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If it’s so good, why has neurofeedback gained such limited traction?

Neurofeedback is a safe, non-invasive treatment that works across the spectrum of mental health concerns. Because the feedback is embedded in either a movie or video game format and requires no conscious effort, it can be used with clients across the life span or who demonstrate little insight or even actively participate in the therapy. The costs of implementing ILF Neurofeedback are reasonable and the entire package of equipment, training and data collection exist now, not in some promised future. This then leads to the question, why has neurofeedback gained such limited traction? The answer, we believe, lays with the barriers, obstacles and headwinds it has faced.

The first barrier is how it arouse outside the usual paths to acceptance of mental health treatments. Most typically, a method is developed, most often within a university setting where researchers then put the idea through a series of controlled studies, preferably with a blinded or double blinded design. Eventually, enough studies and even meta-studies are conducted to compel health insurers to approve the treatment for coverage. This in turn leads to much wider acceptance of the method as clinicians seek training in the new method. This is the model underlying the acceptance of Cognitive Behavior Therapy (CBT) and its allies such as Mindfulness, ACT, etc.

The problem with neurofeedback is that it is a technological treatment relying on proprietary software and hardware. There is no incentive for academic researchers to devote their career to validating a technological product to which someone else would be the financial beneficiary. Put simply, if CBT were a wholly owned product of Johnson & Johnson, how many researchers would be interested in validating it?

The other route to scientific acceptance is to have a well-financed corporation undertake the R & D costs necessary to validate the methodology or device and then recoup those costs in the marketplace. The problem here is that neurofeedback is a training process. The underlying technology is in the public domain and cannot be patented. Thus there is no clear path to recouping the investment. 

Probably the greatest obstacle to its wider implementation is the demand for more research to prove its efficacy. It is true that neurofeedback has not been tested in enough multi-site, multi-year random controlled studies, the so-called “gold standard” for academic acceptance. But an objective consideration of literature would reveal that by just count alone, the existing evidence is significant. The number of published articles on all aspects of neurofeedback in the bibliography of the International Society for Neurofeedback Research, the professional organization runs to 30 single-spaced pages. And while some reports of outcomes of neurofeedback training involve a small number of subjects, recently Dr. Siegfried Othmer of the EEG Institute released a study using an objective measure of improvement following neurofeedback of 12,500 subjects. In a world where fewer than 50 subjects is not unusual, a sample size of this magnitude should command respect.

The constant headwind for neurofeedback has been the charge that it is just a placebo. Part of the problem here is that neurofeedback was discovered before the concept of brain plasticity and neural networks. Dismissing neurofeedback as a placebo is an easy (and lazy) way to assert one’s authoritative expertise without actually investigating the field first hand. Unfortunately, in the early years of neurofeedback’s development, the derision was so intense that it drove many researchers either out of the field or to take their work underground. These pioneers deserve tremendous recognition for their persistence.

Fortunately, the tide seems to be turning. Certainly, the discussion of the value of neurofeedback by Besel VanderKolk, a prominent trauma researcher, has helped bring awareness of the field to more receptive audiences. Still others have only shifted from “all placebo” to “mostly placebo” to now calling it “somewhat placebo”. The term “die hard” exists for a reason.

There are other more practical obstacles to neurofeedback. One is the cost of training and equipment. Compared to nearly all medical treatments, neurofeedback is cheap. In mental health however, the only typical cost is a couple of chairs or sofas, so mental health clinicians are faced with an unaccustomed outlay when considering integrating neurofeedback into their practice. Given that there is a shortage of licensed mental health care providers, most clinicians are already busy and there is little incentive to undertake the time and cost of providing neurofeedback.

Insurance too is an issue. Reimbursement codes for neurofeedback do exist. However, most insurers refuse to recognize them, usually with the claim that it is “investigational”. Of course, if they were to accept the code, then they would be faced with a demand for services they would have to cover. That is not in their financial interest.

Of course, not all barriers, obstacles and headwinds were bad. They pressed the field to work harder, to prove and improve. What we can accomplish with neurofeedback today is light years ahead of what was possible early on. But this is also true for most developments in medicine. The point is that it is time to more forward. It is our belief that taking neurofeedback to agencies and the underserved and difficult to treat clients, we can both serve their clients and gain broader recognition for this exciting treatment.

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