards satisfy basic needs for safety and comfort, and for excitement and exploration. And we might target the left hemisphere when rewards follow completion of repetitive behaviors.
Reward - Habit - Addiction
- Rewarded behaviors create habits
- Positive learning from experience
- Habitual substance use or behavior
- Can be necessary for self-regulation (dependence)
- Can lead to self-destructive behavior (addiction)
Rewards are a normal and essential part of our lives. They allow us to learn from our experience and gain useful skills and habits. People with healthy nervous systems generally find behaviors and substances that support their own good physiological function and provide adequate rewards. People with less well regulated nervous systems might find it necessary to use substances like alcohol or marijuana to manage their brain states and support normal brain function. They might be dependent on the use of those substances or on prescription drugs. Some people live with significant reward deficits, such that they never feel peaceful, safe or happy. They might resort to self-destructive habits for even moments of relief from their suffering.
Neurofeedback for Addiction
- Infra-low frequency neurofeedback for physiological self-regulation - calmness, stability and self-control
- Alpha-Theta for resolution of early trauma and suffering, which drives addiction
For those with self-destructive addictive behaviors, infra-low frequency neurofeedback provides physiological calming and stability and more effective self-control. With the newer infra-low frequency HD applications and lower training frequencies, we now expect to reduce cravings significantly, along with symptoms of anxiety and depression, within the first 20 sessions. This is an important first step before adding Alpha-Theta neurofeedback. Alpha-Theta then allows resolution of early trauma and suffering, which drives addictive behavior.
- Paroxysmal symptoms
- Seizures, headache, mood swings, etc.
- Different from high arousal
- Different from reactivity
Our second category of dysregulation is instability of state. Symptoms of instability such as headaches, mood swings, panic attacks, seizures, etc. are paroxysmal events that arise suddenly and dramatically. Symptoms are usually very uncomfortable and disabling until they subside on their own. Panic attacks, for example, involve sudden feelings of terror and fear of dying. This is quite different from chronic anxiety which involves more constant high arousal and feelings of agitation, fear, etc. Rapid shifts in arousal can sometimes trigger unstable events, but instability of state is not the same as high arousal.
For the sake of neurofeedback there is also an important difference between instability and reactivity. Instability reflects an internal loss of stability and control as for example with mood swings. Reactivity reflects over-reaction to external triggers as with reactive anger outbursts. Reactivity falls under our category of disinhibition rather than instability of state.
- Central nervous system is inherently excitable
- Inhibition is needed to maintain stability
- Most CNS connections are inhibitory
- Injury or loss of inhibitory control leads to hyperexcitability and instability of state
The central nervous system is highly interconnected and therefore inherently excitable. Since each neuron connects with thousands of other neurons, activity could easily spiral out of control. Significant inhibitory control is required to maintain stability. Most central nervous system connections are in fact inhibitory. Injury or loss of these inhibitory connections can lead to hyperexcitability and lack of inhibitory control. Incoming excitation may then set off an explosion of nerve activity rather than contained processing of the input. Depending on where this occurs in the CNS, different symptoms of instability can result – seizure, panic, mood swings, migraine, vertigo, etc.
Neurofeedback for Stability of Brain States
- Left-Right temporal sites (T3-T4)
- Prevents paroxysmal loss of control
- Cortical, subcortical or brainstem
- Increasing use of anticonvulsants
- Increase inhibition
- Stabilize hyper-excitable neuronal circuits
- "state stabilizers"
Many of these symptoms of instability are best treated medically with anticonvulsants. When treating mood swings, anticonvulsants are often called mood stabilizers. We might think of them generally as state stabilizers. The effectiveness of anticonvulsant medications for any symptom is a good indication for T3-T4 as an effective electrode placement with infra-low frequency training.
- Lack of top-down inhibitory control
- Leads to disinhibition
- And release of lower functions
- Immature or primitive actions and reactions
- Impulsivity, tics, OCD, emotional reactivity, etc.
The third category of dysregulation is disinhibition. Disinhibition arises from a combination of agitation and lack of prefrontal self-control. Stress can increase agitation and thereby increase symptoms. Fatigue or sedatives can reduce prefrontal self-control and thereby increase symptoms as well. Symptoms such as tics and hyperactivity can increase with both high and low arousal - or stress and boredom. This is the situation with ADHD for example. Excitement can increase hyperactivity and impulsivity. Likewise, sedatives, fatigue or low blood sugar can decrease prefrontal self-control and release those same ADHD behaviors.
Good brain function depends on sufficient top-down inhibitory control from the highest level of our central nervous system. If we lack good inhibitory control genetically or due to injury, illness or sedating substances, then we become disinhibited, with release of immature or primitive behaviors.
Top-Down Inhibitory Control
- Inhibits subcortical reactions
- Allowing considered action
- Prefrontal - highest level
The cortex is the highest level within our central nervous system, and the prefrontal cortex is the highest level within the cortex. For each individual the prefrontal cortex develops over many years as we achieve maturity and increased self-control. With infra-low frequency neurofeedback we target mature control of function by training prefrontally.
Neurofeedback for Disinhibition
- Prefrontal training (L and/or R) for increased self-control
- Right parietal training for physical calming
Infra-low frequency neurofeedback for disinhibition involves left and/or right prefrontal training for increased self-control and also parietal training for physical calming. Right parietal (T4-P4) training most effectively calms agitation.
Right prefrontal (T4-Fp2) training increases control of emotional reactivity. Lack of emotional control can lead to angry, fearful, oppositional or aggressive behavior. Left prefrontal (T3-Fp1) training increases control of thinking and acting. Lack of control can lead to impulsive and compulsive behavior.
Medication for Disinhibition
- Activating (focusing) medications for increased self-control
- And calming medications for reduced agitation
- Stimulants for increased self-control, not increased arousal
Medication management for symptoms of disinhibition involves calming medications to lower arousal level and reduce agitation, plus activating medications to improve focus and self-control.
Stimulants like Ritalin both calm the body and focus the mind. They are not given to ADHD people to increase arousal level; they are given for increased self-control. Of course stimulants can also increase arousal in some people, who then might require further calming with a more sedating medication such as Clonidine.
Localized dysfunctions are the fourth neurofeedback category of dysregulation. Specific symptoms give us clues about where the brain is dysregulated. We can then target brain circuits related to specific functional deficits. It is clear from our clinical experience over many years that different placements can lead to very specific effects on brain function. It is remarkable how quickly the brain can shift its response with a shift in electrode placement. When trying a new placement to address a specific symptom it is usually obvious within a session or two whether the new site will be useful.
Do we need to engage circuits involved in sensory processing in the back of the brain?
Or do we need to engage circuits involved in creating output in the front of the brain?
Should we target right hemisphere big picture awareness or left hemisphere processing of detail?
Cortical Activation and Control
- Improving specific functions
- Activation and control of specific cortical circuits
- Calming and stabilizing
Electrodes on the scalp pick up cortical EEG activity, which is regulated by subcortical and brainstem circuits projecting to the cortex. We can target specific functional deficits by specific placement of our electrodes during infra-low frequency neurofeedback. Calming and stabilizing brain function then leads to better cortical regulation and better brain function.
Front / Back Brain Functions
Front - Output
- Executive function
- Top-down attention control
- Selection and initiation of behavior
- Inhibitory control of output
Back - Input
- Sensory processing and integration
- Bottom-up attention to environment
- Body and spatial awareness
The back of the brain processes input – sensory information regarding the outside world and also from inside our bodies. Training the back of the brain impacts sensory processing and sensory integration. It impacts body awareness and awareness of our body in space. It also impacts spatial attention – attention to our environment in response to sensory input.
The front of the brain processes output – moving, speaking, singing, thinking, planning, etc. Training the front of the brain impacts executive function and self-control. We can influence the initiation and sequencing of behaviors. And we can impact the ability to inhibit impulsive, compulsive, immature and reactive behaviors so that we have time to consider and decide how to act. Frontal training can also impact internally motivated and goal-directed attention.
Left / Right Brain Functions
We have two brains in our head that function quite differently. It is important that the left and right hemispheres do their separate and distinct jobs well, but also that they communicate and cooperate with each other. Efficiency lies in dividing and specializing roles before sharing the results.
Right brain function is the more integrative. The right brain looks at the big picture in the moment – in the context of its prior history – and helps us navigate through the world while keeping us safe and well. Left brain function is more analytical and sequential. The left brain sees details and helps us organize our behavior to achieve our goals. We might think of left and right brain function as text (L) and context (R).
We will look at symptoms for clues about relative strengths and weaknesses of left versus right brain function. It is important to know that sensory input and motor output from the brain cross over between left and right side. Input from the left side of the body projects to the right brain, and the right side projects to the left brain. Likewise, output to the muscles is controlled by the opposite side of the brain. With brain injury we might see weakness or paralysis on one side of the body and correlate that with injury to the opposite side of the brain.
Auditory input from the ears largely crosses over so that most of the input from the left ear goes to the right auditory cortex. This could be useful to know when dealing with a person with unilateral tinnitus. We might want to target the contralateral sensory areas. Visual input from our eyes partially crosses over such that the right visual field of both eyes projects to the left visual cortex, and the left visual field projects to the right visual cortex. This might help us think about where to train when people report loss or distortion of part of their visual field.
- Novelty & flexibility
- Environmentally-motivated behavior
- Bottom-up control
- Sensing danger
- Early development
The effects of infra-low frequency training with left or right side placements are very different and need to be carefully managed for each client. As we consider symptoms and life history, it is critical that we sort indicators for left side versus right side training.
The right hemisphere is aware of and responsive to the environment – where we are and how we are. The right brain assesses what is expected of us and how we might fit in. It helps us explore new situations and acquire new skills and knowledge. Its job is to keep us alive and safe. Importantly it allows us to feel safe and comfortable in ourselves so that we can be open to others.
Right brain exploration is important in our early lives as we are learning about the world. It is also important later in our lives to support flexibility and creativity.
Right Brain and Developmental Trauma
- Learned self-regulation
- Early development and attachment
- Disruption leads to chronic dysregulation
- Lack of safety and comfort in core self
- Abuse, neglect, developmental disorder, medical trauma
Early development of the right brain allows development of good self-regulation. We learn in the first few years of life to organize our sensory input, and how to self-soothe and to connect with others. When this early stage of development is disrupted by circumstances or by the childs own temperament, there can be a life-long difficulty with core self-regulation. And this can result in chronic dysregulation and chronic disorders. It is truly remarkable that neurofeedback can impact this core self-regulation – even many years later.
Neurofeedback for Developmental Trauma
- Mostly right side training
- Left side training may increase agitation and emotional reactivity
- Sometimes T3-T4 needed for stabilizing
For people with a history of developmental trauma, infra-low frequency neurofeedback begins with right parietal (T4-P4) placement for physical calming. Right prefrontal (T4-Fp2) generally comes next for calming emotional reactivity. Sometimes T3-T4 is required for migraines, panic or other instabilities, but more frequently we need to stay strictly on the right side for some time. Moving quickly to the left side (even T3-T4) may increase agitation and emotional reactivity.
PTSD: Post Traumatic Stress Disorder
- Compounding early trauma
- Lack of resilience and recovery
- Neurofeedback starts with right brain calming
- Later Alpha-Theta for unprocessed trauma
We understand that developmental trauma interferes with learned self-regulation in early life. This leads to a lack of core resilience and to chronic dysregulation. These are the people who do not recover from injuries, losses or traumatic events that occur in most lives. Later stress or trauma can overwhelm and reactivate unresolved earlier trauma. We see this for example in PTSD. The healthy nervous system can often recover from even severe traumas. Those who remain chronically impacted are usually those with pre-existing trauma.
We find that infra-low frequency neurofeedback is very effective in physical and emotional calming with right side placements for PTSD. Later Alpha-Theta is added for resolution of specific traumatic memories.
- Goal-directed behavior
- Planning and organization
- Analysis of detail
- Conscious thinking
- Executing learned skills
- Later development
The left hemisphere is specialized for detailed sensory processing, and organization and execution of skilled behaviors. Our left brain knows the rules and organizes the steps to achieve the goal. It manages the top-down control of attention to our goal-directed task. This is different from right brain spatial awareness which keeps us alert to our surroundings. Left brain attention is obviously important for school performance, where organization and follow-through are essential. We also target the left brain to improve verbal expression, as well as reading, writing and arithmetic.
Left brain function develops later as language and explicit memory come on line. Our left hemisphere manages the conscious, verbal interpretation and narration of our lives. It often feels the need to be in conscious control of everything we do. This can be a challenge in session when we are trying to calm right hemisphere function while the left hemisphere demands a verbal explanation of what is happening.
Cortical Areas and Functions
- Primary sensory & motor areas
- Modality-specific association areas
- Multimodal association areas
We can divide both left and right cortex into different more specific functional areas. Primary sensory areas receive and process information from our eyes, ears, joints, muscle and skin. This is the first and most basic cortical representation of sensory input. Primary motor areas are the final cortical output stage directing the body to move.
Modality-specific association areas represent a higher level of sensory (input) processing and organization of motor output. More information is extracted from each incoming sensory stream, but still separately.
The multimodal association areas are where we put it all together – sensory integration across sensory modalities and organization of behavioral output.
Primary Sensory and Motor Areas
- Visual (V)
- Auditory (A)
- Somatosensory (SS)
- Primary motor (M)
We will look at these functional areas in more detail starting with primary sensory and motor areas. Sensory processing occurs in the back of the brain, output and executive control in the front. Primary sensory and motor areas occupy a relatively small amount of our total cortex. They are involved in the first stage of sensory processing and final stage of motor output.
Somatosensory input from skin, joints and muscles provides information regarding touch and body position from the opposite side of the body. The primary somatosensory cortex lies just posterior to the central sulcus dividing front and back halves of the brain.
Auditory input from the ears to the primary auditory cortex provides basic sound frequency and intensity information mostly from the opposite side of the head.
Visual input from the eyes to primary visual cortex provides basic motion, shape and color information to each hemisphere from the opposite visual field.
The primary motor area has direct output to lower motor neurons in the spinal cord that instruct the opposite side of the body to move.
We might target these primary sensory and motor areas when there are symptoms related to basic sensory processing and motor control. This is more likely with cases of specific brain injury. Visual deficits, for example, might result from traumatic brain injury when the occipital cortex impacts the skull. Or a stroke involving the primary motor cortex might leave the opposite side of the body weak or paralyzed.
Modality-Specific Association Areas
- Visual (V)
- Auditory (A)
- Somatosensory (SS)
- Premotor (PM)
Adjacent to the primary sensory and motor areas are the corresponding modality-specific association areas. Further processing of sensory information and extraction of more complicated properties of the input occur within each sensory modality. We might, for example, target higher level visual processing with posterior temporal placements for reading on the left side and pattern and facial recognition on the right.
The premotor cortex manages higher level organization of motor output, including initiation and sequencing of movements. We might target Broca's area on the left side to improve speech articulation and word finding. Broca's area sits directly in front of the primary motor cortex area controlling movement of face and mouth. We sometimes target the frontal eye fields near the midline, where the brain controls eye movements to orient to stimuli in the environment.
Multimodal Association Areas
- Inferior Parietal (IP)
- Mid Temporal (MT)
- Prefrontal (PF)
There are large areas of the cortex that are not engaged in specific sensory or motor tasks. These areas include inferior parietal, mid temporal and prefrontal cortex. They are involved in the highest level of integration and abstraction of both input and output. They also receive input from limbic areas that provide information on where to direct perception and action in order to survive and achieve our goals.
There are two separate high level sensory processing areas that handle different aspects of the incoming information. First the dorsal stream of sensory processing concentrates input to the inferior parietal area from all sensory modalities. Here the brain extracts "how and where" information – how loud, how fast, how bright, how many, and also where in space and where in relation to body position. Operating in parallel the ventral stream of sensory processing brings input to the mid temporal lobes. Here the brain identifies what things are – object and pattern recognition.
The highest level of organization of behavioral output occurs in the prefrontal cortex. It is also the area that manages self-control. This is where we hold our intentions and execute needed steps to reach our goals, while not reacting immediately and impulsively.
- Temporal pole (TP)
- Insula (I)
- Orbitofrontal (OF)
In addition to sensory input and motor output, we need to consider limbic processing of our internal states and external threats and rewards. The limbic system directs our input and output functions to help us stay alive and achieve our goals. We think of limbic function as primarily subcortical, but there are also cortical limbic areas, which are largely folded under and out of sight. Pulling back the temporal and frontal lobes exposes limbic cortex extending from the orbitofrontal cortex, through the insula, to the temporal pole.
We target limbic areas and limbic function with prefrontal (Fp1 and Fp2) and temporal (T3 and T4) sites.
Limbic Function and Multimodal Association Areas
- Perception and action driven by limbic needs and goals
- High level input and output areas have strong input from limbic areas
- Neurofeedback at multimodal association sites impacts limbic function
In discussing input and output function, it is important to remember that our needs and goals drive all of our brain processing and behavior. We see what we are looking for, and what we have learned how to recognize. And of course we act according to our short-term and long-term needs and goals.
Cortical and subcortical limbic areas communicate strongly with the multimodal association areas. This allows coordination of drives and emotions, plus physiological regulation of visceral state, endocrine balance and immune regulation.
Importance of Multimodal Association Areas
- Highest level of input and output processing
- Newest parts of our cortex
- Last to develop over a lifetime
- First to lose function with dementia or normal aging
We have been shaped through clinical experience over many years to focus on these multimodal association areas as the most effective training sites. We can understand now that the multimodal association areas are managing the highest level of input and output processing, and therefore give us the broadest training effects.
These areas are the most newly evolved parts of our brains and also the last to develop over a lifetime. They are the first to lose function with dementia or normal aging.
There are times when we want to target more specific functions, but we should always begin with the high level organization and function of the multimodal association areas.
Neurofeedback and Multimodal Association Areas
- To aid development of function
- To optimize mature functioning
- To counter loss of function with age or disease
We target these multimodal association areas across the lifespan for maximum clinical effect:
- To aid development of good high level function when that is not developing appropriately, as with developmental disorders.
- To optimize good functioning and improve performance with a mature nervous system. It is generally possible to get more from the nervous system we have by increasing efficiency of functioning with neurofeedback.
- To counter the loss of function with normal aging or dementia. Neurofeedback is very helpful in maintaining good brain function and physiological self-regulation as we age. Even with severe dementia, we typically see significantly better function with training. With degenerative disorders like Alzheimer's, we might need to keep training indefinitely to maintain gains.
Multimodal Association Areas
- P3 & P4
- T3 & T4
- Fp1 & Fp2
Our basic neurofeedback sites target these multimodal association areas – inferior parietal (P3, P4), mid temporal (T3, T4) and prefrontal (Fp1, Fp2). These are the most effective training sites for most people most of the time. We will target these sites first and then add other sites later, but only as needed for more specific training effects.
