Gary Ames, Licensed Psychologist
Specializing in EEG Biofeedback
28 Rock Hill Road, Bala Cynwyd, PA 19004
610.668-3223 phone <> fax 610.668-0213
Informed Consent for EEG Biofeedback
Biofeedback aims to improve the efficiency and effectiveness of the nervous system. Most people with mental health issues have parts of their brain that are overactive or underactive or both. The goal of EEG Biofeedback is to normalize these frequency-amplitude patterns. For example, too many fast brain waves in the back of the head is feels like a busy brain and is common in families with a history of addictions. Biofeedback training is practice in making better brain waves. Within a few hours of practice, we typically see a significant reduction in a broad range of symptoms.
What is EEG Biofeedback?
Biofeedback is a self-healing process using self-awareness and self-control technology. Biofeedback is a training procedure using a brain-computer interface that enhances self-regulation of the nervous system.
In neurofeedback a mind-body signal is monitored using specialized equipment that detects EEG waves. Then some of that information is converted by computer software into audio-visual output and fed back in real time in order to guide the nervous system toward healthy patterns.
During training sessions, EEG biofeedback sensors are placed on the ears and scalp to detect brain wave activity. First, small areas of the ear lobes and scalp are cleaned with an abrasive, Nu-Prep. The sensors are coated with 10-20 Paste to create a good connection so that they can read the microvolts (millionths of a volt) emanating from the brain through the scalp. EEG biofeedback is NOT about electricity going into the brain.
At the end of the session this is cleaned off with an astringent such as witch hazel on a small sponge. This means that the trainer is putting his hands on your head and ears to clean spots, apply sensors and remove paste. This is practically never a problem. Earrings can usually stay on.
An EEG amplifies the brain wave signal and sends it to a computer for processing. The software produces sounds and/or images that are intended to guide the brain to modify its operation toward multiple thresholds.
What is happening during a session?
In eyes open training we inhibit slow brain wave frequencies (1-12 Hz) and very fast brain waves (60-120 Hz) and reinforcing medium fast brain waves (12-30 Hz). There is also coherence training to improve the coordination of information between the two brain hemispheres and throughout the range of brain wave frequencies. This is called cross-frequency coupling. Two sets of exact frequencies for you are determined with an EEG assessment.
During eyes open training sessions there are 2-minute blocks of training with a 20-second break in between. This consists of 16 minutes of one “fast” protocol in 8 sections with breaks and another 8-minute “slow” protocol broken into 4 blocks.
Eyes-closed alpha-theta sessions have no such breaks and default to 24-minute sessions.
In eyes-closed training, only slow theta (4-8 Hz) and alpha (8-12 Hz) waves are reinforced.
Let me know if you often have emotional difficulty sitting quietly with your eyes closed for 24 minutes. Especially for those with a severe history of trauma or PTSD, early sessions may be limited to 7 minutes. There are also relaxation exercises requiring verbal prompts from you in order to distract you during the first couple of sessions. This procedure ensures that all eyes closed alpha-theta sessions are pleasant experiences.
Goal Setting, Evaluation and Protocol Selection
We want to identify issues that most detract from the quality of your life. Two to four primary goals are established. Goals should be quantifiable. Some examples:
- ADHD: Spend 30 minutes a day looking for things I’ve misplaced. Or search 2 times a day…
- Anger: Confront someone for a minor offense 4 times a week. Or yell at 3 drivers per commute.
- PTSD: Bad thoughts of past losses 2 times an hour. Or consumes 70% of my free day.
- Addictions: Think about using drugs 50% of each day. Or can’t hold a job for a week.
- Sleep: When I go to bed it takes me 2 hours to fall asleep. Or I fall asleep 50% of the time at the movies.
Before training begins an assessment and evaluation are performed. An initial determination is made as to what category of training is expected to be most productive for you to achieve your goals. The exception is that for bipolar mood disorder no further assessment is needed until moods stabilize.
The Performance Game
In most cases the EEG assessment consists of a BrainPrint performance game task. Here reference sensors and a ground sensor are applied to both ear lobes. Two active sensors are applied to your scalp, usually a few inches above each ear. You take a mouse in both thumbs and respond to a series of graphics: L, R, P (left mouse button, right, pause) on a continuous performance test. This usually takes 10-20 minutes. The instructions for the performance task are to work as quickly and accurately as you can. This test detects when your brain is working both well and poorly. The results are sent away anonymously and a custom protocol is produced that corresponds with your brain at work. There are two versions of the protocol: 16 minutes and 8 minutes which are specific for low medium and high frequency brain waves.
You may also be asked to complete a SCL-90 symptom checklist to assess progress every 10 sessions. This assessment takes between 7-10 minutes to complete.
Feedback: Screens, Tones
The training screen has 3 main parts. One is text indicating if tension and presence are increasing or decreasing. Another is a What Is / What Isn’t bar that fluctuates. This is a threshold indicator. What Is means what is preferred. You want to be within the 8 EEG thresholds more often. You are asked to right click a mouse whenever the What Isn’t bar turns blue.
The largest screen shows fractal images that change dozens of times per second. Any change in shape, color, or position of the images is based entirely on the morphology of the brain wave input. This is feedback without guidance and is inherently stabilizing to a complex dynamical system.
Most of the EEG guidance comes from the audio output. These complex tones are naturally reinforcing based on the 8 thresholds that are being monitored and trained.
Course of Treatment
After the first session, each session begins with a conversation and assessment of progress on each of your goals. As issues are resolved, new goals may be established at any time.
Initial training sessions at the first site on the scalp above the ears will continue for several sessions and for 5 sessions after meaningful progress has stopped on all goals. The five extra sessions are to consolidate the progress for the future. At that point a re-evaluation is done and a new protocol is determined. Usually the 2 active sensors are moved to the forehead.
That may be a complete course.
You may stop EEG biofeedback training at any time. A normal course often consists of 20-30 sessions. These can occur as often as 2-4 times per day or 2-5 times per week. Progress is harder to see when sessions are conducted only once per week or less.
If you complete 20 sessions within 12 weeks or less then you can expect the benefits derived to be sustained long term. Some practitioners note that their clients report that brain functioning improvements continue growing for 6-8 months after completing a course of training as consolidation of the central nervous system occurs.
Sometimes we may do some eyes closed alpha-theta sessions or other forms of neurotherapy.
Adverse Effects and Contraindications
Hundreds of research studies have been published on EEG biofeedback since the late 1960s. No research study has mentioned adverse effects or contraindications. That means EEG biofeedback will not hurt you and anyone can do it. Thus, it is safe for pregnant women and those with a recent head injury to do neurofeedback.
However, practitioners have noticed that slight adverse reactions sometimes occur. They are rare, minor and go away on their own such as a headache or arousal which is sometimes noticed as more vivid dreams. If they occur and are unpleasant, they can be prevented in subsequent sessions by altering the protocol to prevent unwanted effects. This may slow progress and you we can discuss how to proceed. The final decision is yours.
In eyes-open sessions you will see a fractal graphic with rapidly changing images. As far as we are aware, this has never caused any seizure activity. These images can be blocked for those with schizophrenia.
Detect and Report
At the beginning of each session you will asked to notice what you have felt and to report those impressions. Each session begins with reviewing the goals established in the beginning. You will be asked if there are changes, and if so, how much—0-100% in either direction. For example, if you started with 3 panic attacks a week and now report only 1, then that is 66% resolved.
It is important for you to detect or notice these areas within yourself for the 24 hours after a session and report it to me so that protocols can be adjusted for you if needed. Note that this system does not produce a useful EEG record showing objective progress in the brain waves. It is not about your EEG, it is all about the quality of your life.
Also, you will be asked specifically about the 24 hours after each session in the following categories:
• