Neuroscientist Dr. Tato Sokhadze on Neurofeedback

Neurofeedback Effectiveness: Insights from a Neuroscientist

Dr Tato Sokhadze is a neuroscientist with extensive research experience in neurofeedback. He has taken time to answer this preliminary question from a scientific perspective. Because, despite being around for many decades, neurofeedback is unfamiliar to many. Here Dr Tato provides an overview of Neurofeedback and its efficacy for our community.

1. What is your background?

I have a PhD in Human Physiology and post doctorates in Psychopharmacology and Cognitive Neuroscience. I hold several faculty appointments, I am Professor at University of South Carolina School of Medicine in Greenville, Clinical Professor at CUSHR at Clemson University, and Gratis Associate Clinical Professor at University of Louisville School of Medicine where I was Director of the Evoked Potentials lab at Cognitive Neuroscience labs of Psychiatry & Behavioural Sciences Department. And I am President of the Foundation for Neurofeedback and Neuromodulation Research (The FNNR).

I have over 30 years of experience in application of cognitive neuroscience, neurofeedback and neuromodulation methods in human clinical psychophysiology research and applied neuroscience. I have specialized expertise with event-related potentials (ERP), HRV, QEEG and research and treatment of autism, ADHD and substance abuse.

2. What is neurofeedback?

Neurofeedback is a self-regulation technique that utilizes equipment that can provide the individual with feedback about the activity of the brain helping to learn to change and regulate brain activity¹. The most popular form of brain activity trained using neurofeedback is EEG.

3. How did neurofeedback come to be?

The neurofeedback method originated in the late 60s thanks to the pioneering work of Joe Kamiya at the University of Chicago and Barry Sterman at UCLA. Kamiya was the first to discover that people could learn to alter their own brain activity, while Sterman’s work laid ground for the application of self-regulation of brainwaves for clinical treatment.

4. What has neurofeedback been used for?

Neurofeedback has been used for treatment in many neurological and psychiatric disorders, such as attention deficit hyperactivity disorder (ADHD), epilepsy, autism spectrum disorder, traumatic brain injury (TBI), post-stroke rehabilitation, depression, anxiety disorders, addiction, sleep, to name a few of clinical applications. Furthermore, neurofeedback is also used in the healthy population to train memory, attention, and other cognitive capabilities in adolescents and young adults, as well as in the elderly to prevent cognitive decline. Moreover, the method has been used actively for performance improvement in athletes, to improve creativity and as an aid in meditation.

5. So ‘Does neurofeedback really work?’ What is the status of the scientific data supporting neurofeedback?

Yes. There is an impressive and growing body of research, including multiple controlled trials, numerous studies comparing neurofeedback with other interventions, and an enormous amount of clinical case series that had shown encouraging results of clinical application of neurofeedback training for various conditions. Meta-analyses and numerous reviews’ results indicate that neurofeedback is superior to waitlist, to other active standard treatment conditions, and many showed superiority in placebo-controlled studies conducted according to best randomized clinical trial (RCT) designs.

Despite this, neurofeedback is not yet considered as a mainstream intervention. Although neurofeedback is a technique that has been in existence for so many decades, it has remained subject to critique, largely due to questions about clinical efficacy and specificity. I will start to address some of the reasons why I believe most of the objections of methods' critics are not relevant, as well as the major obstacles preventing recognition of even so well-established clinical application as treatment of ADHD using neurofeedback.

6. How have you applied neurofeedback in your research and treatment practice?

I am a strong proponent of neurofeedback methods, both for the treatment of mental disorders and for performance improvement. I started using heart rate and blood pressure biofeedback back in the 80s to treat psychosomatic disorders such as borderline hypertension, and in the 90s I used Peniston alpha/theta brainwave training to treat patients with alcoholism.

This protocol and its modifications are still considered as most effective in substance use disorders. I published several review papers and chapters explaining the rationale of application of neurofeedback in drug and alcohol dependence².

My own treatment research studies supported positive behavioural and functional effects of neurofeedback in treatment of cocaine use disorder and stimulant abuse, including cases with post-traumatic stress disorder (PTSD) comorbidity.

At the same time, in most of my conceptual reviews I always emphasize that neurofeedback should not be considered as mono-therapy for addiction treatment, but rather be combined with other treatment approaches. For example, in opioid dependence, neurofeedback can be combined with buprenorphine-based maintenance, or with some form of cognitive behavioural therapy (CBT).

Similarly, in adolescents using illegal stimulants, it might be useful to combine neurofeedback with treatment of comorbid conditions such as ADHD, conduct disorder, or oppositional-defiant disorder (ODD). During many years of effective application of neurofeedback in children with autism spectrum disorder, I also found that by combining neurofeedback with other interventions, such as repetitive transcranial magnetic stimulation (rTMS) and sensory integration methods we were able to achieve more significant positive clinical outcomes³.

With emergence of new neuromodulation techniques such as audio-visual stimulation (AVS), transcranial direct current stimulation (tDCS), pulsed electromagnetic field (pEMF) stimulation and photobiomodulation, the combination of neurofeedback with the above methods promises even more venues of possibilities as they may work synergistically to improve the treatment outcomes.

7. How do you measure the success of neuromodulation interventions?

There are also several other approaches that I use during neurofeedback. For example, psychophysiological monitoring to determine how well the trainee is engaged in the self-regulation process, as this helps to recognize treatment non-responders.

As a rule, I always tried to use not only behavioural and clinical outcomes but also cognitive tests using event-related potential (ERP) methods to have objective functional measures of treatment progress. So far, I have used neurofeedback for more than 30 years and I know that it works firsthand.

However, much more effort, rigorous treatment research studies, and randomized clinical trials are needed to convince clinicians and regulatory agencies about the utility of neurofeedback for specific clinical indications.

8. The elephant in the room: Why is neurofeedback not in mainstream medical usage?

Neurofeedback is a technique that has existed for many decades, however, its use has not yet been broadly adopted in the mainstream. There is an impressive and growing body of research including multiple gold-standard designed randomized, placebo controlled trials.

Results for various conditions have indicated superiority of neurofeedback to other active standard treatments. I contend that there are 3 reasons for mainstream critique of its clinical effectiveness: suboptimal clinical trial design that does not account for (1) human learning mechanisms, nor (2) personalization for the individual, nor (3) combine adjunct psychology and/or meditation.

There are still questions asked whether it's pseudoscience or a placebo effect. So it is necessary to address “the elephant in the room” question regarding why neurofeedback is not mainstream and why some scientists and clinicians aren't convinced about the efficacy of the method. Here I will go into detail on the 3 reasons why it is not mainstream:

1. Studies need to be structured with an understanding of human learning mechanisms.

It is necessary to use a scientific approach to understand the basis of the operation of the feedback loop in neural systems. Self-regulation, in cybernetics terms, usually refers to the principle of so-called “negative feedback.” In other words, control by means of “negative feedback” is an arrangement that enables any machine or biological system to optimize and adjust an activity according to the set goal.

When a feedback-based model is applied to the complex forms of behavior in animals, and eventually in humans, the controlled system must have capability for learning⁴. Without considering learning mechanisms it is impossible to understand the basis of neurofeedback and self-regulation skills acquisition.

Even the most outspoken opponents of neurofeedback recognize that neurofeedback helps in acquisition of self-control skills, though it does not always lead to desired behavioral changes. A better understanding of the learning processes underpinning neurofeedback could be a key element to develop the use of this technique in clinical practice^5,6.

Among the learning theories implicated in neurofeedback, most neurofeedback specialists conceptualize it as a form of operant conditioning. Unfortunately, many opponents of the methodology of neurofeedback do not recognize that. For instance, Thibault et al.⁷ published a series of papers making the same argument about the role of placebo and “suggestion therapy” in neurofeedback based on the finding of similar outcomes when comparing results of several so-called “genuine” neurofeedback and sham feedback in controlled clinical trials.

Pigott, Cannon and Trullinger⁸ in a must-read excellent rebuttal carefully analyzed flaws in study designs of RCT studies cited by Thibault et al. and revealed that these studies' methodologies were antithetical to the established science of operant conditioning thereby preventing subjects from learning self-regulation.

The authors methodically explained why the premise that beneficial effects of neurofeedback are due to placebo effect is incorrect, as the reviewed studies compared two forms of false-feedback, not true operant conditioning of the EEG. Many reviews and meta-analyses are sometimes biased by selection of the studies better fitting their negative narrative. The flaws in design of the reviewed studies and neurofeedback protocols procedural arrangement errors are often not recognized.

Majority of double-blinded RCT studies use the auto-thresholding procedure resulting in the violation of operant conditioning learning principle of shaping. This results in negative outcomes of these studies with poorly designed control conditions, inappropriate protocols, inappropriate designs, or inappropriate equipment. Thus, some of these studies have not investigated neurofeedback, defined as a learning process utilizing operant learning mechanisms of brain activity.

Not all neurofeedback research and clinical studies can claim to involve operant conditioning, as they do not have fundamental components of operant conditioning paradigm 1. The gold standard for efficacy assessment in medicine is still RCT and future well-designed clinical trials must consider specifics of neurofeedback methodology and adopt design accordingly.

2. Personalization of neuro-modulation protocols and 3. psychological adjuncts are required for improvement of outcomes

The role of the therapist in the neurofeedback process and familiarity with learning rules is very important. In the words of Ute Strehl⁹, “Different from the usual bottom-up targets in behavior therapy, which are overt behavior, neurofeedback tries to directly change cortical activity. But with the help of the equipment brain activity becomes overt, too. The therapist will need to know the laws of learning as well as how to applicate neurofeedback training in order to be a competent partner in this top-down behaviour therapy approach”.

Psychological factors play an important role in neurofeedback outcomes, as attention, motivation, and mood are known to affect performance and learning. There is a need to explore predictors and biomarkers of positive outcomes and improve the process of identifying, in advance, those subjects who are or who are not likely to benefit from that specific neurofeedback protocol.

Previous studies indicate that a certain percentage of subjects cannot gain control over their brain activity even after repeated training sessions and are considered non-responders. A possible solution for treatment ineffectiveness reported in some studies is to take a more personalized approach and adapt the treatment protocol to the needs of each subject. There are many more important factors affecting outcomes of neurofeedback training, for instance one of them is a dosage, or in other words, the number of optimal training sessions.

In clinical settings, the schedule of training, frequency, and time in session, are important determinants of success. However the number of training visits due to practical feasibility considerations and costs is often limited. Hopefully, new developments in availability of reliable neurofeedback devices for home use might make an important difference in this regard, especially in the current realm of pandemic.

There are many reasons why the sound scientific methods and neurofeedback treatments may be difficult to align, however, these issues can be addressed with appropriate treatment plans and rigorously designed studies based on sound scientific premises. This is a matter of dedicated time and money.

9. Why have you agreed to be an advisor to Sens.ai?

There are 3 reasons:

(1) I am excited about the integration of brain stimulation with heart rate variability (HRV) coherence training and neurofeedback. These are the best tools available to clinicians for neuromodulation.

(2) I am pleased to see functional tests included in the form of Event Related Potentials which is a standard measure for research labs.

(3) They have developed algorithms for protocol personalization based on the guidance of a prominent leader in this field, Jay Gunkelman.

I think Sens.ai is well poised to bridge the gap between clinical knowledge and scientific and medical mainstream acceptance.

10. What do you recommend for further reading?

Probably the best account about the history of neurofeedback, its status and vision of the future can be found in a recently published book edited by Evans, Dellinger, and Russell titled “Neurofeedback: The First Fifty Years”¹⁰.

The book has a coverage of the field by the well-recognized neurofeedback pioneers where they share their views and contributions on the history and their insights about the future of neurofeedback. I would strongly recommend reading this book to have a better understanding of the origin, development, and future of neurofeedback from the scientists and clinicians who were at the very frontiers of this field.

Another useful reading for the clinical service providers interested in clinical efficacy of neurofeedback application can be found in “Evidence-Based Practice in Biofeedback and Neurofeedback”¹¹ periodically published (4th edition is already in press) by the Association for Applied Psychophysiology and Biofeedback (AAPB) where the leading experts in their respective areas examine the evidence for the efficacy of treating various disorders with neurofeedback and rate their efficacy according to “The Guidelines for Evaluation of Clinical Efficacy of Psychophysiological Interventions”¹² adopted both by the AAPB and International Society for Neurofeedback & Research (ISNR).

The best account of operant conditioning as a basis of neurofeedback can be found in a classic paper by Sherlin et al.¹³ and in an editorial by Cannon¹. Probably the best discussion regarding the gold standard of a double-blind RCT of neurofeedback in ADHD justifying need, rationale and strategy can be found in a paper by Kerson and Collaborative Neurofeedback Group¹⁴. Discussion of the history and status of neurofeedback application in ADHD can be found in Arns et al.^5,6.

References

1. Cannon, R. L. (2015). Editorial perspective: Defining neurofeedback and its functional processes. NeuroRegulation, 2(2), 60-60.

2. Sokhadze, T. M., Cannon, R. L., & Trudeau, D. L. (2008). EEG biofeedback as a treatment for substance use disorders: Review, rating of efficacy, and recommendations for further Research. Applied Psychophysiology and Biofeedback, 33(1), 1-28.

3. Sokhadze, E. M., El-Baz, A. S., Tasman, A., Sears, L. L., Wang, Y., Lamina, E. V., & Casanova, M. F. (2014). Neuromodulation integrating rTMS and neurofeedback for the treatment of autism spectrum disorder: An exploratory study. Applied Psychophysiology and Biofeedback, 39(3-4), 237-257.

4. von Glasersfeld, E. (1979) Cybernetics, experience, and the concept of self. In: M. N. Ozer (Ed.) A cybernetic approach to the assessment of children: Toward a more humane use of human beings. Boulder, CO: Westview Press, pp. 67–113.

5. Arns, M., Heinrich, H., & Strehl, U. (2014). Evaluation of neurofeedback in ADHD: the long and winding road. Biological Psychology, 95, 108-115.

6. Arns, M., Batail, J. M., Bioulac, S., Congedo, M., Daudet, C., Drapier, D., Fovet, T., Jardri, R., Le-Van-Quyen, M., Lotte, F., Mehler, D., Micoulaud-Franchi, J. A., Purper-Ouakil, D., Vialatte, F., & NExT group (2017). Neurofeedback: One of today's techniques in psychiatry? L'Encephale, 43(2), 135-145.

7. Thibault, R. T., Veissière, S., Olson, J. A., & Raz, A. (2018). Treating ADHD with suggestion: Neurofeedback and placebo therapeutics. Journal of Attention Disorders, 22(8), 707-711.

8. Pigott, H. E., Cannon, R., & Trullinger, M. (2021). The fallacy of sham-controlled neurofeedback trials: A reply to Thibault and colleagues (2018). Journal of Attention Disorders, 25(3), 448-457.

9. Strehl, U. (2014). What learning theories can teach us in designing neurofeedback treatments. Frontiers in Human Neuroscience, 8, 894.

10. Evans, J. R., Dellinger, M. B., & Russell, H. L. (2020). Neurofeedback: The first fifty years. New York: Elsevier. ISBN 9780128176597

11. Tan, G.,Shaffer, F., Lyle,R., & Teo, I. (2017). Evidence-based practice in biofeedback and neurofeedback (3rd ed.). Wheat Ridge, CO: Association for Applied Psychophysiology and Biofeedback.

12. La Vaque, T. J., Hammond, D. C., Trudeau, D., Monastra, V., Perry, J., Lehrer, P., Matheson, D., & Sherman, R. (2002). Template for developing guidelines for the evaluation of the clinical efficacy of psychophysiological interventions. Applied Psychophysiology and Biofeedback, 27(4), 273-281.

13. Sherlin, L., Arns, M., Lubar, J., Heinrich, H., Kerson, C., Strehl, U., & Sterman, B. (2011). Neurofeedback and basic learning theory: Implications for research and practice. Journal of Neurotherapy, 15(4), 292-304.

14. Kerson, C., & Collaborative Neurofeedback Group (2013). A proposed multisite double-blind randomized clinical trial of neurofeedback for ADHD: Need, rationale, and strategy. Journal of Attention Disorders, 17(5), 420-436.