Parietal Sites for:
- Body relaxation and awareness
- Spatial awareness
- Sensory integration
Considering first these basic sites, parietal training impacts high level sensory processing. Specifically this is the target of the dorsal stream of sensory information. This is where we impact the perception of how big, loud, bright, fast, etc. things are, and how they relate spatially to us and to each other.
The right brain looks at the big picture and at the whole body in space. With right parietal training we can impact body awareness and body relaxation. We impact the ability to interpret our sensory input and thereby relate to our environment (sensory integration). And we can calm overall reactivity to sensory stimuli.
The left brain processes detail. With left parietal training we can impact timing and attention to detail. We can impact awareness of left and right and fine control of the dominant hand. Left parietal training can improve ability to calculate with numbers. And it can calm light sensitivity while reading.
Temporal Sites for:
- Emotional regulation
- Physiological regulation
- Auditory processing
- Object and pattern recognition
The mid temporal lobe is the target of the ventral stream of sensory processing. This is an area of high level sensory integration regarding what things are – object and pattern recognition. With left temporal lobe training we can impact recognition of objects and symbols including letters in reading. Right temporal training can impact recognition of patterns and faces.
Temporal lobe training can also impact auditory processing, since this is where the primary and modality specific auditory areas are located. This is different from targeting auditory sensitivity with parietal training.
Temporal placements have always been strong sites for impacting emotional and physiological regulation as well.
Prefrontal Sites for:
- Impulse control
- Planning and organization
- Obsessive and compulsive symptoms
- Fear and attachment
- Emotional control
Prefrontal placements allow us to impact the highest level of output organization. Good prefrontal function allows us to hold information in our minds, while we plan and execute appropriate sequences of actions so as to achieve our goals. It also allows us to inhibit more primitive and immature reactions while we consider how to act. This is a key issue in ADHD where the person might act impulsively before he has time to consider the possible consequences of his actions.
Good prefrontal function is the key to good self-control (of thinking, acting and feeling). As the brain develops, prefrontal function gradually matures. This allows us to behave in a more mature fashion with greater self control. Symptoms of disinhibition such as OCD, tics, impulsivity, emotional reactivity, etc. all argue for prefrontal training. Whether that is left or right prefrontal depends on exactly what symptoms and who has the symptoms.
The right hemisphere regulates core emotions that keep us alive and safe in the world. Right prefrontal training impacts control of emotional reactivity. Right prefrontal training can reduce anger, fear, impatience, despair, etc. The left hemisphere regulates conscious planning and executing of goal directed behavior. Left prefrontal training impacts control of thinking and acting.
Learned Fears and Habits
- Implicit Memory
- Intuitive knowledge
- Early development
- Context free
- Emotional and somatic
- Traumatic memories
- About current experience
- Explicit Memory
- Later development
- Context with narrative of life
- Logical and cognitive
- About past events
Our last category of brain dysregulation relates to learned fears and habits. Learning occurs throughout the central nervous system. We tend to focus on explicit, conscious memories that can be recalled within the story line of our lives, but this system only comes on line when we are a few years old. An older and deeper learning results in implicit memories. This learning shapes how we perceive and respond to the world, and how we understand ourselves. Some of these memories are formed in our early pre-verbal life experience, while some may relate to later traumatic experiences.
Our subcortical and subconscious brain function is designed to keep us alive and safe. It can learn well in one traumatic event that a situation is life-threatening and to be avoided at all costs. Later attempts to talk ourselves out of this belief and reaction can be ineffective. The combat veteran might know that he is no longer on the battle field, but his brain remains hyper-vigilant and hyperreactive. A sight, a sound, or a smell can trigger a flashback of the life-threatening and traumatizing event.
These learned fears and habits indicate that Alpha-Theta training will be an important component of our neurofeedback program. Alpha-Theta allows people to internally access and resolve traumatic experiences while in a safely relaxed witness state.
AT: Relaxing Cortical Control
- Low arousal state
- Lack of sensory input
- Release of cortical control
- Allows subcortical processing
and resolution of subconscious
fears and habits
- May or may not reach conscious
Alpha-Theta neurofeedback involves relaxing cortical control and allowing subcortical processing of subconscious memories. We support a low arousal state in session with reduced sensory input. Training is typically done eyes-closed in a dark room with headphones and a comfortable chair, blanket and pillows for maximum physical comfort. This reduces external distractions and frees the brain to process its own internal material.
Feeding back alpha and theta EEG activity promotes synchronous low frequency brain waves and a disengaged cortex. This allows memories to surface and be processed in a deeply relaxed state. The memories may or may not reach conscious awareness during this process. In either case, traumatic memories are stripped of their emotional charge and filed away as memories that can later be consciously recalled without reactivating the trauma.
Alpha-Theta Training Allows
- Fears and attachment deficits related to developmental trauma
- Habits formed through addictive experience
- Fears and behaviors formed during traumatic experiences
- After improved stability and control of state with infra-low frequency training
Alpha-Theta training is especially helpful in resolving fears and attachment issues resulting from trauma in early development, or in later traumatic situations. It is helpful with habits formed through addictive experiences, where an addictive substance or behavior gives profound relief from unrelenting pain or misery. And it is helpful with habitual behaviors such as smoking that might no longer serve a useful purpose, but are maintained by long-term associations.
Before Alpha-Theta training we always start with infra-low frequency training for physiological calming and stabilizing. This allows a more successful Alpha-Theta experience and training effect. With PTSD for example, infra-low frequency training resolves the physiological consequences of trauma – agitation, hyper-vigilance, reactivity, sleep disturbance, etc. Alpha-Theta training then addresses unresolved traumas and emotional triggers. Together these two approaches are remarkably effective with PTSD.
- Patterns of dysregulation
- Sensory and cognitive
- Physical and behavioral
- Immune, endocrine and autonomic nervous system
- Appetite and eating disorders
- Attachment & personality disorders
- Developmental disorders
- Brain injury and seizures
- Peak performance
- Medication efficacy
- Summary: Basic functions
- Symptoms as clues to patterns of disregulation
- Symptom categories related to neurofeedback variables
- Not about diagnoses
In the assessment section we discussed a clinical model of brain regulation and dysregulation relevant to neurofeedback. This gives us a language and basic neurofeedback tool-kit for addressing specific modes of dysregulation. In this symptom profiles section we will map specific symptoms to our basic categories of dysregulation.
We are not treating these symptoms with specific protocols, but rather using the symptoms to guide our understanding of how the nervous system is dysregulated. Then the categories of dysregulation give us ideas on how to craft an effective neurofeedback program for each individual.
Patterns of Dysregulation
Reviewing the basic categories:
- Arousal indicators help us read the impact of training frequency choice on arousal level – whether to adjust training frequency higher or lower for comfort in session and optimal effectiveness.
- Instabilities result in symptoms that arise paroxysmally, such as migraines or seizures, and require stabilization with T3-T4 training.
- Disinhibition results in immature or primitive behaviors that are released by insufficient prefrontal inhibitory self-control and exacerbated by increased agitation. Parietal calming and improved prefrontal control are indicated.
- Localized dysfunctions are indicated by symptoms, or by known details of brain trauma or brain imaging that point to dysfunction of specific brain circuits that can be targeted with specific placements.
- Learned fears and habits that trigger dysfunction suggest Alpha-Theta training.
Mapping symptoms to these categories helps us understand a client's responses to training and helps us make decisions on how to adjust training over time for best effect.
1. Physiological Arousal
Physiological arousal is a core brain state variable. And sufficient calming of arousal is a basic component of effective neurofeedback training. Chronic high arousal is evident with chronic anxiety, agitation, insomnia, muscle tension, etc. Our challenge for each brain is to find an ILF training frequency that will be sufficiently calming but not sedating. As we move the training frequency in session or from session to session, we track changes in physiological arousal to find the optimal training frequency for each individual.
- Paroxysmal symptoms that arise suddenly
- Seizures, headaches, mood swings, etc.
- ILF neurofeedback for instabilities:
- L-R temporal sites (T3-T4)
- Improve stability of brain states
- Reduce instability symptoms
- Cortical, subcortical or brainstem
Symptoms of instability are recognized by their sudden onset and predictable course. Migraines, for example, might begin with a characteristic aura and then progress to head pain and nausea in a familiar sequence with each event. These symptoms are explosive, and typically quite disabling. They are very different from chronic symptoms related to high arousal.
With infra-low frequency neurofeedback we address instabilities most effectively with left-right temporal lobe placements (T3-T4). This gives the most stabilizing effect across the whole brain. It also addresses the particular vulnerability of the temporal lobes to hyper-excitability and resulting symptoms of instability.
- Insufficient top-down inhibitory control
- Leads to disinhibition and release of lower functions
- Immature or primitive actions and reactions
- ILF neurofeedback for symptoms of disinhibition:
Symptoms of disinhibition are seen as uncensored and unmodulated actions or reactions. The behaviors burst forth without thought or consideration of possible consequences. This is typically seen as a lack of self-control. Self-control is expected to increase with maturation and increasing prefrontal function. Acting without good self-control may therefore appear as immature behavior. Common symptoms of disinhibition include obsessive thoughts, impulsive or compulsive behaviors including tics, and emotional reactivity. These symptoms tend to increase with stress or agitation. They also tend to increase when people are bored or sedated.
Reducing symptoms of disinhibition requires calming of the agitation that drives the behavior. Right side parietal training generally reduces agitation, but that is not sufficient by itself. In fact, right parietal calming by itself often increases symptoms of disinhibition. Improved prefrontal control is also necessary to strengthen self-control. This might be right prefrontal training to address emotional reactivity or left prefrontal training for control of thoughts and actions.
4. Localized Dysfunctions
- AS CLUES TO ELECTRODE PLACEMENT
- Executive function
- Sensory Processing
- Detail analysis
- Goal directed behavior
- Body and emotional awareness
We gain additional clues on potentially effective training sites by looking at specific functional deficits. By targeting specific brain areas we can impact specific brain functions and dysfunctions.
Posterior placements on the back half of the brain specifically impact input processing. And anterior placements on the front half of the brain specifically impact output processing. It is important that we consider whether functional deficits involve input or output processing for each brain.
Right side placements impact right brain functions, which help us know how and where we are in the moment. Good right brain function helps us feel safe and calm in ourselves and connect more easily with others. Left side placements impact left brain functions, which help us plan for the future and organize our behavior to meet our goals. Knowing whether functional deficits relate more to left or right hemisphere function can help us choose effective electrode placements over a course of neurofeedback.
Specific symptoms can be targeted by more specific electrode placements within these general areas.
5. Learned Fears and Habits
- Alpha-Theta after ILF calming and stabilizing for:
- Unresolved loss or trauma
- Chronic pain
- Eating disorders
- Personality disorders
Our last category of dysregulation involves learned fears and habits. A history of traumatic or emotionally stressful experiences suggest that we include Alpha-Theta training. For some clients Alpha-Theta will be a critical part of their overall neurofeedback training. For others it may not be specifically indicated, but still offer a pleasant and sometimes profound relaxation and sorting out of life issues. We always begin with infra-low frequency training to calm and stabilize the nervous system and reduce hyper-vigilance and reactivity. Alpha-Theta is then added later as needed for further resolution of learned fears and habits.
We expect to include Alpha-Theta training for all adults with chronic disorders and dysregulation of their core sense of self. This includes those with PTSD, addictions, chronic pain, eating disorders and personality disorders. We expect all adults to gain some benefit from Alpha-Theta because we all have some unprocessed emotional experiences, even if they do not qualify as traumatic. Teenagers sometimes also enjoy and benefit from Alpha-Theta. Children can do Alpha-Theta when needed, but that is not as commonly done.
Four Quadrants - Training Effects
- Mental calming
- Planning and organization
- Verbal and written expression
- Logical thinking
- Awareness and processing of detail
- Dominant hand awareness
- Symbolic processing
- Stored knowledge and skills
- Calms emotional reactivity
- Emotional comfort and security
- Emotional expression
- Common sense
- Physical calming
- Body and spatial awareness
- Sensory integration
- Orientation to time and space
In the following symptom profiles we will map specific symptoms to our basic categories of dysregulation and basic electrode placements. First putting together the understanding of front versus back and left versus right brain function, we can look at the specific training effects of the four brain quadrants.
Training the right back promotes physical calming and body awareness. We impact sensory processing of the big picture – how I am and where I am in space and time. We also impact sensory integration – the ability to make sense of our environment and how our bodies interact with it.
Right front training calms emotional reactivity. This is how we impact core emotional regulation, which allows an internal sense of safety and comfort. Core emotional regulation results in less emotional reactivity since people feel less threatened by others. Right front training can enhance emotional expression and the desire to connect with others. It can also impact common sense, understanding how the world works and basic cause and effect thinking (as opposed to left brain logic).
Left front training can produce mental calming, which allows clearer, faster, more organized thinking and goal-directed behavior. It can impact verbal and written expression and logical thinking.
Left back training can impact awareness and processing of detail. This means symbolic processing as in reading, writing and arithmetic. Left back training can improve awareness of left and right and dominant hand awareness, which allows control and timing of skilled movements. Here we can impact access to stored knowledge and skills.
Four Quadrants Plus Left-Right
- Mental calming
- Planning and organization
- Verbal and written expression
- Logical thinking
- Stabilizing for headaches, seizures, panic, mood swings, etc.
- Awareness and processing of detail
- Dominant hand awareness
- Symbolic processing
- Stored knowledge and skills
- Calms emotional reactivity
- Emotional comfort and security
- Emotional expression
- Common sense
- Physical calming
- Body and spatial awareness
- Sensory integration
- Orientation to time and space
We need to add one more piece to the four quadrants just considered. Inter-hemispheric training (left minus right – or equivalently, right minus left) has the effect of stabilizing brain function. T3-T4 is our strongest placement for symptoms of instability such as headaches, seizures, panic, mood swings, etc. Instability symptoms are usually very unpleasant and disabling. It is difficult to function when the brain is going out of control. Neurofeedback is particularly effective with instability symptoms. A very slight change in the brain's ability to maintain stability can make a very significant change in the incidence and intensity of symptoms. It is necessary to carefully optimize training frequency with instabilities. The consequence of training a less than optimal training frequency can be increased symptoms and significant discomfort.
This is now the basic template for deciding where to train. Whatever the symptom category, we need to ask the same questions. Do we need physical calming, calming of emotional reactivity, mental calming, awareness and processing of detail and/or stabilizing? We will now apply this template to different symptom categories, always with the same core categories of where to train in mind.
Basic Placements for ILF Neurofeedback
In targeting these basic brain areas and brain functions, we always start with placements involving the basic sites we identified as multimodal association areas. For infra-low frequency training we use bipolar placements, which measure the difference between two active sites. Our basic placements always include T3 and/or T4 in each pair of sites.
For each client we first work toward finding which combination of these basic placements is most effective.
- Right back - T4-P4
- Right front - T4-Fp2
- Left front - T3-Fp1
- Left back - T3-P3
- Left-right - T3-T4
Later we might add other sites for more specific effects, but only as necessary after training basic sites.
- (As needed after
- R-side training)
- Mental calming
- Obsessive worry
- Compulsive behavior
- Panic attacks
- Emotional reactivity
- Fear and anger
- Hyper-vigilance and paranoia
- Attachment problems
- Obsessive or compulsive
- Physical tension
- Lack of body awareness
- Feeling disconnected from body
Anxiety covers many different symptoms and different patterns of dysregulation. For anxiety and other symptom groups, we will break them down into our categories of dysregulation that relate to our training options.
Right back training reduces physical symptoms of anxiety. Tension in the chest or abdomen is often the most urgent symptom of anxiety. Other components of anxiety might then surface over time as the physical anxiety resolves with training. This body calming also helps body awareness and feeling more grounded in the body.
Right front training calms core emotions and quiets emotional reactivity, fear and anger, hyper-vigilance and paranoia. An important concept for neurofeedback is that people with any disruption of their early development due to their own temperament, or due to early life circumstances (abuse, neglect, separation, stressful medical treatments, etc.) need to start with right side training. Presenting symptoms might include attachment problems, personality disorders or lack of resilience leading to chronic disorders. Right back training calms the body. Right front training calms emotional reactivity.
Left front training calms conscious worry. Obsessive thoughts and compulsive behaviors suggest the need for prefrontal training for increased self-control along with right parietal calming. Whether that is left or right prefrontal, or both, depends on the individual. We should look at other indicators for left or right side training, and for the quality of the obsessions or compulsions. Right prefrontal might be more effective when symptoms involve the core sense of self-worth, whereas left prefrontal might be appropriate for symptoms related to more conscious order or neatness.
Left back training does not relate directly to anxiety symptoms as far as we know. Training here targets skills and knowledge, which might or might not surface as an issue once anxiety subsides.
Left-right training is stabilizing against panic attacks. People with panic attacks might have baseline anxiety, but panic attacks are discrete events in which the brain goes out of control. They respond specifically and well to our stabilizing training.
Anxiety is a state of emergency – an urgent need to protect oneself from danger. We often need to start with right side training to calm the perceived threat to our physical and emotional survival. As that fear subsides, we might need to add left-right training for symptoms of instability that become obvious. And later left front training might also become necessary for calming conscious worries.
Mood regulation is an issue for most people, even when there is no diagnosable disorder. We should always track changes in mood as we optimize training. We should continue to track arousal indicators to help optimize training frequency. And we should consider Alpha-Theta indicators for people with anxiety and across all symptom categories.
- Obsessive negative thoughts
- Planning for the future
- Mood swings
- Dissociative episodes
- Emotional overwhelm
- Anger and rage
- Self-injurious behavior
- Body tension and pain
- Lack of body awareness
- Lack of pain awareness
People often think of depression as low arousal the opposite of high arousal anxiety, but this is clearly not the case. Depressed people can be highly agitated. Depression is not fundamentally an arousal problem, but rather an emotional (limbic) problem. Depressed people are reward deficient. They do not experience pleasure in their lives. Neurofeedback is very effective
Right back training calms body tension and pain that often accompanies depression. It helps people be more aware of their bodies and more appropriately aware of acute pain. People with self-injurious behavior may lack a normal sensitivity to pain, which could stop self-injury. Right back training reduces physical agitation and is the first step in reducing such harmful behavior.
Right front training calms core emotional misery – overwhelm and despair, anger and rage. These are not left brain issues of conscious cheerfulness and optimism, but core issues of self-worth. People are driven to self-injurious behaviors in an attempt to relieve their misery with endorphins released with injury to the body. It takes extreme emotional pain to drive such self-destructive behavior. And it takes a lack of normal pain sensation to make it possible. Neurofeedback is usually effective in remediating self-injurious behavior.
Left front training impacts more conscious and positive emotions. It can have a significant antidepressant effect – promoting cheerfulness and optimism. Our right brains keep us safe. Our left brains take us out into the world to accomplish goal-directed tasks. We often need to calm right brain fears and despair before we can work on left brain contentment and happiness. Prefrontal training also impacts obsessive thinking. This is often left prefrontal for conscious worries. It is sometimes right prefrontal when the obsessions involve more core emotions and self-loathing.
Left back training is not an issue in mood regulation as far as we know.
Left-right training is effective in stabilizing mood swings. The diagnosis of Bipolar Disorder is not an important issue for the sake of neurofeedback. What is relevant is whether a person's mood is unstable and unpredictable. Are the mood swings arising from the person's physiology (instability) or in response to environmental triggers (reactivity)? Instabilities are impacted by left-right training. Emotional reactivity is calmed with right front training. Dissociative episodes arise as significant instabilities, but they typically result from severe early trauma. Instability argues for left-right training, but early trauma argues strongly for right side training. We might start with both right side and left-right placements to most efficiently sort out what is most helpful.
Alpha-Theta training is generally an important part of training for depression. Unresolved traumas contribute significantly to depression. Chronic depression, like other chronic disorders, can often be tied to developmental trauma that results in lack of resilience and lack of emotional comfort.
- Goal directed attention
- Mental calmimg, Impulse control
- Working memory
- Planning and organization
- Erratic swings in mood or energy
- Emotional rebound or headache with stimulants
- Attention to detail
- Dominant hand awareness
- Left/right awareness
- Oppositional behavior
- Attention to environment
- Body awareness
- Spatial and time awareness
- Physical calming
Attention is a complicated process involving the function of different brain areas. The major components of attention from a neurofeedback perspective are right parietal spatial attention and left prefrontal goal-directed attention. But many clients come with a diagnosis of ADHD who are really much more complicated, and who require a more comprehensive approach.
First, the right brain manages attention to the environment.
Right back training impacts attention to our surroundings. We need to be able to respond appropriately to events around us. People with attention deficits often hyper-focus on one activity and completely disconnect from their surroundings. They are unable to easily shift focus, which annoys those around them. Right back training also helps body awareness and calms physical hyperactivity. Training right back for attention deficits without also training prefrontally may cause disinhibition that is observed as impulsive and immature behavior.
Right front training calms defensive focus on threats in the environment – hyper-vigilance, oppositional and emotionally reactive behavior. Hyper-vigilance conflicts with calm focused attention. If we are hyper-vigilant in an attempt to stay alive in a dangerous situation, we do not have the leisure to plan and organize. Again the right side often needs calming first before we can work on the left. Many people diagnosed with ADHD are also oppositional or aggressive. These behaviors arise out of emotional reactivity and require right front training before moving to the left side.
The left brain manages internally motivated, detail and goal-directed attention.
Left front training helps planning and organization – the ability to hold a plan in mind and execute a sequence of behaviors to achieve a goal. Left frontal training promotes calm sustained focus and inhibitory control of impulsive reactions, allowing time for deliberate action.
Left back training supports attention to detail, awareness of the dominant hand and fine motor skills. While the right parietal cortex represents the whole body in space, left parietal function allows awareness of the left and right sides of our bodies and our world.
Left-right training is stabilizing for those who present with attention problems plus instability of mood or energy level. It is helpful for those who struggle with emotional rebound or headaches when taking stimulant medications.
Alpha-Theta is also useful for adults who have grown up with ADHD symptoms. As children and as adults they may have been criticized for inconsistent behavior and low achievement. This certainly impacts their self-esteem and self-confidence. Alpha-Theta can help get rid of that emotional baggage and allow the development of more positive expectations.
ADHD: 2 Neurofeedback Subtypes
Narrow focus on present moment
Lack of body awareness and control
L prefrontal for attention and impulse control
R parietal for hyperactivity and spatial awareness
Need for temporal lobe stabilization
In addition to L prefrontal and R parietal
R prefrontal as needed for oppositional or aggressive behavior
Can be sensitive to training frequency
For the sake of neurofeedback, we can describe two subtypes of ADHD. The first is simple uncomplicated ADHD. This group is not mean or angry, just immature and unaware of their own behavior and how it affects others. They live in the moment, unable to consider consequences of future behavior or remember why people are upset with past behavior. They are often smart and creative and energetic, but they have difficulty with organization and follow-through. So they frustrate themselves and others. The key neurofeedback components for this group are right parietal training for spatial awareness and physical calming, and left prefrontal training for focused attention, impulse control, planning and organization. Importantly the uncomplicated ADHD children or adults are generally poor reporters of change with neurofeedback. They always feel great and don't understand why others are upset with them. So we don't expect good feedback from them on how they feel in session or from session to session. And we should not jump around with different training frequencies in search of something they will feel. We usually depend instead on reports from family members, school or therapists rather than asking ADHD people how they feel. It is essential that we find someone who can report on changes in behavior to help us optimize the training.
The complicated subtype might come labeled as ADHD but really have more complicated issues. They might have instabilities including mood swings, headaches, asthma, sleep-walking, etc. In which case left-right temporal lobe stabilization is needed in addition to right back and left front. These are sensitive nervous systems that will be more sensitive to neurofeedback effects and better reporters of how they feel. People with instabilities usually require careful optimization of the training frequency.
Our complicated subtype might have oppositional, emotionally reactive or aggressive behavior. These behaviors are typically related to developmental trauma and attachment issues – either due to the child's temperament or due to early life experience. In these cases we need to stay on the right side with T4-P4 for physical calming and T4-Fp2 for emotional calming. Even with a diagnosis of ADHD, left side training may be too agitating for this complicated subtype.
People with oppositional and aggressive behavior may also have mood swings or other instabilities that require T3-T4. The expected combination of sites is then T4-P4, T4-Fp2 and T3-T4, not T3-Fp1.
ADHD Starting Sites
- Simple ADHD or ADD
- ADHD with instabilities such as headaches, asthma, sleep walking, etc.
- ADHD with oppositional, aggressive or emotionally reactive behavior
- Adoption or developmental trauma
Many clients come with a diagnosis of ADHD. It is important that we consider other symptoms as well as early life experiences in deciding how to begin neurofeedback training.
For those ADHD (or ADD) clients without more complicated symptoms or life histories, we need to start with T3-T4 to involve both hemispheres. Beginning with right side T4-P4 training alone may cause disinhibition, increasing ADHD symptoms. After optimizing the training frequency at T3-T4, we can then add right (T4-P4) and left (T3-Fp1) placements for more specific effects on ADHD symptoms.
For ADHD clients who also have symptoms of instability, we should begin with T3-T4 both for the ADHD and also for the instabilities. Later T4-P4 and T3-Fp1 can be added to the T3-T4 placement.
For ADHD clients who show oppositional, aggressive or emotionally reactive behavior, it is important to start training on the right side only (T4-P4). This also applies to those with a personal history of adoption or developmental trauma. Any left side placement, including T3-T4, can lead to increased agitation and emotionally reactive behavior. If, however, right-side only training leads to increased instabilities, then T3-T4 might also be necessary.
- Mental calmimg to allow sleep onset
- Organization of sleep states
- Night terrors
- Sleep walking
- Night sweats
- Restless leg syndrome
- Hyper-vigilance and fears interfering with sleep onset
- Physical calming to allow sleep onset
- Physically restless sleep
Sleep symptoms and changes in sleep with training are useful information in assessment and tracking training effects. Again we need to break this down into the categories related to our training variables. We expect strong and specific effects on sleep depending on placement and also on training frequency.
Right back training is the key piece for insomnia – meaning difficulty falling asleep or falling back to sleep during the night. Physical calming helps people relax and fall asleep. It calms physical restlessness and muscle tension including teeth grinding (bruxism). Right back training also calms anxiety related nightmares or vivid dreams during sleep. It is sometimes necessary to focus on T4- P4 alone to sufficiently impact insomnia. When starting neurofeedback, people often report an increase in dreaming. With our modern life style, many people are sleep and dream deprived. Neurofeedback can allow a rebound of dreaming that settles down again within a few sessions. As sleep becomes more organized with training, dreaming also occurs later in the sleep cycle and is more likely to be remembered on awakening.
Right Front training calms fears and hyper-vigilance which might interfere with sleep onset or set off scary dreams or flashbacks. Prefrontal training may also be helpful with bruxism because grinding can be released with insufficient inhibitory control (disinhibition).
Left front training is sometimes helpful when a busy mind interferes with falling asleep. This means worry and mental chatter, not fears and hyper-vigilance.
Left back training is not an issue for sleep symptoms as far as we know.
Left-right training is helpful in organizing sleep rhythms and stabilizing the brain during rapid shifts in sleep state. Some people can fall asleep easily and sleep for many hours but still feel unrested in the morning. This results from a lack of deep sleep, and is helped by T3-T4 training. Both deep sleep and dream sleep are critical for good mental and physical health. Deep sleep allows physiological rest and repair. Without it, people can develop fibromyalgia and other chronic disorders. Dream sleep allows a sorting out of our mental images and experiences of the day. Managing the shifts back and forth between deep sleep and dreaming and getting it all done before morning is a complicated task. During dreaming, for example, it is important that we do not physically act out our dreams. We actually paralyze our bodies (everything below the eyes) as we dream. Then as we awake from the dream, we need to shake off the paralysis. If the timing is off, we might experience sleep paralysis – awake but completely unable to move for a short time. The brain is most vulnerable to getting out of control in a number of ways during these dramatic shifts in sleep states. There are many sleep problems that are related to this difficulty maintaining stable brain function during these shifts – night sweats, panic, migraines, seizures, restless leg, sleep walking, night terrors, etc.
It is important to recognize the difference between night terrors and nightmares. Nightmares are scary dreams which can often be recalled. They are related to anxiety and respond best to right side calming. During night terrors people look terrified and their eyes are frequently open, but they are not responsive to assistance and do not remember the event in the morning. Night terrors are very responsive to left-right brain stabilizing training. Instabilities in general require careful attention to training frequency. Night terrors, sleep-walking, restless leg and other sleep instabilities can increase when training too low as well as too high. People with instabilities are often strongly impacted by disruptions in the sleep cycle. They may have difficulty with daylight saving or time zone changes. These sensitivities improve with stabilizing training.
Sensory and Cognitive Symptoms
- Executive function
- Planning and organization
- Verbal expression
- Motion sickness
- Auditory processing
- Math calculation
- Left/right confusion
- Common sense
- Emotional expression
- Early language
- Basic number sense
- Visual-spatial skills
- Sensory integration
With specific sensory processing or cognitive symptoms, more specific training sites might be useful. However it is still worthwhile to begin with the basic sites for overall effects. These symptoms might reflect learning difficulties for a school-aged child. They might be issues for an adult wishing to optimize good mental function. Or they might relate to loss of function with dementia or normal aging. Neurofeedback is helpful in maintaining good self-regulation and good function as people age. It should be part of an anti-aging program along with good nutrition, social engagement, and mental and physical exercise. Dementia symptoms are very responsive to neurofeedback. Targeting high level function with our basic placements can make a significant difference in mental and physical abilities. With a rapidly progressing dementia such as Alzheimer's, it may be necessary to continue training frequently and indefinitely to maintain functional gains as long as possible.
Right back training is helpful in improving visual-spatial skills including drawing. It can impact basic number sense and spatial concepts necessary for understanding geometry. Right back training is very helpful for those with sensory integration issues (sensory processing disorder), improving the ability to put together sensory information about the world with a sense of one's own body in space. It also calms sensory overload for those who experience sensory input as too strong and painful.
Right front training helps emotional expression – not words and grammar, but appropriate emotional communication. This might be prosody or body language in an Asperger's child. It might be the acquisition of language in an autistic child, increasing the desire to connect and communicate with others. If basic right side placements are not sufficient, T4-F8 is sometimes helpful in getting language started. Right front training can help common sense. This means a basic understanding of how the world works and how to interact with others.
Left front training helps executive function – planning and organization, the control of conscious deliberate actions to achieve goals. Left front training can improve verbal expression for those who have already acquired language skills. T3-F7, targeting Broca's area, often helps word finding and verbal articulation.
Left back training impacts cognitive processing. This is the cortical area for manipulation of symbols in reading, writing and arithmetic. T3-T5 might specifically target the ventral stream of sensory processing which supports object recognition. This allows decoding of letters and words, and thereby helps reading. T3-P3 might target the dorsal stream of sensory processing, which processes intensity, quantity, movement, etc. It helps mathematical calculation, and also calms visual sensitivity which interferes with visual processing in reading. This visual sensitivity and interference is known as Irlen syndrome, which can also be helped with individualized colored lenses.
Left-right training helps vertigo when there is no structural cause for the symptoms. Most vertigo is best understood as a migraine variant, and as such it is highly responsive to T3-T4 training. Dizziness, like headache, always calls for careful training frequency adjustment. If dizziness or headache arise in session, or do not reduce in session, then it is wise to try adjusting the training frequency at T3-T4. Left-right training impacts motion sickness, auditory processing and sometimes tinnitus. There is also a component of auditory sensitivity with tinnitus indicating parietal training. T4-P4 is usually helpful with tinnitus, and sometimes T3-P3 is helpful for ringing in the contralateral right ear.
Alpha-Theta can be helpful for people losing cognitive function through dementia, brain injury or normal aging. Along with the cognitive deficits may come a loss of job status, social connections and self-worth. Alpha-Theta can help people process these losses. Alpha-Theta can also be helpful for those who have struggled with learning disabilities throughout their lives.
Physical and Behavioral Symptoms
- (As neede after R-side training)
- Impulse control
- Compulsive behaviors
- Motor and vocal tics
- Erratic shifts in mood or energy level
- Learned skilled movements
- Aggressive and controlling behavior
- Oppositional behavior
- Thrill seeking
- Emotional reactivity, Road rage
- Self-injurious behavior
- Balance and coordination
- Muscle tension and spasticity
- Hyperactivity and tremor
- Parkinson's symptoms
- Constipation and bruxism
Right back training impacts physical balance and coordination. The brain becomes more aware of the body and the body in relationship to space. Right back training calms muscle tension, spasticity, bruxism, tremor and hyperactivity. It is usually helpful with core symptoms of Parkinson's. It also helps constipation. Constipation is common in those who live in high arousal emergency mode. When dealing with emergencies, we stop paying attention to our bodies and taking care of our bodies. T4-P4 leads to relaxation and body awareness, which quickly impacts chronic constipation.
Right front training calms emotional reactivity that drives oppositional and aggressive behavior, including road rage. It calms reward seeking behavior in those with reward deficits. And it reduces self-injurious behavior by reducing the core emotional misery motivating the behavior. T4-P4 also helps in this case by normalizing pain threshold. Encopresis generally responds well to right side training -- T4-P4 for body awareness and sometimes T4-Fp2 to calm emotional reactivity.
Left front training is sometimes helpful for behavioral control after calming with right side training. Impulse control can be strengthened with left prefrontal training. This does not mean impulsive anger or aggressive behavior (indicating right prefrontal training), but simply acting without thinking. Compulsive behaviors and tics call for prefrontal training. This could be left or right or both. We need to look at what is driving the behavior. Behavior driven by fear or self-loathing likely indicates right prefrontal training. Behavior driven by a simple need for completion or order might indicate left prefrontal training. Visual orientation to stimuli is directed by the frontal eye fields, controlling gaze to the opposite visual field. We have some good experience with frontal training (T3-F3 or T4-F4) for strabismus, where the two eyes do not track together.
Left back training targets execution of skilled movements. This relates to fine motor skills involving dominant hand awareness and control.
Left-right training calms erratic shifts in mood or energy level or behavior. Nystagmus has also shown improvement with T3-T4 training.
Alpha-Theta can be helpful in changing habits that no longer serve us well. Behaviors might have developed as a means of coping with or escaping from discomfort or difficult circumstances. Circumstances change, yet we might hold fast to the behavior.
Immune, Endocrine and Autonomic Nervous System
- PMS (sadness, mental fog or worry)
- IBS, Sugar craving
- Endocrine disregulation
- Immune deficiency
- Autoimmune disorders
- Hot flashes and night sweats
- PMS (instabilities including migraine)
- PMS (reactive or aggressive symptoms)
- Chronic constipation
- Heart palpitations
- PMS (physical agitation)
The central nervous system modulates and regulates immune, endocrine and autonomic nervous system functions. When we train on the cortical EEG, we have strong and specific impact on these limbic systems. It is useful to track these symptoms from session to session for clues in optimizing training variables. It is also important to track symptoms so that relevant medications can be adjusted as needed.
Right back training calms the body, which helps chronic constipation, reflux, high blood pressure, heart palpitations and tachycardia.
Left-right (T3-T4) training helps stabilize and organize physiological functions. This can help irritable bowel symptoms of episodic diarrhea and constipation, although dietary management may also be required. Sugar craving and reactivity are related to hypoglycemia. Poor sugar regulation is a problem for many people, but not all. With hypoglycemia blood sugar rises after sugar consumption and then crashes. The low blood sugar status then compromises good brain function, leading to sugar craving, dizziness, mood swings, hyperactivity, etc. Blood sugar regulation responds specifically and well to T3-T4 training. Thyroid function also responds well to left-right training. For those taking thyroid medication, levels should be checked periodically and adjusted as needed. Asthma responds strongly and quickly as well. People often find they no longer need to use their inhalers after twenty sessions of neurofeedback. Hot flashes and night sweats reflect an instability of body temperature, and respond well to training.
Immune function improves so that people may stop getting all the colds and flus that go around. This training also calms autoimmune disorders including multiple sclerosis, lupus, Hashimoto's thyroiditis, etc. Neurofeedback is not a cure for autoimmune disorders, but it can be helpful in calming self-destructive immune responses and supporting healing.
We are now seeing good effects with diabetes. With type 1 diabetes neurofeedback helps body awareness, allowing better management of symptoms. Insulin use typically decreases with better self-regulation as well. Those with type 2 diabetes can benefit from better appetite and blood sugar regulation.
PMS symptoms include pretty much any symptom of dysregulation a woman is likely to experience. PMS is not a disorder or a specific group of symptoms, but the individual's reaction to hormonal shifts with the menstrual cycle. Women have wildly differing severity of symptoms. The issue is not the magnitude of hormonal shifts, but rather the individual's sensitivity to those changes. We can look at the specific symptoms for clues regarding electrode placement. T3-T4 stabilization is helpful for instabilities such as migraines, mood swings or seizures as PMS symptoms. T4-P4 calms PMS related physical tension or agitation. T4-Fp2 helps emotional reactivity or aggressive behavior. And T3-Fp1 can help sadness, mental fog or obsessive worry.
- Low pain threshold
- Chronic aching pain
- Headache and other migraine symptoms
- Trigeminal neuralgia
- Fear, Anger
- Emotional reactivity
- Early trauma
- Muscle tension
- Chronic nerve pain
- Lack of pain awareness
Acute pain is a normal and necessary function of the nervous system. Chronic pain on the other hand reflects a dysfunction of the nervous system. The nervous system might create the experience of pain when there is no offending stimulus. Or it might amplify and extend the pain response to a minor stimulus. Neurofeedback can be helpful in reducing this inappropriate action or reaction of the central nervous system. Neurofeedback generally has a strong impact on pain symptoms. The effects range from fast and complete remediation of symptoms to long-term training to help manage severe chronic pain symptoms.
Right back training is helpful in calming muscle tension and chronic nerve pain. Physical injury might cause muscles to tighten up in order to protect the injured area. Then tightness causes more pain, which causes more tightness, and so on. T4-P4 is usually effective in eliminating sciatica pain. In most cases this is related to a muscle clamping down on the nerve. If there is a more structural cause for the sciatica pain, then we can still be helpful but not completely resolve the pain. Chronic nerve pain (burning, shooting pain) is specifically responsive to T4-P4 training, but other placements and Alpha- Theta training are also useful with chronic pain syndromes. T4-P4 is also helpful for those who lack appropriate pain awareness. This is a problem because acute pain is an alarm signaling lifethreatening injury. Acute pain may be uncomfortable, but it also protects us. Neurofeedback does not increase pain sensitivity in general, but it can help normalize pain sensitivity where that is an issue.
Right front training helps calm emotional reactivity to pain. Chronic pain is an on-going trauma that can lead to fear and anger, hyper-vigilance and emotional reactivity in many people. It is also frequently true that people who develop chronic pain have suffered developmental trauma, resulting in lack of resilience and core self-regulation. Such people then fail to recover from traumas and injuries, leading to chronic dysregulation. This is more reason to train T4-Fp2 and also Alpha-Theta.
Left front training can be helpful in normalizing pain threshold in those who are overly sensitive to aches and pains. This can reduce chronic aching pain in the same way that antidepressants are sometimes helpful.
Left-right training is very effective in stabilizing against headaches and other migraine symptoms. For the sake of neurofeedback, we do not need to distinguish between different types of headaches. Many different stressors can set off a headache, and many different symptoms can arise from a headache event, but with neurofeedback we are targeting the core central nervous system dysregulation. T3-T4 is also effective with other migraine symptoms beyond headache, such as abdominal pain, vertigo, visual distortions, etc. All these symptoms are very responsive to training and highly sensitive to the exact choice of training frequency. Headaches as a component of more severe chronic pain syndromes become more difficult along with the other chronic pain symptoms. Trigeminal neuralgia also responds very well to T3-T4. This is a debilitating pain syndrome involving intense facial pain. Medically it is treated with anticonvulsants. We have had very positive effects recently with T3-T4 infra-low frequency training for arthritis pain – both rheumatoid arthritis and osteoarthritis.
Fibromyalgia involves pain throughout the body, plus other symptoms including mental fog, sleep disturbance and fatigue. People with fibromyalgia have very sensitive nervous systems that are highly responsive to T3-T4 infra-low frequency training. As with other types of chronic pain, there is also reason to train right side and Alpha-Theta.
Appetite and Eating Disorders
- Impulsive and complusive eating
- Hypoglycemia and sugar craving
- Eating for reward or punishment
- Appetite awareness
- Picky eaters
By improving self-regulation, neurofeedback is quite effective in normalizing appetite. Eating is something we all do every day, and we all have complicated relationships to food and eating. Like sleep, appetite and eating are issues that should be tracked from session to session with all clients for clues to optimizing placements and training frequency. Eating disorders and obesity, however, are more than just appetite problems. They reflect addictive behaviors arising from reward seeking behavior. They can usually be impacted by right side training and Alpha-Theta.
Right back training improves appetite awareness, which allows us to know when we are hungry or full, making it easier to eat appropriately. It is amazing how many people decide cognitively what and when and how much to eat, without relevant feedback from the body. Conscious attention and self-control have their limits, so this can be a constant struggle – to remember to eat or to manage how we eat. With T4-P4 training we see quick changes in appetite awareness and eating behavior. This also helps picky eaters, who may lack awareness of their need for food and/or experience extreme sensitivity to food texture. They might also be rigid in their food choices because they cannot tolerate change. All of these issues are impacted by right side training.
Right front training helps eating behaviors driven by a desire for reward or punishment, or an extreme need for control. Starvation or binging and purging are self-injurious behaviors that cause the release of endorphins. And endorphins provide some relief from pain and misery. As one anorexic client explained, "It covers up the pain." Over-exercising is also a frequent component of anorexia. People get caught in a cycle of eating to feel better and then feeling worse about eating, which leads to more eating to feel better. This same cycle applies to food restriction or any other addictive and self-destructive behavior. T4-Fp2 calms the emotional discomfort that drives the behavior. T4-P4 is also important for better body awareness, and AT for resolution of traumatic experiences and triggers that sustain the behavioral cycle.
Left front training helps conscious self-control, which helps impulsive and compulsive eating. This is not the compulsive eating driven by emotional pain, but just feeling a desire to eat when not really hungry. People might eat when bored or restless or to increase energy level. This disinhibited behavior can be helped with left front training. T3-Fp1 for self-control is best combined with T4-P4 for body and appetite awareness. This can help people make better decisions about what and when to eat.
Left-right training is specifically helpful with sugar craving. T3-T4 training stabilizes the physiological response to sugar so that the craving and reactivity subside.
Attachment and Personality Disorders
- (As needed after R-side training)
- Obsessive worry
- Complusive behavior
- Mood instability
- Dissociative symptoms
- Attachment deficits
- Lack of empathy
- Emotional reactivity
- Thrill seeking
- Physical calming
- Body awareness
- Social-emotional awareness
Attachment issues relate to developmental trauma. Any disruption of early development can interfere with learning how to self-regulate and self-soothe. Without this core emotional selfregulation people do not feel safe or comfortable in themselves or in the world, and often they are unable to connect with others empathetically. The trauma might result from the child's own temperament and/or from early life circumstances. The bipolar child, for example, creates his own trauma and attachment problems by being reactive and diffiult to soothe from birth. Traumatic early life circumstances might include neglect or abuse or separation – even for life-saving medical treatment. The right brain is involved in this early development of self-regulation. Even many years after the events, right side training can be very helpful in calming emotional reactivity and allowing meaningful attachments.
From a neurofeedback perspective, we can think of personality disorders as resulting from a combination of temperament and circumstances in early development. Lack of learned core selfregulation can lead to self-protective and reactive, aggressive or paranoid behavior, for which we do right side training. There may also be issues of instability of state and impulse control, for which we might later train T3-T4 and possibly T3-Fp1. For both attachment disorders and personality disorders we expect Alpha-Theta to be an important part of the total neurofeedback program. Once people feel calm and safe enough to let go and drop into a deep state, traumatic experiences can be safely accessed and resolved during Alpha-Theta sessions.
Right back training calms physical agitation and increases awareness of self and others.
Right front training is the key placement for calming emotional reactivity and enhancing empathy in attachment and personality disorders. It reduces aggressive behavior, rages, paranoia and hypervigilance. All these behaviors reflect an attempt to defend ourselves and stay alive in a dangerous world. When we feel safe in ourselves, we are less likely to perceive and react to presumed threats in our environment. This also reduces thrill-seeking behavior – another attempt to achieve some reward by those who lack feelings of positive reward from normal life activities.
Left front training might be useful later in training after sufficient right-side calming. Then T3- Fp1 might help residual executive function deficits including impulsive or compulsive behavior, obsessive worry, planning and organization. Moving to the left side too soon can cause an increase in agitation and aggressive behaviors. For people with bipolar tendencies, left side training might trigger a hypomanic episode. Some people may never tolerate left side training.
Left-right training is often helpful for stabilizing mood swings, panic, migraines, etc. It is also helpful in stabilizing against dissociative episodes, including Dissociative Identity Disorder. Of course the dissociation is a result of severe early trauma, so we generally start with both T3-T4 and right side placements.
- (As needed after R-side training)
- Impulse control
- ADD and OCD symptoms
- Headaches and seizures
- Mood swings
- Attachment deficits
- Emotional meltdowns
- Emotional expression
- Early language
- Balance and coordination
- Sensory integration deficits
Developmental disorders cause disruption of early life experience, which interferes with learning core self-regulation. There are core deficits in the ability to calm physically and emotionally and to manage sensory input. This means that developmental disorders, including Autism and Cerebral Palsy, respond best to right-side infra-low frequency training.
Right back training helps with physical calming – reducing hyperactivity, spasticity and constipation. It also helps awareness of body in space – impacting balance and coordination. Sensory integration benefits as well – the ability to make sense of sensory input and to understand the world and how we interact with it. T4-T6 training can be specifically helpful with reading the intentions of others and improving social awareness.
Right front training calms emotional reactivity – reducing rages, emotional meltdowns and attachment deficits. It also helps emotional expression – the ability and desire to communicate with others regarding feelings, desires and interests. Right front training helps with the acquisition of new skills, including language. T4-F8 is sometimes specifically useful in promoting language development in those with delayed speech acquisition. This should be tried after first using the basic right front placement of T4-Fp2. Frontal training, including T4-F8, can be too activating for some people. So it is better to do prefrontal training first for self-control.
Left front training is sometimes helpful for attention or obsessive-compulsive symptoms. Some people with developmental disorders do well with right-side training and never tolerate or benefit from left-side training. Those with Asperger's, however, often do well with some left front training. This should be after sufficient right side work.
Left-right training is sometimes useful in this population for instabilities including headaches, seizures and mood swings. With most autistic clients we stay on the right side. But autistic people with migraines or seizures can sometimes benefit from T3-T4 training. People with Asperger's sometimes benefit from mood stabilizers and also from T3-T4 training.
Alpha-Theta can be very helpful for adults with developmental disorders since their lives have been marked with challenges and traumas.
Brain Injury and Seizures
- Executive function
- Impulse control
- Short-term memory
- Verbal expression
- Word finding
- Migraine and vertigo, seizures, hallucinations, mood swings, TBI
- Math calculation
- Receptive language deficits
- Emotional control
- Emotional expression
- Balance and coordination
Brain injury is another area where more specific placements might be useful in targeting specific deficits. However we still begin with basic sites for more general effects. Here we are considering the loss of brain functions that developed over a person's life time. For brain injury in utero or soon after birth, it becomes a developmental issue, which then indicates right side training.
For any brain injury we need to ask who the person was before the injury and how function changed with the injury. How would we have trained this person before the trauma? Those issues are still relevant. And what symptoms have now emerged or intensified? The symptoms give us clues about how and where the brain is now dysregulated. We might also get important information from medical reports and brain imaging results. Traumatic brain injury occurs with acceleration or impact of the brain against the skull. TBI often results in injury to prefrontal areas when we travel at high speeds and then collide with windshields and other immovable objects. In addition to local bruising, there are broad disruptions of brain communication and self-regulation, including brainstem dysregulation. T3-T4 is usually a necessary piece for TBI to improve stability of brain function. People with TBI are often highly sensitive to neurofeedback as well as other interventions. And they are often highly sensitive to training frequency optimization. We now know that injured brains need rest to recover. Any effortful activity can interfere with healing. It is sometimes necessary to reduce neurofeedback session length or frequency of sessions to avoid stressing the injured brain.
Stroke may result in more localized brain injury than TBI, so we may be targeting more specific deficits. Even so, we need to start with basic placements and consider who the person was before the stroke. A stroke sufferer might have been a hard-driving person with high blood pressure, whom we would have wanted to train right side. After a left brain stroke that person might lose language and right side physical strength. So we would then have reason to train both right and left sides.
Other brain injuries might result from infection, anoxia, chemical exposure, brain surgery, etc. In such cases there should be medical reports and presenting symptoms to help guide training. Neurofeedback is almost always helpful and worth doing for brain injury. But we don't know in a specific case what is possible and how completely the brain can recover or compensate for the loss of function.
Seizures might be related to brain development problems or to brain injury. In either case, they generally respond best to T3-T4 training. The infra-low training frequency range is especially effective with seizures. As with other instabilities, people with seizures are very responsive to neurofeedback and very sensitive to training frequency adjustments.
Right back training is helpful with the usual symptoms responsive to physical calming. Brain injuries may result in hyperactive behavior, tremor or spasticity. Balance and coordination often respond well to T4-P4 training, which improves awareness of body in space. Occasionally balance responds better to T4-O2 training when the problem is visual field deficits.
Right front training is helpful with emotional control – reducing emotional reactivity and meltdowns. It can also enhance emotional expression – tone and gesture in speaking and the ability to connect with others. Prefrontal training is generally an important part of our work with brain injuries. Of course this is important for injuries related to the brain colliding with the front of the skull. It is also important for more diffuse brain injury which still compromises prefrontal function. The prefrontal cortex has the task of managing and coordinating overall brain function. Dysfunction of any part of the brain increases the burden on the prefrontal cortex, and prefrontal training can help the brain compensate for its dysfunction.
Left front training is helpful with executive function. This helps self-control which is often a significant issue in brain injury. Left prefrontal training helps people wait, consider and decide before acting – instead of impulsively reacting. This allows more mature behavior. Left-front training also helps verbal expression and word-finding. T3-F7 training targets Broca's area, impacting word-finding and articulation.
Left back training helps recovery of acquired knowledge and skills that are lost or impaired after brain injury. This means understanding written and spoken language, mathematical calculation and execution of skilled movements. T3-P3 is specifically helpful with calculation and with reading deficits related to visual distortions or over-sensitivity to light when reading. T3-T5 can help reading by improving the ability to decode letters and words.
Left-right training is helpful with instabilities, which are a common consequence of brain injury. These might include headaches, vertigo, mood swings, hallucinations or seizures. Infra-low frequency neurofeedback is highly effective in targeting neuronal excitability and instabilities. T3-T4 serves as our generic anticonvulsant. When the seizure focus is on the primary somatosensory or motor strip resulting in motor seizures, it can be useful to target the specific body area according to the sensori-motor homunculus.
Alpha-Theta is sometimes useful in helping people recover from the trauma and loss associated with brain injury. It is important to do sufficient stabilizing first so as to avoid precipitating symptoms of instability.
- Mental calming
- Impulse control
- Planning and organization
- OCD symptoms
- Physiological and emotional stability
- Fine motor skills
- Reading and calculation skills
- Emotional reactivity
- Aggressive or controlling behavior
- Physical calming
- Body and spatial awareness
Peak performance neurofeedback clients are those who seek to enhance their performance in areas where they are already skilled, rather than seeking relief from symptoms. These are high achievers, focused and driven. They push themselves and often push others out of the way. They actually have just as many issues as our other clients, but they tend to identify with their skills rather than their deficits. In our assessment we need to consider all symptoms, but it is useful to focus the conversation on performance and what might be interfering with success. Peak performers do not want to relax and slow down. They value their drive and speed. Our goal is to calm them down rather than slow them down. This allows faster and more efficient performance – as in martial arts. The QIK CPT test is very useful with this population to document improvements in performance.
Right back training helps with physical calming and body and spatial awareness. This is helpful in any type of physical performance. Peak performers often push themselves too hard, which can be counter-productive. Better body awareness allows people to know when to rest and recover, building up rather than tearing down the body.
Right front training calms emotional reactivity. Impatience, anger and frustration lead to inconsistent performance. Driven and competitive performers can drive away others who might offer cooperation and support. They might be aggressive and controlling, which is counterproductive and unhealthy for all involved.
Left front training promotes calm mental focus, good executive function and self-control. Good organization and follow-through allows the peak performer to stay focused and complete tasks.
Left back training helps with the timing and control of fine motor skills which might be helpful in sports performance. It also supports peak mental skills with enhanced sensory processing.
Left-right training reduces instabilities of state that disrupt performance. These might include mood swings, headaches, panic attacks, irritable bowel syndrome, etc.
Alpha-Theta training is also useful with peak performers. After improving physiological selfregulation with infra-low frequency training, it is usually helpful to include Alpha-Theta training for resolution of traumatic experiences that can undermine self-confidence and optimal performance. Synchrony training can also help the peak performer maintain a calm focus under pressure.
- Stimulants for attention or impulse control
- Muscle relaxants
- Stimulants for hyperactivity
We have been considering what symptoms tell us about how the brain is dysregulated and how and where we might best train to improve function. Looking at what substances and behaviors people use to improve how they feel and how they function also gives us useful information in deciding what to do. For any substance use or behavior we want to know what problem the client is trying to solve and how this is helpful. If we know what a client has learned to do to manage his physiology, we will know something about what we need to do with neurofeedback training.
Sometimes substances or behaviors are used to support good function – allowing the person to get up, go to work, maintain focus, etc. Exactly which substances help and how give us clues about possibly effective electrode placements. People also use substances or behaviors to turn on their reward system – to feel alive, excited, powerful, etc. These reward experiences are highly addictive, as the withdrawal of the reward leads to craving for more reward. People use substances for relief of pain and misery, which is also highly addictive. Any kind of addictive behavior suggests that we train primarily right side and Alpha-Theta.
Right back training is appropriate when people benefit from substances that relax the body. This includes antihypertensives, muscle relaxants, and sedatives including alcohol. These substances might be used for physical calming that allows good function. Sedatives might also be used as an escape from physical pain and tension leading to addiction. T4-P4 should be helpful in either case. Stimulants have a dual action of focusing the mind and also calming the body. When people with ADHD respond well to stimulants, we expect to train both T4-P4 for physical calming and also T3-Fp1 for mental focus and impulse control.
Right front training is our neurofeedback analog of antipsychotic medications. T4-Fp2 calms emotional reactivity and aggressive behavior. It is also important with addictions. Opiates or sedatives may be used for pain relief or pleasure, which may then become addictive. T4-Fp2 training helps people feel emotionally calm and safe in themselves and reduces the drive for relief.
Left front training might have a good effect for those who benefit from stimulant medications. Both T3-Fp1 and T3-F3 can have effects similar to antidepressant medications.
Left-right training is suggested by the effectiveness of anticonvulsant medications. T3-T4 is our usual stabilizing placement. Marijuana also has a stabilizing effect and is often the drug of choice for people with bipolar mood swings. Alcohol calms anxiety, but bipolar people might feel too sedated with alcohol, and therefore prefer marijuana. If marijuana is helpful, that is reason to try T3-T4 training.
With neurofeedback training the brain achieves greater self-regulation, and we expect the need for medications and other substances to decrease. The use of cigarettes or marijuana, for example, might just fall away as improved self-regulation reduces the need. Sometimes side effects of medication increase as a previously effective dose becomes more than is needed or tolerated. With prescribed medications it is important that symptoms and dosage be monitored and adjusted as needed by the prescribing physician during training.
Summary: Basic Functions
- Conscious goal-directed behavior and self-control
- Physiological self-regulation
- Emotional stability
- Detail sensory awareness
- Analytical sensory processing
- Emotional security
- Emotional self-control
- Spatial and body awareness
- Sensory integration
These are our basic categories for electrode placement with infra-low frequency training. Whatever the symptom category, we need to sort symptoms according to these simple categories. It is useful to consider again the basic brain functions related to these brain areas.
The back of the brain is receiving and processing sensory input, which allows us to make sense of our environment and how our body moves through that environment. The front of the brain is constructing and executing output, which allows us to act in the world to stay safe and to accomplish our goals. Our prefrontal cortex also manages self-control, inhibiting habitual reactions so that we have time to consider and decide how to act.
The right brain keeps us oriented to our environment in the present, keeps us aware of threats and opportunities, and keeps us safe and alive. The left brain lets us find what we are looking for and execute behaviors we have planned.
Combining front/back and left/right brain function:
- Right back – body and spatial sensory awareness and processing
- Left back – detail and analytical sensory awareness and processing
- Right front – exploring new environments and trying new behaviors while maintaining emotional self-control
- Left front – executing planned and well-learned behaviors, while maintaining conscious self-control
Temporal lobe left-right placement accesses limbic function – self-regulation of physiological functions plus drives and emotions to maintain internal balance and health.
1 Channel Training
- 1 channel Infra-low Frequency HD
- Neurofeedback Process
- Starting Placement and Training Frequency
- Adding Basic Sites
- Training Frequencies for Basic Sites
- Basic Site Sequences
- Adding Other Sites
- Training Frequencies for Other Sites
- Training Frequencies for Inter-hemispheric Sites
- Training Multiple Sites
- Adding Alpha-Theta Training
1 Channel Neurofeedback
- Implementing the treatment plan
- The neurofeedback process
- Beginning with ILF HD
- Starting placement and training frequency
- Adding basic sites
- Adding other sites
- Adding Alpha-Theta
Neurofeedback assessment leads us to an understanding of how our client's brain does and does not function well. We consider symptoms, test results and other information to identify modes of dysregulation that relate to our specific training options. We develop an overall treatment plan, which includes how and where we expect to train over time – right side, left side, front, back, Alpha-Theta.
Then we begin the training process and gradually and systematically implement our training plan. Every step of the way, we are open to modifying our plan and our understanding of the client based on the response to each change in training frequency or addition of training site. We do not start right away with all sites that are expected to be useful. We need to start with one site, optimize the training frequency at that starting site, and see exactly what effects are achieved with training at that site. We might need to shift starting site if the results are not positive. We then add other sites, one at a time, as needed and as tolerated. This is the heart of the clinical process. What are we doing, and what else do we need to do? Our understanding of the client, our model of their functioning and understanding of how we need to train, changes and grows as we progress with training.
In this section we will discuss the neurofeedback process beginning with 1 channel infra-low frequency training. We will discuss factors in selecting a starting site and finding an optimal training frequency. Then we will look at the process of adding basic sites, other sites when necessary and finally AlphaTheta when appropriate.
1 Channel Infra-low Frequency HD
- Bipolar placements
- EEG and spectral display
- EEG history graphs
- Physiological monitoring
A neurofeedback program begins with infra-low frequency training to achieve physiological selfregulation. The 1 channel ILF HD application in Cygnet is optimized for signal processing and feedback presentation in the infra-low frequency range.
1 channel bipolar placements for ILF training involve both plus and minus (signal and reference) electrodes recording EEG activity at the scalp. The difference signal (signal minus reference, or equivalently reference minus signal) is displayed as 1 channel EEG and spectral. This is the EEG signal from which the feedback to the client is derived. What is generally called the ground electrode does not contribute directly to the training signal and can be placed anywhere on the head. In fact, for safety reasons the client is always isolated from actual system ground. Bipolar placement is distinguished from referential placement, in which the difference signal is derived primarily from one electrode on the scalp with reference to a quasi-neutral site such as the ear.
EEG history graphs show average amplitudes within different frequency bands over the course of a session. These graphs might indicate some changes over time in muscle tension, closed eyes, sleep or movement. But caution should be used in interpretation of these signals that are highly corrupted by artifacts as people blink, speak, and move during the session.
Other physiological measures are now available as additional information to the clinician. Heart rate, skin conductance, and hand temperature can be measured with a combination sensor on the finger. EMG (muscle tension) is also measured as high frequency activity from the EEG sensors.
1 Channel Bipolar Placements
1 channel bipolar placements involve three electrodes – plus, minus and ground. The placements are labelled as the plus and minus electrode sites, for example T3-T4. For 1 channel training it does not matter which site is plus or minus. T3-T4, for example, is equivalent to T4-T3. The ground electrode can go anywhere on the head and does not contribute directly to the difference signal. All three electrodes must always be attached, however, since the ground serves as common reference for the plus and minus electrodes.
Bipolar placements can involve both plus and minus electrodes on the same side of the brain, for example T4-P4. Or plus and minus electrodes can be on opposite hemispheres, for example T3-T4.
1 Channel Bipolar Placements
With the Neuroamp EEG amplifier, 1 channel bipolar placements require that electrodes be connected to channel 1 plus and minus inputs, and the common ground. Electrodes plugged into channel 2 inputs will not be seen by a 1 channel application.
For infra-low frequency training we use silver/silver chloride electrodes, which give us a more stable signal in the infra-low frequency range. The brain is amazingly good at separating signal from noise, but we want to give it the best information that we can. Some care is required in handling these electrodes, since they will be damaged by exposure to any substances other than distilled water and electrode paste. They should be cleaned with distilled water to remove residual paste before they are allowed to dry.
1 Channel ILF HD
The 1 channel ILF HD display shows a 10-second sweep of the EEG signal, which is the difference signal between the channel 1 plus and minus electrodes. This includes activity in the conventional EEG frequency range from delta to high beta. Infra-low frequency activity is filtered out for this display to maintain a stable baseline.
The spectral display shows the distribution of amplitudes across the same frequency range. The current values are displayed in front, which then scroll to the back over 10 seconds until they disappear. When we see some transient or rhythmic activity in the EEG trace, we can look at the spectral and see that activity represented in terms of frequency. Infra-low frequency activity is also filtered out for the spectral display. Artifacts and infra-low frequency EEG would dominate the spectral display if they were not attenuated.
Training signal and inhibit bars show the feedback information that is represented in the games for the client. The infra-low frequency training signal is selected by moving the slider along the infralow frequency range of 0.001 to 10 millihertz. The most recent update of Cygnet has expanded the lower training frequency limit from 0.01 to 0.001 millihertz. The inhibit bar shows the combined activity of multiple inhibit bands across the usual range from delta to high beta.
EEG History Graphs
History graphs show the amplitudes of the conventional EEG frequency bands over the whole session. These trend lines are highly smoothed, so they do not show the rapid changes that are represented in the feedback display. They can show gradual trends over the session. They also show a considerable amount of artifact, reflecting movements during session, particularly in the delta band.
- COMBINATION SENSOR
- EMG (muscle tension)
- HR (heart rate and heart rate variability)
- GSR (galvanic skin response)
- T (hand temperature)
- SI (stress index)
A new combination sensor for Cygnet allows monitoring of additional physiological variables during the session. The time scale can be adjusted to show changes over a shorter or longer time frame. This physiological monitoring option is available with all Cygnet applications including ILF HD, Alpha-Theta and Synchrony. For the clinician these measures provide more information about the physiological state and stress level of the client during a neurofeedback session. We expect this to be useful in detecting otherwise unreported state shifts.
Muscle tension (EMG) is derived from a high frequency range measured by the EEG electrodes. This is well above the normal EEG range, although some EMG activity can also be seen in the higher frequency end of the EEG spectral display. Since the EEG electrodes are on the head, the EMG measurement will relate primarily to muscle tension in the jaw, neck or face.
Heart rate tracks the average heart rate which might increase with sympathetic arousal. We also expect to see normal fluctuations in heart rate with the breath. When people are quiet and still, we expect to see a rhythmic variation in heart rate, increasing while breathing in and decreasing while breathing out. The lack of a normal heart rate variability is a sign of physiological dysregulation.
Galvanic skin response (GSR) is a measure of the ease of electrical conduction through the skin. Skin conductance relates to sweat gland activity, which increases with sympathetic arousal. GSR increases rapidly in response to emotional triggers, and then settles gradually with relaxation.
Hand temperature is related to peripheral blood flow. In stressful situations blood flow is usually decreased in the extremities and increased in the vital organs and major muscles of the body. This is useful in reacting to danger in a fight or flight situation. When people feel calmer and less stressed, their hands and feet are often warmer.
Stress index is an indicator of changing stress levels throughout the session. It is largely based on heart rate variables.
- Neurofeedback display is a mirror
- Brain gains more information about its own activity
- Allows better self-regulation and better function
- Not fixing brain waves
Our understanding of neurofeedback has evolved significantly over the past 30 years of clinical experience and instrument development. We all believed initially that we were doing operant conditioning on brain waves. If we rewarded the brain for making better brain waves, we would get better brain waves and better brain function. That model however fails to explain the effects we now see, particularly with infra-low frequency training.
We now understand neurofeedback as a process of allowing the brain to see its own activity and self-correct. Increasing awareness of one's internal state allows improved self-regulation and better function. This is somewhat similar to the practice of mindfulness while focusing on the breath. We don't need to reward the brain for doing it "right." And we don't need to fix the brain waves. We let the brain see what it is doing in the moment, which allows it to let go of dysfunction and function more optimally. Neurofeedback is not treating symptoms or curing disease. It is simply promoting healthy self-regulation and good brain function.
- Detect and inhibit rapid increases in amplitude in
delta to high beta range
- Brief events
- Alerting brain to dysfunction
- With multiple bands covering range
- Inhibits disrupt or limit feedback display
Our EEG feedback has two components – a selected infra-low frequency training band and the standard multiple inhibit bands. The inhibits show the brain when it has gone off track. The multiple inhibits respond to rapid increases in amplitude at any frequency from delta to high beta. All the individual inhibit bands are combined into an overall inhibit amplitude that influences the feedback game display. The effect of the inhibit is to disrupt or limit the game display in some way. A black fog, for example, enters the tunnel in Inner Tube, or the picture whites out in Advanced Media Player. These are usually brief and mild disruptions that inform the brain without punishing it.
Artifacts can also trigger inhibits. Cygnet automatically removes most artifacts in real time, but some may slip by and trigger the inhibits. This is not a significant problem since our brains are good at separating signal from noise. And our brains certainly know when we are blinking or moving.
Inhibits - Automatic
Individual inhibit bands contributing to the combined inhibit bar are usually hidden, but can be displayed when selected from the measurement menu. Inhibit frequency bands and thresholds are all set automatically. It is possible, but not usually necessary, to change the overall strength of the inhibits with a slider on the inhibit window.
Sudden increases in amplitude at any frequency are seen in the movement of the corresponding inhibit bar. The movement of all of the inhibit bars in relationship to their individual thresholds are combined into one overall inhibit bar. The height of the combined inhibit bar then controls the inhibit function in the game.
- Reflects changes in signal level within one specific
infra-low frequency band
- Shows ebb and flow of a normal EEG rhythm
- Not good or bad
- Reward drives feedback display – size or speed
Training frequency selection is an important part of clinical decision making in infra-low frequency bipolar training. The brain is surprisingly responsive to the specific choice of training frequency. It is necessary to carefully adjust training frequency for best effect with each brain.
The gradual ebb and flow of the signal level in the selected frequency band is reflected in the speed or size of the feedback display. There is nothing inherently good or bad about an increasing or decreasing signal level. It is simply information to the brain, not a judgment. In the infra-low frequency range, these changes can be extremely slow.
This is the frequency we select to show back to the brain through its impact on the feedback display. We want to make the brain aware of this signal. We are not asking the brain to make it bigger, but simply to witness its slowly changing level.
Training Frequency - Selected for Individual
The ILF HD application in Cygnet shows the training signal level as the height of the yellow bar in the signal window. The range (or height of the window containing the training frequency bar) is adjusted automatically to optimize feedback to the brain. We expect to see the training bar change very slowly when we are working in this infra-low frequency range. The training frequency signal level controls the speed or size of the feedback display, so we also expect the feedback related to the training signal to change very slowly in session.
The training frequency is selected by adjusting the slider across the infra-low frequency range. This is a logarithmic scale from 0.001 mHz to 10 mHz. One millihertz (mHz) is one thousandth of a Hertz, or one cycle per 1000 seconds.
EEG Signal Level and Amplitude
What exactly do we mean by signal level and amplitude? And how do they control feedback in different frequency ranges?
At higher frequencies we track the overall amplitude of the wave form as seen here for 10 Hz activity. The signal completes 10 cycles each second, which would be much too fast for direct feedback. The amplitude, however, rises and falls more slowly, providing a more comfortable feedback display.
With infra-low frequencies we track the raw signal level, not the amplitude. We are not interested in the overall height of the wave (the amplitude), which we might not even know within the duration of one session. Instead we are interested in where we are on the wave in the moment (the magnitude of the actual signal at that moment). This is something like attending to your own breath. Your brain tracks the rhythm as you breathe in and breathe out, not just the overall volume of the breath. Similarly in our case of infra-low frequency training, the self-regulating brain is only interested in its behavior in the present moment. At 0.1 Hz (or 100 mHz), one full cycle takes 10 seconds. With our usual infra-low training frequencies, we are far below 0.1 Hz, which gives us a very slowly changing signal level. We find that this is actually more direct and more useful information for the brain, which gives us stronger training effects than at higher training frequencies.
An increasing training signal translates into more speed with the car, train, rocket or jet ski. That might be more fun, but it does not mean one is doing anything better. We are just tracking the rising and falling wave form. Just like breathing in and breathing out are equally useful, one is not better than the other. Here the information is in the dynamics of the signal as it goes up and down, not how far it ultimately goes.
Adjusting the Training Frequency
- What shift in brain state is comfortable?
- What training frequency improves outcome?
- Short-term and long-term effects
- Surprisingly specific to the individual
Training frequency effects are surprisingly specific. There can be a huge change in training effect with one small step in training frequency. As we adjust training frequency we need to track both short-term and long-term effects. Short-term effects reflect state shifts in session which might last a few hours to days. Of course, we are most interested in the long-term effects – the improved regulation of state that becomes permanent. We find that good effects in session are usually a good indicator of good long-term outcome. Whatever keeps people in a comfortable state in session is likely to produce the best outcome over multiple sessions.
As we work with an individual client, we learn what symptoms shift with a higher or lower training frequency. During a sequence of sessions, we adjust electrode placements and training frequency as needed for optimum effect.
- State changes during session
- Observation and client report
- EEG and physiological measures
With infra-low frequency feedback most people are able to notice and report state shifts in session. This might be a change in physical relaxation, alertness, emotional state, head or body pain, heart rate, etc. The general rule is that shifting to a higher training frequency invites the brain to shift to a state of higher physiological arousal. Similarly shifting down in training frequency leads to a lower state of physiological arousal. We are looking for the optimal training frequency which results in a state of relaxed alertness. Often we can observe changes in body posture, breathing, speech, etc. for clues as to how the person is feeling. Or we might see changes in our physiological measures, although we cannot rely on measurements entirely to guide our selection of the optimal training frequency. The person's experience is the most useful information in guiding the choice of optimal training frequency.
- Learned ability to shift state
- Learned ability to maintain state
- Increased stability and flexibility of state
- Enhanced self-regulation
- Better function from the brain you have
Short-term state shifts within a session help guide us to a comfortable training frequency that is not too agitating or too sedating. But shifting to a new brain state is not the goal of neurofeedback. The exercise of shifting state repeatedly over a number of sessions leads to improved flexibility and stability of state. We are working toward improved self-regulation of brain function. A calmer and more stable brain is then capable of better function.
Starting Placement and Training Frequency
- Starting site T4-P4 or T3-T4 or both
- Adjust training frequency as needed during session
- Core sites – calming and stabilizing
The first decision is whether to start with right side training (T4-P4 for calming), left-right (T3-T4 for stabilizing), or a combination of the two. We plan to stay with the starting placement long enough to optimize the training frequency and to see what symptoms it is and is not impacting. We would like to see how the effects develop over a few sessions, not just the effect within the first session. Then we gradually add more placements as needed. If we can see where the current placements are taking us, we have a clearer idea of what else is needed.
After carefully selecting the best starting placement, or placements, it still might become necessary to change starting placements within the first session or the first few sessions. Our understanding of the client changes and grows as we observe the specific effects of training. Sometimes we have to revise our approach as we go.
Starting with T4-P4
- Developmental trauma or attachment issues
- Chronic disorders
- Lack of resilience
- Priority is calming
How do we decide whether to start training right side or left-right? Developmental trauma is the key issue in deciding whether right brain calming needs to come first before any left brain training. During early development our nervous system is learning physiological and emotional selfregulation. If that step is missed due to the child's own temperament or due to external circumstances, we then have a nervous system that lacks resilience. A healthy nervous system recovers over time from the injuries, losses and traumas of life. People who lack resilience often develop chronic symptoms of dysregulation. People with chronic pain, chronic mood disorders, chronic insomnia, chronic addictions, etc. generally respond best to T4-P4 as a starting placement for physical calming. If we train the left hemisphere without sufficient right-brain calming, the consequence is increased agitation. Even when there is no report of developmental trauma, we should consider chronic dysregulation as indication of lack of resilience and a good reason to start training right side.
Starting with T3-T4
- Balance of left and right side effects
- Priority is stability and L/R balance
Why would we not start everyone with right side training for physical calming? We certainly expect T4-P4 to be a useful component of training for most people. But for some people we need to think first in terms of left/right balance. If we train right side without also training left, we can get some nervous systems unbalanced. Too much calming without inter-hemispheric stabilization or left-brain activation can leave some people too sedated or destabilized. Starting with T3-T4 includes both hemispheres, which includes needed stabilization and/or activation.
The choice of starting placement is fundamental for the whole training process. It is important to get this choice right for each individual. Sometimes that might take a few sessions to completely sort out.
Starting with both T4-P4 and T3-T4
- Strong indications to start right side
- Developmental trauma, addiction, etc.
- And significant instabilities
- Mood swings, seizures, panic, dissociation, etc.
There are people who have strong reasons to start right side (T4-P4), and also strong reasons to start with left-right (T3-T4). Sometimes we need both placements within the first session or first few sessions. The issue is not just how to get the best positive effect, but also how to avoid a negative effect. We want to avoid increased agitation in people with early trauma, so we want to stay on the right side. But we also want to avoid precipitating significant instabilities such as seizures, migraines, panic or dissociation, which might happen if we do not include T3-T4.
This comes down to clinical judgment in deciding which placement to start with. At which site do we want to start finding the optimal training frequency in the first session? We might start with T4-P4 in the first session with someone with a trauma history and panic attacks. We would be adjusting the training frequency at T4-P4 for optimal calming. Then we might take that optimal training frequency to T3-T4 within the first session or the first few sessions to see how the person responds. If the effect is positive and calming, then we can continue with both starting sites. If the effect is too activating, we back off to T4- P4 alone. Some brains do best with right side training even when symptoms of instability suggest otherwise.
There are times when we might start T3-T4 with a person who has seizures and also a developmental disorder. If we can find a good training frequency at T3-T4, then we might try adding T4-P4 in early sessions. If that is destabilizing rather than calming, we can safely go back to T3-T4 alone.
Adjusted Training Frequency in First Session
- Adjust training frequency in first session for best effect
- Decrease training frequency for more calming
- Increase training frequency for more activation
- Move frequency every 2-3 minutes to optimize effect
We expect to impact brain state within the first few minutes of training, although people differ in terms of their self-awareness and ability to report changes. We need to inquire about changes and give some guidance in what to look for. It is useful to ask about changes in body relaxation and mental alertness. Always give options - more, less or just the same. All options are equally valid and useful. It is important to encourage feedback without suggesting a desired response. We should also observe clients for changes in physical tension or activity, alertness, mood, facial expression, tone of voice, posture, etc. Basically we are working toward physical relaxation and mental alertness.
After selecting an appropriate starting frequency, start moving the frequency down every two or three minutes to explore the range down to 0.01 mHz. If the person shows signs of low arousal like uncomfortable sedation, nausea or inexplicable sadness in session, then move back up gradually as far as necessary for good effect. If the person feels agitated or feels no effect, keep moving down to 0.01 mHz and stay there for the rest of the first session. There is nothing better or worse about training higher or lower. Our job clinically is to find what works best for the individual.
Very few people train higher than 0.5 mHz, so that is a reasonable starting frequency for people with no obvious need for a strong calming effect. Moving down through the range 0.5 to 0.01 mHz gives the brain an opportunity to judge the difference in effect with each step down. This might include people with instabilities like migraines and seizures.
Clients with high arousal symptoms such as anxiety and insomnia are expected to optimize in a lower frequency range. Starting with 0.1 mHz and working down from there should reach a comfortable training frequency more quickly.
People with extreme arousal symptoms such as those associated with developmental and attachment disorders are expected to train with a very low training frequency. We want to avoid increasing agitation with these clients and we may not get good feedback during the session. For all those reasons, it makes sense to start at 0.01 mHz and stay there for the full first session, unless there is good reason to change.
Adjusting Starting Placements
- If unable to find a comfortable training frequency at first site:
- Move to T4-P4 for more calming effect
- Move to T3-T4 for more stabilizing effect
- Move to T3-T4 for left/right balance
- Sometimes both T3-T4 and T4-P4 needed as starting sites
We try to make a good choice regarding starting placement – T4-P4 or T3-T4, but sometimes it is not the right choice. How do we know when to change starting placement, or add a second placement as we start training?
We might find T3-T4 too activating at any training frequency in the first session or first few sessions. That is usually an indication that we need to move to right side training (T4-P4). Left side training, even T3-T4, can be too activating for some people. Then we move to right side training with T4-P4.
Starting with T4-P4 might set off symptoms of instability, typically headaches, nausea or dizziness. We should try adjusting the training frequency first. If that is not effective, then move to T3-T4 and try optimizing the training frequency there. Some brains need stabilizing first before tolerating right side training.
Starting with T4-P4 also might set off symptoms of disinhibition. Disinhibition means loss of selfcontrol. This might look like immature, impulsive behavior. Or it might involve loss of emotional control. Training right back (T4-P4) is very calming, which can be a problem for some people when it is not balanced with prefrontal training for control. So there is a left/right issue and also a front/back issue. When the response is more like ADHD immaturity and impulsivity, we can move to T3-T4 as a stepping stone toward T3-Fp1. Training both sides with T3-T4 is usually enough of a left side effect to eliminate the disinhibition. When the response is loss of emotional control, we might need to add T4-Fp2 to reduce emotional reactivity.
Some people need both starting sites, T4-P4 and T3-T4 right away. In that case we continue to divide each session into two parts. Both starting sites should optimize at the same training frequency, so any adjustment of the training frequency at one site should also be applied at the other site.
Refining Starting Placement and Training Frequency
- Allow time to optimize starting placement
- Allow time to optimize training frequency
- Observe what symptoms are changing
- Observe what symptoms are not changing
- When do we need another site?
In the first session we plan to explore training frequencies down to 0.01 mHz. If more calming is still needed in later sessions, we can gradually and carefully explore the range from 0.01 down to 0.001 mHz. It is best to move down through this lower range very gradually and carefully. We want to see the effect of each move, before shifting lower. That may mean one step down per session, such as 0.01 to 0.009 mHz.
It is usually helpful to stay with the starting placement or placements for a few sessions. This will be the foundation of everything else we do, so we want to get it right. We want to see what effects it does and does not produce. We may be tempted to add other sites quickly, but that can confuse and complicate the process of figuring out what works best.
Throughout infra-low frequency training our decisions will be which training sites with what training frequencies. The key is to know what specific effects relate to training at each site and what it looks like when we are too high or too low with the training frequency. Our first step in the process is the starting site and training frequency. All along the way we will optimize sites and training frequency based on training effects in session and also changes from session to session.
Adding Basic Sites
- Add new site when needed to address more symptoms
- Keep only if helpful
- And if tolerated - no negative effects
- Start with basic sites
We continue to monitor and adjust the training frequency throughout training, but our focus shifts in time to selection of effective training sites. After some sessions to establish the most effective starting site and training frequency, we are ready to add more training sites to target specific symptoms that are not responding to the starting site or sites alone. The effect of training each new site should be observable against the baseline of starting site training effects.
If adding a new site has a good effect, then we keep it in the mix for as long as we continue infralow frequency training. If the new site makes things worse, it could be a training frequency issue, and adjustment of the training frequency might yield a better effect. More typically a bad effect means that we should not train that site – at least not yet. If we expect a site to be useful and it is not, then we might need to rethink our understanding of the dysregulation involved. Sometimes a new site is not tolerated, but then later it is useful. This is common with PTSD, for example, where we need to start with right side training only. Once the right brain calms sufficiently, we can often add in left side sites that were not tolerated earlier in training.
We always start by gradually adding some combination of the basic sites discussed earlier in the assessment section.
Multimodal Association Areas
- P3 & P4
- T3 & T4
- Fp1 & Fp2
Our basic sites include temporal (T3 and T4), parietal (P3 and P4) and prefrontal (Fp1 and Fp2) areas. These are the areas involved in the highest level of input and output functioning of the central nervous system. The basic sites give us the broadest effects in developing and maintaining good high level brain function for most people. Most of our clients complete infra-low frequency neurofeedback training with some subset of these basic sites.
After exploring the effects of training at these basic sites, we sometimes need to add other more specific sites. Starting with the basic sites, many specific symptoms are impacted. That then clarifies what still remains to be done and simplifies the decision of what to do next.
Training Frequencies for Basic Sites
- All right side sites same training frequency
- T3-T4 same as right-side
- All left side sites training frequency 2 x right side
Finding the best training frequency at the starting site helps us predict the optimal training frequency at other training sites to be added. There is a strong expectation that the training frequency at other sites will follow some simple rules. Of course we should always do what is comfortable and effective for the client, but we expect that things will sort out in time according to these rules. The rules have emerged from our clinical experience and are quite robust.
First, all right-side bipolar sites should train with the same training frequency, which should be the same as for T3-T4. This includes both starting site options, T4-P4 and T3-T4.
All left side bipolar sites should train with the same training frequency, which is higher than the optimal right side training frequency. The simple rule about left and right side training frequencies is that the left side training frequency is expected to be two times the right. So a right side training frequency of 0.25 mHz, for example, translates to a left side training frequency of 0.5 mHz. This doubling only applies to the infra-low frequency range.
Basic Site Sequences
- When starting with T4-P4 (Right side calming)
- When starting with T3-T4 (Stability and left/right balance)
- When starting with both T4-P4 and T3-T4
From the assessment process, we have an overall plan of what sites should be helpful for that individual. We begin training by focusing on the best starting site or sites and finding the optimal training frequency. Some symptoms begin to resolve, which makes it easier to see what symptoms are not yet improving. This helps us decide what to target next with the addition of new training sites. While we want to be responsive to the client's comfort in session and desire for further symptom relief, it is important to be systematic in adding new sites. It is best to add one new site at a time and judge the specific effects of that change, so that we can decide whether to keep or discard the new site. The overall goal is to know exactly which site is producing what effect. Then we can most efficiently combine sites into an overall infra-low training program.
There are common sequences of sites that develop for the majority of clients during training. We will discuss these basic site sequences for those who start right side only (T4-P4), those who start with a left-right balance (T3-T4), and those who start with both.
Basic Site Sequences
Starting With T4-P4
- Developmental sequence
- Right - back to front, then left - front to back
- As needed and as tolerated
For people who need to start with right side calming, we think in terms of adding placements in a developmental sequence. T4-P4 is the core placement for physical calming and sensory integration. Some people need to stay at T4-P4 for a while before they can tolerate the next step, which is T4-Fp2 for core emotional regulation. Sometimes we need to add T4-Fp2 more quickly to address rages and aggressive behavior that are not reduced with T4-P4 alone.
T3-T4 is sometimes needed to address instabilities such as migraines or seizures. If the brain is not ready for T3-T4 it will result in increased agitation. Some people with developmental trauma need to stay with strictly right side training for some long while.
We have experience with people who train for an extended period of time beginning on the right side, who then move on to benefit from left side training. We see this often with PTSD where we need to start right side to avoid agitation. After some reasonable number of sessions there is often benefit from left side training as well. And we have seen some autistic children move over time from intolerance of left side training to tolerance and significant gains.
Left side training can be approached cautiously by first adding T3-T4, which gives some left side training effect. T3-Fp1 should be the first full left side placement. It is generally more easily tolerated than other left side sites including T3-P3.
Basic Site Sequences
Starting With T3-T4
- Add sites as needed
- Maintaining left/right balance
For those who start training with T3-T4 for stability and left/right balance, we need to maintain that balance as we add new training sites. Some people with serious symptoms of instability need to stay with T3-T4 alone for some while. Any addition of left or right side placements to address other symptoms may interfere with control of their instability symptoms.
T4-P4 is usually the first right side site to be added to T3-T4, and T3-Fp1 is the usual first left side site. In adding one or both of these training sites, we need to make sure that we keep the brain balanced. Both left and right side sites can be added in the same session when necessary. If the addition of one site in a session causes some negative symptoms, it is important to understand the cause and the possible solution. When a person does not tolerate the addition of T4-P4 alone, that might actually be a problem of adding right side training without the balance of left side.
If left and right side placements are tolerated and helpful, then other left and right side basic sites can be added as needed.
Basic Site Sequences
Starting With Both T4-P4 and T3-T4
- Right to left developmental sequence
- Maintaining T3-T4 for stability
Those who need both starting sites for sufficient calming and stabilizing may need to continue with T4-P4 and T3-T4 for some sessions. When they are ready for the addition of other basic sites to address additional symptoms, we expect to follow the same developmental sequence as for those who start with T4-P4. But T3-T4 will stay in the mix to maintain stability throughout.
We see people with bipolar disorder as needing both right side calming and stabilizing. It is important to remember that they generally do not tolerate left side training, since it can move them toward mania.
Adding Other Sites
- In addition to basic (multimodal association area) sites
- As needed for more specific symptoms
- More often with brain injury or specific learning disabilities
We always train basic sites first and see how far that goes in resolving symptoms for each individual. For the majority of clients, the general effects of these high level sites give us what we need for a satisfactory training outcome. But sometimes there are specific symptoms that are not sufficiently addressed with basic site training. There are other less frequently used sites that can be helpful in these specific situations. This is more common with brain injuries or specific learning disabilities.
Less Frequently Used
Other sites include frontal (F3, F7, F4, F8), central (C3, C4), posterior temporal (T5, T6) and occipital (O1, O2).
Other right side sites can be useful with autism and other developmental disorders. This includes T4-F8 for acquisition of language and emotional expression, and T4-T6 for the ability to read the facial expressions and body language of others. T4-O2 is sometimes an emotionally calming placement for those with trauma or developmental disorders. Occipital placements might also be helpful with visual deficits related to TBI or premature birth.
Other left side sites can be useful with brain injury or processing deficits. T3-F7 can be helpful for word finding and improved verbal articulation. T3-T5 can be helpful with decoding words when reading. T3-F3 can have a strong antidepressant and energizing effect.
Frontal Sites for:
- Orientation to sensory input
- Initiation and sequencing of movement
- Speech & emotional expression
- Activating effect
Frontal and prefrontal training have very different effects. Prefrontal training improves planning, organization and self-control. This is like the brakes and steering in brain function. Frontal training is more activating – like stepping on the gas. Frontal training impacts the initiation and sequencing of output – moving and talking. On the left side Broca's area controls motor speech. Training here with T3-F7 can have a strong impact on articulation and word finding. The comparable area on the right side (T4-F8) is often helpful with acquisition of language and emotional expression in developmental disorders.
The frontal eye fields control our visual orientation to new stimuli. Targeting the frontal eye fields by training frontally (T3-F3 or T4-F4) can be quite helpful with strabismus, where the two eyes do not track together to focus on input. T3-F3 can get people energized and motivated, but can also be too activating for many people.
Because frontal training is activating, it is important to do sufficient prefrontal training first. We want brakes and steering in place before we step on the gas. Some people never tolerate frontal training because it is too activating and agitating for them.
Central Sites for:
- Physical weakness or paralysis
- Motor seizures
The central strip straddles the anterior parietal and posterior frontal cortical areas. This is where the brain processes somatosensory input and executes motor output. Although central sites have been used historically in a number of published neurofeedback studies, we now achieve stronger training effects on most common symptoms with our basic sites. Central sites are still useful for impacting more specific symptoms related to primary somatosensory or motor function. On the input side, this might be an inability to feel what we touch, or seizures precipitated by touching some part of the body. On the output side, this might be weakness or paralysis after brain injury, or seizures that start with a particular movement of the body.
Somatosensory (and Motor) Homunculus
We can target dysfunction of specific parts of the body with specific placements along the central strip. Both the somatosensory (input) and motor (output) cortex map the opposite side of the body in a predictable fashion. Areas of the body that are more sensitive to touch or have finer motor control have a larger cortical representation. Hands, face and mouth, for example, have much larger representations than trunk or legs.
With motor seizures or deficits in feeling or moving, it is clearly helpful to target the specific area related to the involved body part. C3 and C4 are close to the areas related to the left and right hands. So we might, for example, target post stroke paralysis of the right hand and arm with T3-C3.
We use central strip placements for deficits in feeling and moving. We do not generally use central strip placements for deficits in sensory integration, coordination, spasticity, tremor or sensory hypersensitivity. Those are all indicators for parietal training.
Posterior Temporal Sites for:
- Visual object and pattern recognition
With posterior temporal placements we are targeting high level visual processing in the ventral stream. On the left side (T3-T5) we might impact reading by improving the ability to decode letters and words. On the right side (T4-T6) we might impact the ability to read facial expressions and body language. This can lead to more comfort in social situations, which can be helpful for those on the autistic spectrum.
Occipital Sites for:
- Visual processing
- Emotional calming
We can target basic visual processing with occipital lobe training. This is sometimes useful with traumatic brain injury when the brain has impacted the front and back of the skull. We might improve double vision, visual acuity, color vision or depth perception. Projections to the primary visual cortex partially cross over so that each hemisphere processes input from the contralateral visual field of both eyes, not from the opposite eye ball.
We have also seen very significant improvement in visual deficits related to premature birth. Premature birth and exposure to oxygen while in intensive care can lead to abnormal development of the primary visual areas and abnormal visual cortical activity.
Right hemisphere occipital (T4-O2) training can be profoundly calming emotionally. This is different from the physical calming effect of T4-P4. We have specifically observed this in people with emotional trauma. It is sometimes also helpful with autistic individuals.
Once we have left and right side training frequencies optimized for the basic sites, we also know what the optimal training frequency should be at other training sites.
All right side placements with reference to T4 train with the same optimal training frequency, which is the same for T3-T4. All left side placements with reference to T3 also train with the same optimal training frequency, which is two times the right side training frequency (in the infra-low frequency range). If we know what training frequencies are effective at left and right side basic sites, we can simply extend those training frequencies to the other sites.
Training Frequencies for
divide T3-T4 training frequency by 2
divide T3-T4 training frequency by 4
There are some people who do not tolerate our usual basic placements. They might do well with T3-T4, but then respond badly to left and right side placements as we try to incorporate parietal or prefrontal sites. Sometimes this is a matter of further optimizing the training frequency or waiting a while longer, but these clients might also do better with inter-hemispheric training by combining T3-T4 with P3-P4 and Fp1-Fp2.
Training frequency rules for inter-hemispheric placements are a little more complicated, but very important for optimizing training effects. The optimal training frequency is first established at T3- T4. Moving forward to Fp1-Fp2 requires that we divide the T3-T4 training frequency by 2. Moving back to P3-P4 requires that we divide the T3-T4 training frequency by 4.
It is important to remember that going from right to left with our usual basic placements means increasing the training frequency. Moving front or back with inter-hemispheric training means a lower training frequency.
Training frequency examples for inter-hemispheric sites:
- T3-T4 1.4 mHz – Fp1-Fp2 0.7 mHz – P3-P4 0.35 mHz
- T3-T4 0.2 mHz – Fp1-Fp2 0.1 mHz – P3-P4 0.05 mHz
Training Frequencies for Other
For those who do better with inter-hemispheric training sites, we might want to add other sites beyond the basics. We should already know the optimal training frequencies at the basic interhemispheric sites. Then we need to know which other sites train with the same training frequencies.
Other inter-hemispheric placements on the central strip (C3-C4) and posterior temporal area (T5- T6) train with the same training frequency as T3-T4.
Inter-hemispheric frontal sites (F3-F4 and F7-F8) train with the same training frequency as prefrontal (Fp1-Fp2).
Inter-hemispheric occipital (O1-O2) and parietal (P3-P4) train with the same training frequency.
Adjusting Training Frequencies at
- Continue adjusting as needed – especially for sensitive individuals
- When optimal frequency at one site changes, adjust other sites accordingly
- Expect training frequencies to settle down over time to usual left/right differences
Training frequencies require continued attention throughout training. Some people need a training frequency adjustment after their brains have settled in with a number of sessions. Some people are enormously sensitive to training and require frequent small adjustments of training frequency over the course of training. This is often the case for people with fibromyalgia.
Sometimes we uncover the need to adjust training frequency when adding a new site. Prefrontal training, for example, is especially powerful and can cause discomfort when the training frequency is not adequately optimized. If we do need to adjust the training frequency at a new site, then we should go back and adjust for other sites accordingly. The optimal training frequency at T3-T4 might seem to be 0.2 mHz, for example, but then T3-Fp1 at 0.4 mHz results in a headache. Readjusting the training frequency at T3-Fp1 down to 0.3 mHz in order to reduce headache symptoms then indicates a readjustment at T3-T4 to 0.15 mHz, which should be more effective as well.
- LOW: Increase Training Frequency
- Sedated, slowed down
- Dizziness, nausea
- Groggy, lethargic
- Sadness, crying
- Emotional sensitivity
- Lack of deep sleep
- Difficulty waking
- Low blood sugar symptoms
- HIGH: Decrease Training Frequency
- Agitated, speeded up
- Physical tension, muscle spasms
- Hyperactivity, impulsivity
- Tics, OCD
- Heart palpitations, tachycardia
- Emotional reactivity
- Anxiety, fear, anger, despair
- Aggressive behavior
- Difficulty falling asleep
We use common arousal indicators to understand symptom changes with training, which helps us adjust the training frequency for optimal effects. Increasing the training frequency results in increased arousal. Decreasing the training frequency results in decreased arousal.
If we train with too high a frequency, the brain responds by getting too speeded up. Training too high results in increased agitation – physical, emotional, mental or physiological. This is usually distressing to the client and sometimes to those around him. Training too high can produce increased muscle tension or spasms, hyperactivity or impulsivity, tics or OCD symptoms, and sometimes heart palpitations or increased heart rate. Emotional agitation might show as increased anxiety, fear, anger, despair or emotional reactivity. Sleep can be disturbed with difficulty falling asleep or increased nightmares.
High arousal is appropriate in emergency mode, but not as a long-term state. In an emergency we need to focus on and respond to the emergency. We do not pay attention to our long-term needs to take care of our bodies or plan for the future. Hence constipation is a common symptom for people who live in emergency mode, and increased constipation can be a marker of training too high.
If we train with too low a frequency, the brain responds by getting too slowed down. This is usually very unpleasant for the client. Being sedated might cause people to feel dizzy, nauseous, heavy, groggy or sad. Too low can cause emotional sensitivity, which is different from emotional reactivity related to training too high. Too low can cause excessive sleepiness and also lack of deep sleep. This might cause people to fall asleep and back to sleep easily, but wake frequently and not feel rested in the morning, despite many hours in bed. This is different from waking during the night and having difficulty falling back to sleep, which might be related to training too high. Too low can cause people with an asthma vulnerability to have difficulty taking a deep breath. This is different from the chest tension with increased anxiety when training too high. Too low can also precipitate symptoms of low blood sugar.
Training Frequency and Sleepiness in Session
- Too high? Too low? Or unimportant?
- Relaxation leads to sleepiness for many
- Too low – if sedated and groggy
- Too high – if exhausted and eye strain
- OK – if comfortably relaxed (may feel sleepy)
Sleepiness in session is a tricky issue. It often confuses our interpretation of training effects in session and the search for an optimal training frequency. Training optimally is very relaxing for most people. And for some people relaxation leads to sleepiness. Many people are significantly sleep deprived and are running on adrenaline and caffeine. They will, of course, feel sleepy when they relax. ADHD people tend to run at high speed and then fall asleep as soon as they are bored or still. A quiet relaxing neurofeedback session puts them to sleep as would a movie without enough action scenes. A comfortably relaxed sleepiness is probably a good effect and does not require a training frequency adjustment. We don't want to over-stimulate people in an attempt to keep them awake, when they really need to calm down and sleep better.
We want to calm people with training, but not sedate them. Feeling sedated is not comfortable. Feeling groggy or slowed-down in session or after a session does suggest that the training frequency is too low. If that is so, a higher training frequency should immediately feel better.
It is also possible that training with too high a training frequency can make people feel exhausted, and may cause difficulty keeping eyes open. This feels different from sleepiness. Lowering the training frequency quickly reduces the discomfort. If we do change the frequency appropriately in session to address grogginess or exhaustion, there should be an immediate benefit. If not, go back to the starting training frequency and judge the training effect by what happens after the session.
- Divide session time among sites
- Adjust order of sites for best effect as needed
- Adjust time at each site as needed
- Train all beneficial sites in each session
We are typically training 2 to 5 sites in each session. It is usually sufficient to divide the total training time equally among the selected sites. For example, a 30-minute session might be 2 sites at 15 minutes each, 3 sites at 10 minutes each, 4 sites at 7.5 minutes each or 5 sites at 6 minutes each. There are times when we want more focus on one training one site, so it might make sense to spend more training time at that site.
We can also adjust order of sites to maximize overall training effect. We might start right back for physical calming as the first placement in session and work toward left front to end with mental alertness when that is part of the mix. Training all basic sites would then be in the following order: T4-P4, T4-Fp2, T3-T4, T3-P3, T3-Fp1. Sometimes it is more effective to work in the reverse order, ending with T4-P4 in order to leave the client in a more calm and relaxed state. It is also possible to start a session with T4-P4 and also end with it for physical calming as the first and last step.
It is best to train all useful sites in each session. We might completely eliminate a symptom, but that does not mean we have eliminated the vulnerability. Not including a needed site in sessions can, in fact, set off symptoms. This means that we need to be efficient in our selection of training sites. We want to keep training only those sites that give a positive effect. Sometimes the number of training sites becomes inconveniently large, which is possible for example with the specific deficits of brain injury. Then we might divide the placements into 2 or more groups and alternate training groups over sessions.
- After achieving physiological flexibility and stability with
infra-low frequency training
- With continuation of infra-low frequency training as needed
Infra-low frequency bipolar training is helpful in normalizing physiological self-regulation. That is the first step in our training process for everyone. And that might be all that is needed for some individuals. Others have unresolved traumatic experiences, fears and habits that continue to trigger uncomfortable feelings and behaviors. For these people we also include Alpha-Theta training.
With PTSD for example, we might succeed in physiological calming and stabilizing with infra-low frequency training, significantly reducing flashbacks, hyper-vigilance, insomnia, anger, etc. But there might still be triggers related to the traumatic experience that set off uncomfortable reactions. Alpha-Theta feedback holds the person in a deeply relaxed state in which the traumatic memories can safely surface and be processed, with or without conscious awareness. Memories are then put into long-term storage from which they can be recalled without the accompanying emotional state.
Infra-low frequency training prior to Alpha-Theta provides time for the client to become comfortable with the neurofeedback process. We are asking people to relax deeply with eyes closed during the Alpha-Theta session. This requires some level of comfort and trust. We might typically add Alpha-Theta training after 10 or 20 sessions of infra-low frequency training, but that can be sooner or later depending on the individual.
When people successfully begin Alpha-Theta training, most will also continue some infra-low frequency sessions along with the Alpha-Theta. The client can usually judge which kind of training would be most helpful on a given day. Infra-low frequency training calms and stabilizes the person's state. Alpha-Theta allows the client to work through unresolved issues.
Alpha-Theta should be useful for any adult since we all have unresolved emotional experiences. Children can also benefit from Alpha-Theta, but it is less frequently used for them.
Relaxing Cortical Control With
- Allows subcortical awareness and understanding
- Internal experience without conscious judgment
- Rewarding synchronous EEG activity can be destabilizing
For 1 channel Alpha-Theta training we use a referential placement (Pz to a neutral reference). We are feeding back information about synchronous alpha and theta activity in the back of the brain around Pz. This promotes relaxation of cortical processing and release of cortical control. This is very different from the exercise in cortical control with infra-low frequency bipolar training. There is some possibility that increased EEG synchrony might set off instabilities such as migraine or dissociation. This adds to the rationale for sufficient stabilizing with infra-low frequency bipolar training before beginning Alpha-Theta.
For the Alpha-Theta session we set up a sensory deprivation environment with eyes closed and maximum physical comfort, minimizing orientation to the outside world. This also supports a deep state. The cortex relaxes into a witness state, which allows subcortical processing to occur without conscious judgment or control.
1-Channel Midline Referential AT
1-Channel Alpha-Theta involves a referential placement with plus and minus electrodes at Pz and A1 or A2, on the ear lobe or mastoid bone behind the ear. The ground electrode can go anywhere on the head. It is shown here on the top of the forehead. So the placement is Pz-A2.
Silver/silver chloride electrodes are recommended for all clinical work. Metal (gold or silver) electrodes are also adequate for Alpha-Theta sessions, but it is important to have all electrodes of the same material. Do not mix electrodes types. Ear clips can be used for the reference electrode on one ear and also for the ground on the other ear.
The 1 channel Alpha-Theta Cygnet screen shows the 1 channel EEG trace and also the spectral display. We typically see rhythmic alpha activity in the EEG during eyes-closed sessions. This activity appears as peaks in the spectral display around 10 Hz. The dominant frequency is displayed digitally and also by the small ball that moves along the frequency scale. Dominant frequency is only meaningful when there is some frequency that stands out above the rest. When alpha spindles subside and there is no peak frequency, the dominant frequency indicator wanders down to lower frequencies. That doesn't mean that there is a lower peak frequency, but just the lack of any clear dominant frequency. Most of what you see on the clinician screen in session relates to the ebb and flow of rhythmic alpha activity.
Alpha and theta bars show changes in amplitude within the alpha and theta training bands. Thresholds for training bands are set automatically by the software. Adjustments can be made to the alpha and theta frequency bands with the sliders on the frequency scale. We sometimes move the Alpha frequency up to 10.5 Hz for a less sedating effect, but the default frequencies are effective for most people.
Automatic artifact rejection removes artifacts sometimes caused by movements during a session.
Alpha-Theta Training Bands
- Alpha 10 Hz for mental calming
- Theta 7 Hz for deeply relaxed state
- Standard training frequencies appropriate for most clients
In Alpha-Theta training we are feeding back to the brain information on the ebb and flow of alpha and theta EEG rhythms. Alpha, usually about 10 Hz, is the normal resting rhythm in the sensory cortex in the back of the brain. Alpha amplitude typically rises as soon as the eyes are closed, which cuts off visual input to the brain. As the cortex relaxes in alpha, sensory processing is suppressed, but the person is still fairly alert. Theta, at about 7 Hz, reflects a more deeply relaxed state. The person is more disconnected from the outside world and more internally focused. Deep state experiences sometimes include dream imagery and odd body sensations such as floating. Standard alpha and theta training bands of 10 Hz and 7 Hz are effective for most people.
Adjust Alpha Training Frequency as Needed
- 10 Hz generally effective
- Raise alpha training frequency as needed when too sedated or depressed after session (10.5 Hz is usually sufficient)
These standard Alpha and Theta training frequencies of 10 Hz and 7 Hz are effective for most people. However, there are some people who are too sedated with 10 Hz alpha. Following an Alpha-Theta session people should feel deeply relaxed and refreshed, like after a good nap. If people feel sedated – slowed down, groggy or sad, then 10 Hz might be too low. Adjusting the alpha training frequency slightly higher makes a big difference in the effect of training. Moving from 10.0 to 10.5 Hz is usually sufficient to give a good effect for these people.
- Gentle tones, music and environmental sounds
- To achieve and maintain a deep state
- Alpha-Theta Reflections
- Optional binaural beats
- Optional guided imagery
During Alpha-Theta sessions, people typically relax with eyes closed. In the original Alpha-Theta program there is no visual display, so the feedback is entirely auditory and tactile. In order to support a relaxed state, the sounds are calming. There are two layers of auditory feedback. First, there is a chime when Alpha exceeds its threshold, and a deeper gong when Theta exceeds its threshold. Behind the chime and gong sounds are environmental (water) sounds, which constitute the second layer of auditory feedback. A running stream sound is present when alpha is dominant. As the brain sinks deeper into a theta dominant state, the water sounds shift slowly to an ocean surf sound. Chime and gong sounds respond quickly to changes in training band amplitudes, whereas the water sounds shift slowly with more sustained state shifts.
The newer Alpha-Theta Reflections program provides additional layers of feedback and additional feedback options. There are meditative visual displays for those who are more comfortable with eyes open during some part of the session. The auditory feedback includes alpha and theta background sounds and also music. Options include binaural beats, a delta inhibit to discourage sleep, and recorded guided imagery that plays in the first few minutes of the session.
- Usually eyes closed during part or all of session
- Physical comfort and emotional safety allow deep relaxation
- State will cycle between Alpha and Theta dominance
- Processing occurs internally in deep states
- Desired effect - deeply relaxed, refreshed and awake at end of session
Physical comfort and emotional safety are important during the Alpha-Theta session to allow deep relaxation and withdrawal from the external world. We offer the client eye-shades, headphones, blanket and pillows. Sensory deprivation and physical comfort help promote a deep state. If the clinician stays in the room, he or she needs to be calm and centered so as not to interfere with the client's deep state. If the clinician leaves the room, there needs to be some way to monitor what is happening so the client can get assistance if needed. It is possible to use a remote access program to see the Cygnet clinician screen and history graphs on a computer in another room.
During the session people typically cycle between lighter and deeper states of consciousness. There is no intention to go to a particular state and deeper is not better. It seems to be the shifting back and forth that is most effective. In these deep internally focused states, unprocessed memories can arise spontaneously. They may be witnessed by the conscious mind – or not. They are then processed and stored as explicit memories stripped of their emotional charge. Events can then be consciously recalled without retraumatizing.
It is important that we allow the client to remain in a deep state during this process. Even when people look uncomfortable in session, it is important not to disturb them. Difficult material can be handled internally in a deep state that might be frightening if the person were suddenly fully awake.
At the end of the session, we first allow people time to become fully awake and oriented to their environment before we start talking. Eventually we expect to hear people report that they feel relaxed, refreshed and awake. They may still need a few minutes to become fully alert before driving home.
Guided Imagery Before Alpha-Theta
- Pre-session induction
- Guided imagery
- Visualizing ideal self
- Positive suggestions
- Speaking to the subconscious
Induction techniques can be used before or during the first few minutes of the Alpha-Theta session to suggest desired positive changes to the subconscious. Guided imagery may help the client visualize the ideal self before the session or as the session is beginning. During the remainder of the session it is important to let the brain follow the feedback sounds without outside interference and without internal striving.
Therapists often work with clients directly after Alpha-Theta sessions to help process the imagery and experiences of the session. When the client is seeing separate therapists for neurofeedback and for psychotherapy, that processing can take place at a later therapy session.
Alpha-Theta History Graphs
- Individual differences in EEG trends
- Importance of relative shifts in amplitude
- Typical profile:
- Alpha rises with eyes closed
- Alpha falls with deeper relaxation
- Changes in Alpha amplitude greater than changes in Theta
- New combination sensor and physiological monitoring
Alpha-Theta history graphs can give us interesting information about state changes during the session. In an Alpha-Theta session the EEG is recorded from the back of the head in people who are typically relaxed and still with eyes closed. This results in much less artifact than we see during infra-low frequency training. So the trend lines are less corrupted by eye-blinks, talking and moving around. There are still significant individual differences in EEG patterns, however, which make it impossible to know the client's experience in session just from looking at the history graphs.
In reviewing the EEG history graphs, we are interested in the relative shifts of alpha and theta amplitudes over the session, not the absolute values. People talk about cross-over as an actual crossing over of the alpha and theta trend lines. But different people have very different baseline EEG patterns and different EEG changes with state shifts. For one person alpha might stay above theta for the entire session. For another theta might be at the top of the graph. All of these people are able to shift states toward relaxation and sleep in their normal lives, even though their EEGs might look very different.
We are primarily looking at the changes in alpha amplitude. When alpha amplitude rises and then drops in the session, that usually means a shift to a deeper state. That drop might or might not put alpha below theta. The feedback is intended to help the brain let go and shift to deeper states. We are not really concerned with EEG amplitudes, except as they relate to state shifts. And we are not trying to teach the brain to make more or less alpha.
Be careful not to assume that you can judge a person's Alpha-Theta experience by looking at the trend lines. There are times when the graph looks like absolutely nothing happened, but the client reports profound effects. The client's experience is real; the trend lines are just a graph of EEG amplitudes. It is useful, however, to listen to the client's report and then correlate that with what you see in the graph. You might see a sudden rise in delta activity related to a brief period of sleep, or a drop in alpha amplitude related to a period of imagery.
The new combination sensor and physiological monitoring will provide more clues about state shifts during Alpha-Theta sessions.
Typical Alpha-Theta History Graph
Here we see the alpha and theta history graphs over the course of a typical session. Alpha rises quickly at the start of the session with eyes closed. With deeper relaxation, we see a drop in the alpha amplitude. Early in the session or early in training, there may be an excitement or fear with going deeper. We then see the alpha amplitude jump back up again. Eventually relaxation is tolerated and the alpha amplitude stays lower for a while. That is often the time of internal imagery and processing. Toward the end of the session, we might see the alpha rise again as the client is ready to be done.
We should avoid disrupting the session when a person is in a deep state. We should also give the client time to slowly reorient to the external world as we remove the blanket, headphones, electrodes, etc.
When Not Ready For Alpha-Theta
- Anxious and hyper-vigilant clients may be unable to relax and benefit from AT
- Return to infra-low frequency training until calmer
There are several considerations in deciding when to begin Alpha-Theta training with a client. We want people to be prepared for a positive experience and outcome. They need to be able to relax and let go of conscious control to fully benefit from the Alpha-Theta session.
It is typical for anxious clients to have difficulty relaxing sufficiently in session to benefit from Alpha- Theta. Many people also report that they would like to meditate, but they just can't calm their thinking mind enough to do it. People with PTSD are typically hyper-vigilant and do not feel safe tuning out the world around them and truly relaxing.
It is useful to discuss the process before attempting Alpha-Theta. Ask whether this sounds comfortable and possible for the client. If we start Alpha-Theta too soon, the client might be bored or annoyed with the isolation and sensory deprivation. We might arrange to check in part way through the session to see whether they want to continue. It is also possible that a highly anxious person might be frightened by the deeply relaxed state achieved in Alpha-Theta.
If the first Alpha-Theta session is not a positive relaxing experience, then we go back to infra-low frequency bipolar training. It is important to explain that this does not represent a failure of the client or of the process. It is just an issue of readiness. Then revisit the issue after more infra-low calming. Some people find it useful to do some infra-low frequency training directly before Alpha-Theta to help them relax in the session.
When Not Ready For Alpha-Theta
- ADD clients may fall asleep when relaxed
- Return to infra-low frequency training until able to relax without falling asleep
As we try to get people physically comfortable and then move them toward a deeply relaxed state with feedback on alpha and theta EEG activity, we run the risk of putting them to sleep. This is especially true for ADD clients who tend have a limited range of brain states – full speed or sleep. When the ADD client withdraws from stimulation, he gets bored and goes to sleep. For an effective Alpha-Theta session we need a state of deep relaxation while still awake.
If we start Alpha-Theta and the client just falls asleep, it is time to go back to infra-low frequency training. With better regulation of brain states it should be possible to relax and benefit from Alpha-Theta sessions without falling asleep.
When Not Ready For Alpha-Theta
- Instabilities may be triggered when enhancing synchronous EEG activity with AT
- Return to infra-low frequency training until more stable
It is also possible to trigger symptoms of instability by promoting synchronous EEG activity in Alpha- Theta. Synchronous EEG activity takes us away from cortical control and stability as it releases subcortical processing and awareness. For those with instabilities it is important to increase stability first with bipolar infra-low frequency training. Headaches are sometimes helped by Alpha- Theta training, but they can also be triggered during a session. Other instabilities such as vertigo, seizures, panic, dissociation, etc. can arise with Alpha-Theta if there has not been sufficient stabilization first.
If symptoms do arise in session, we would first go back to infra-low frequency training. Sometimes Alpha-Theta might be beneficial but cause problems if not balanced with some bipolar infra-low frequency training. Alpha-Theta and bipolar training might then be done in alternate sessions or combined within one longer session.
Combining 2 Channels
- Sum or difference of 2 EEG channels
- 2 channel electrode options
2 channel Cygnet applications involve two separate EEG signals that are combined by adding or subtracting. The feedback is then determined by the combined sum or difference signals. For 2 channel ILF HD the training signal is derived from the difference of the two channels. This gives us exactly the same training signal feedback as 1 channel ILF HD. Working with the difference signal promotes differentiation and control of cortical function. The inhibits, on the other hand, are set on the sum of the two channels. Since dysregulated EEG activity is more likely to be seen in the sum than in the difference of channels, we have more effective inhibit information with the 2 channel application. We find that this enhanced inhibit feedback increases the overall effectiveness of the program.
For both 2 channel Alpha-Theta and Synchrony the two channels of EEG are added together for training and inhibit feedback. Deriving the training signal from the sum of channels promotes synchronous activity at the two training sites. This leads to deactivation of cortical function and release of deeper states of consciousness.
2 Channel Infra-low Frequency HD
- Reward on difference – same as 1 channel ILF HD
- Inhibits on sum – stronger training effects
- Transitioning from 1 channel to 2 channel ILF HD
- May require more careful adjustment of training frequency
- Same feedback options
Moving from 1 channel ILF HD to 2 channel ILF HD involves a more complicated electrode setup, but also gives us a stronger training effect. The difference in training effect results entirely from a difference in the inhibit feedback. A difference signal automatically subtracts out anything that is common in the two input signals. It is more sensitive to what is different, but less sensitive to what is the same. This is useful for feedback on the training signal, but not as useful for the inhibits. If we are trying to catch dysregulation with our inhibits, it is more useful to work with the sum rather than the difference.
Most people report a stronger effect with the 2 channel application. Sometimes shifting a client from 1 to 2 channel training requires a readjustment of the training frequency to fine tune the effect of training. Sometimes it is helpful to back up to starting site or sites to find the optimal training frequency before adding back other training sites. If 2 channel training is the goal, then it is easier to start new clients with the 2 channel application rather than transitioning at a later time.
Feedback displays and functions are otherwise the same with 1 channel and 2 channel ILF HD applications.
2 Channel ILF HD
The 2 channel ILF HD Cygnet screen shows EEG and spectral displays for channel 1 and channel 2 separately. This might allow us to see where artifact or abnormal EEG activity is coming from. For example, a 1 channel T3-Fp1 signal will show significant eye-blink artifact. A 2 channel display will show (T3 – reference) and (Fp1 – reference) signals separately. Then the eye-blink artifact will be seen in only one EEG trace and only one spectral.
The one yellow training bar shows the signal level at the selected training frequency. The training signal is derived from the difference between the two channels of input. This is the same training signal that we would have with 1 channel ILF HD.
The one gray inhibit bar is a combination of the multiple inhibits set on the sum of the two channels. This is different from, and stronger than, the inhibits in 1 channel ILF HD.
2 Channel ILF HD With 4 Electrodes
And Combined Reference
For 2 channel ILF HD we can use four electrodes on the head by linking the two reference inputs. A short jumper cable can be used to connect channel 1 reference (minus) to channel 2 reference (minus). Then one electrode can be plugged into the combined reference input and attached to the head at Cz. A separate ground electrode can go anywhere on the head - shown here on the forehead.
The other two electrodes become signal (plus) inputs for channel 1 and channel 2. They are moved around during a session for different training sites. The session report shows the training placement as T4-P4 with a blue (difference) line connecting them. In this case Cz is circled since it serves here as reference for both channels. Cz is typically used as the common reference for 2 channel ILF HD. The activity at Cz will be part of the displayed EEG signals, but it will be subtracted out for the training signal. For the difference signal, (T4-Cz) - (P4-Cz) = T4-P4. Meanwhile Cz will contribute to the inhibit signal and that might be a good thing. For inhibits on the sum of channels (T4-Cz) + (P4-Cz) = T4+P4-2Cz. Abnormal amplitudes at Cz are a reasonable target for down training.
2 Channel Alpha-theta
- Training on sum of channels
- Stronger feedback on synchronous activity at 2 sites
- Default sites Pz and Fz
- Stronger clinical effect in session
2 channel Alpha-Theta combines input from two sites - front and back midline – for a stronger training effect. Our default sites now are Pz and Fz (more accurately slightly in front of Fz at the hair line.) P3 and P4 are alternative sites which we found useful in the past. Fz+Pz involves core brain circuits that maintain our sense of self.
2 Channel Alpha-theta
The 2 channel Alpha-Theta clinician screen shows three EEG traces – channel 1, channel 2 and channel 1 + channel 2. At the bottom of the screen are separate spectral displays for channel 1 and channel 2. The larger spectral display in the middle is for the sum (channel 1 + channel 2). We can often see rhythmic activity around 10 Hz in the EEG and in the spectral displays. Synchronous activity in the two channels will add together to give a larger EEG trace and a larger spectral peak.
Alpha and theta training bars and feedback relate to the sum of channels signal. All feedback options are the same as for 1 channel Alpha-Theta.
2 Channel Alpha-theta With 5 Electrodes And Combined Reference
With 2 channel ILF HD the training signal is derived from the difference of the two channels. That subtracts out the reference signal input, so we have a clean training signal, e.g. T3-T4. With 2 channel Alpha-Theta and synchrony we derive our training signals from the sum of two channels. That means we have input from both reference electrodes in our training signal – in addition to our Fz+Pz signal.
Reducing the amplitude of those reference signals gives us a cleaner training signal. First we can select A1 and A2 as reference sites, which should be lower amplitude than placements higher on the scalp. And then we can use a jumper cable to connect the two reference inputs to the Neuroamp – further reducing the combined reference signal.
The session report shows the sum of channels as a red line connecting Fz and Pz. A1 and A2 are circled to indicate their use as reference inputs. The ground electrode is shown on Cz, but it is not indicated on the session report.
2 Channel Synchrony
- Achieving calm focus
- Similar to mindfulness
- Still and quiet
- Eyes open or closed
- Visual feedback – fractals, abstract or nature
- Auditory and tactile feedback
- Readiness for synchrony
2 channel synchrony provides feedback on synchronous activity within one frequency band across two areas of the brain.
Usually we are working with alpha or gamma training frequencies, and our starting placement is Fz + Pz. Feedback supports a quiet and peaceful state, but not generally as deep as with Alpha-Theta. People are usually seated upright with eyes open during some part of the session. Visual feedback options include intricate fractals, abstract patterns or natural scenes. Auditory feedback includes layers of sound with relaxing music. Binaural beats are optional.
2 channel Synchrony adds a third option to our neurofeedback process. We can think first of infralow frequency training as promoting physiological self-regulation. Alpha-Theta then provides a process for accessing and resolving unprocessed traumas and otherwise inaccessible experiences. Synchrony promotes a state of calm focus which has many of the same benefits as mindfulness exercises. The question is how we might best combine these three options.
2 Channel Synchrony
The 2 channel Synchrony screen shows the EEG for channel 1, channel 2 and the sum (channel 1 + channel 2). It also shows spectral displays for channel 1 and channel 2, and for the sum of channels. So far this is like the 2 channel Alpha-Theta display. With Synchrony there is just one training frequency to be selected. The yellow bar shows the training amplitude relative to its feedback threshold. Feedback on the amplitude of the sum of channels promotes synchronous activity at and between the two training sites. In addition there is a separate feedback on a tighter measure of synchrony between the two sites. When that threshold is exceeded a gong is heard - except when inhibits exceed threshold. We want to promote good synchrony, which reflects a healthy relaxation of cortical control. We do not want to promote abnormal synchrony leading to symptoms of instability. When any of the multiple inhibits exceed threshold, the synchrony gong is not allowed.
2 Channel Synchrony With 5 Electrodes
For 2 channel Synchrony sessions we use five electrodes, and combined reference inputs, just as we do with 2 channel Alpha-Theta. Our usual Synchrony placement is Fz+Pz with references at A1 and A2, and ground on Cz.
We are finding 10 Hz (Alpha) synchrony to be most effective in calming the nervous systems of people with anxiety, OCD, or hard-driving type A behavior. 10 Hz synchrony can be added to ILF training once the optimal placements and training frequency are established. P3+P4 might be a useful alternative placement to Fz+Pz for 10 Hz synchrony. Some people with instabilities and hyper-excitable nervous systems respond poorly to alpha synchrony. They might do better with 40 Hz synchrony.
We are finding 40 Hz (Gamma) synchrony to be helpful with some ADD people – promoting a calm, clear focus. Anxious people may find the 40 Hz over-stimulating and prefer 10 Hz. An alternative placement for 40 Hz synchrony is Fp1+Fp2.
- Certification in the Othmer Method
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*Continuing Education for Psychologists: EEG Info courses are co-sponsored by Amedco and EEG Info. Amedco is approved by the American Psychological Association to sponsor continuing education for psychologists. Amedco maintains responsibility for this program and its content. 40 CE credit hours for Introductory Course in Neurofeedback, 23 CE hours for Advanced Clinical Summit, 22.5 CE hours for Practicum Weekends (per topic), 45 CE hours for Practicum Week, 45 CE hours for OnDemand Training Course.
Othmer Method Certification
Whether you’re seeking certification, or just taking steps towards the responsible application of this powerful neurofeedback tool, we recommend the following learning path:
• A detailed list of these requirements can be found at EEGinfo.com/certification
Before attending a course, read this Protocol Guide a few more times. Each read will further ground you in the material and make for a stronger foundation for the live courses and hands-on work ahead.
Augment your protocol guide reading with the OnDemand Intro Course, a 45 CE video course that will
refresh and expand what you’ve learned in the protocol guide, and prepare you for the hands-on courses
Get Hands-On: all the in-person courses center on conducting sessions and discussing the results. The best learning often takes place when you apply what you’ve learned and discuss the results with your classmates and with the experienced instructors. Begin with the Introductory Course and proceed on to the Practicums, and eventually attend the annual Clinical Summit.
Othmer Method Certification
Spend your first year participating in case discussions and learning through the online community along
with individual and group phone consultations.
To complete your certification, finish 400 sessions on a minimum of 20 clients while you continue training your own brain, and make steady progress on the books, videos and chapters from the required certification materials.
As your final step, along with all your required certification notes, you will submit your session notes from an example case, demonstrating your understanding of the method.
Get started today at EEGinfo.com/courses
OnDEMAND TRAINING COURSE
Get Educated & Inspired – Online
Perfectly suited to view before you start any hands-on neurofeedback course, or revisit these videos any time along your road as a refresher. This OnDemand course provides a framework for the decision making and practical work ahead of you by exploring the research, history, and theory behind the method, along with the clinical rationale and case reports to put you on a path towards excellent decision making in neurofeedback.
Also visit the Education Community Membership chat board where video results from this OnDemand course, pulled by their transcripts, will appear in your keyword searches, along with member discussions, protocol guide excerpts, research articles and more.
This course offers 45 Continuing Education Credits
Introductory Course In Neurofeedback
The most important step towards mastering neurofeedback and the Othmer Method is your hands-on experience, and especially the guidance and discussions in the introductory course. The introductory course is entirely focused on giving you that hands-on experience, supported by your reading beforehand, a small amount of lecture before each practicum session, and followed by discussion groups led by your instructors after each session. You will leave this class with the crucial tools to start practicing on clients right away.
Continuing Education: 40 CE's
Sign up today at EEGinfo.com/courses
Follow this class with at least a few months of consistent sessions on yourself and on clients, along with phone consultations to discuss and learn from the results through the membership or one-on-one mentoring, before proceeding on to the practicum courses.
Also available at a re-attend price for those looking to join again as a refresher.
After completing the intro course and at least three months of sessions with supervision, or for the neurofeedback veteran looking to come back and refresh their skills and hear about the latest thinking, technology and updates, the practicums are three days of hands on work, questions and discussions with no structured lecture time. This class is simply hands-on practicum and discussions to enable your next giant leap forward beyond the intro course.
Practicum One includes one day on assessment, and two days on infra-low training. Practicum Two includes one day on synchrony, and two days on alpha-theta. The practicums are also offered together as an optional 6 day week -- ideal for those coming from far away.
22.5 CEs Practicum 1 & Practicum 2
45 CEs Practicum Week
Sign up today at EEGinfo.com/courses
Advanced Clinical Summit
Connect. Learn. Share.
Hear speakers from around the globe, join discussion groups with a rich variety of professional backgrounds -- often extending back decades, hear case presentations from instructors and peers, and try the latest technology. The clinical summit is simply a lot of fun while remaining a powerful tool to improve your craft and enhance your practice year after year.
This annual event is available in-person or online with video and chat board discussions.
Continuing Education Credit: 23 Hours
More information: EEGinfo.com/courses
In-person attendance requires at least one full year of clinical practice in neurofeedback. Online seats are limited to professionals with at least some neurofeedback knowledge.
Education Community Membership
Keep learning and stay up to date with your colleagues and with the latest developments. Have peace of mind with equipment support and emergency loaner equipment sent overnight.
• Online discussion community with a giant searchable archive
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• Group phone consultations (1 per month)
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With EEG Institute Clinicians
Our clinicians are available for professional consultations to meet your needs, from answering basic clinical questions to discussing your most difficult cases.
Group phone consultations are part of the Education Community Membership
A Boy's Journey Towards Self-Discovery That Inspired His Parents To Change The World
Brian’s Legacy chronicles the emotional journey of a dedicated father and his troubled son. As a young adult, Brian Othmer recorded his journey in a diary, which reveals a young man determined to understand himself and his brain, and to answer the question that drives him: “Where do I fit in this world?”
In this phoenix-from-the-ashes story, Brian’s journal entries are paired with his father’s recollections. Throughout the Othmers’ heartbreaking odyssey, they finally discover something that works: neurofeedback. Through their work in neurofeedback, Brian’s legacy lives on.
Homecoming For Veterans
Homecoming for Veterans (HC4V) is a national outreach program
dedicated to providing free neurofeedback for veterans and
active duty service members suffering from PTSD, TBI and
substance abuse. Our network consists of independent clinicians
donating their time and resources to help those in need.
For more information and to stay up-to-date, please subscribe to Homecoming for Veterans at:
Infra-Low Frequency Neurofeedback for Optimum Performance
Siegfried Othmer and Susan F. OthmerBiofeedback, 44(2), pp. 81-89 (2016) DOI: 10.5298/1081-5937-44.2.07
The Growing Role of Neurofeedback in Integrative Medicine
Siegfried Othmer and Susan F. OthmerTownsend Letter, November 2015, pp.67-73
Restoring the Brain: Neurofeedback as an Integrative Approach to Health
Hanno Kirk, editor, Taylor and Francis, Boca Raton, Florida (2015).
Endogenous Neuromodulation at Infra-Low Frequencies
Siegfried Othmer, Susan F. Othmer, David A. Kaiser, John PutmanSeminars in Pediatric Neurology, 20(4): 246-260 (2013)
Clinical Neurofeedback: Training Brain Behavior
Siegfried Othmer, Sue Othmer, and Stella LegardaTreatment Strategies – Pediatric Neurology and Psychiatry, 2(1):67-73 (2011)
Clinical Neurofeedback: Case Studies, Proposed Mechanism, and Implications for Pediatric Neurology Practice
Stella B. Legarda, Doreen McMahon, Siegfried Othmer, and Sue OthmerJournal of Child Neurology,(26)8:1045-1051 (2011)
Post Traumatic Stress Disorder - The Neurofeedback Remedy
Siegfried Othmer, PhD, and Susan F. Othmer, BABiofeedback Magazine, Volume 37, Issue 1, pp. 24–31 (2009)
Neurofeedback Treatment for Pain Associated with Complex Regional Pain Syndrome Type 1
Mark P. Jensen Ph.D., Caroline Grierson, R.N., Veronika Tracy-Smith, Ph.D., Stacy C. Bacigalupi, M.A., Siegfried Othmer, Ph.D.Journal of Neurotherapy, 11(1), pp. 45-53 (2007)
Performance Enhancement Applications of Neurofeedback
Siegfried Othmer and Susan F. OthmerCase studies in applied psychophysiology: Neurofeedback and biofeedback treatments for advances in human performance, W. A. Edmonds, & G. Tenenbaum (editors), Wiley-Blackwell, West Sussex, UK, pp. 17-30 (2011)
Neurofeedback for the Autism Spectrum
Siegfried and Susan F. OthmerCutting-Edge Therapies for Autism, Fourth Edition, 2011-2012, Ken Siri and Tony Lyons, Editors, Skyhorse Publishing, pp. 105-110 (2012)
EEG Neurofeedback Therapy
Siegfried Othmer and Mark SteinbergChapter 19 in Clinical Addiction Psychiatry, D. Brizer and R. Castaneda, editors, Cambridge University Press, pp. 169 - 187 (2010)
Neuromodulation Technologies: An Attempt at Classification
Siegfried OthmerChapter 1 in Introduction to QEEG and Neurofeedback: Advanced Theory and Applications (Second Edition), Thomas Budzynski, James R. Evans, and Andrew Abarbanel, Eds, Elsevier 2008, pp. 3-26
Efficacy of Neurofeedback for Pain Management
Siegfried Othmer and Susan F. OthmerChapter 50 in Weiner’s Pain Management, Seventh Edition: A Practical Guide for Clinicians, edited by Mark V. Boswell and B. Eliot Cole; Taylor and Francis, Boca Raton, Florida, p. 719-739 (2005)
EEG Biofeedback: An Emerging Model for Its Global Efficacy
Siegfried Othmer, Susan F. Othmer, and David A. KaiserIn Introduction to Quantitative EEG and Neurofeedback, James R. Evans and Andrew Abarbanel, editors, Academic Press, San Diego, pp. 243-310 (1999)
Increased understanding of brain function and acceptance of self-regulation remedies have inspired a groundswell of interest in neurofeedback. With the Othmer Method again setting the standard for clinical effectiveness, clinicians around the world are turning to Susan Othmer’s Protocol Guide for the latest in neurofeedback techniques.
In this Sixth Edition of the Protocol Guide, neurofeedback clinicians can learn about the groundbreaking Infra-low Frequency Training, developed by Susan Othmer - resulting in greater success with disorders ranging from autism to migraines to PTSD.
Over the last 30 years, Susan Othmer has worked personally with thousands of clients and supervised hundreds of clinicians. She has trained over six thousand professionals - the majority of the neurofeedback field - in The Othmer Method, her symptom-based, client-centered approach. The Protocol Guide conveys this expertise in a straightforward and easy to reference manual that allows clinicians to understand and follow this same set of guidelines in their own work.
"The Othmer Method has become integral to my therapeutic practice. It is an invaluable technique for dealing with a wide range of clinical conditions. The Protocol Guide has a permanent place on my desk and I use it frequently."
Lina Guertin, MD, MBA
Diplomate of the American Board of Psychiatry and Neurology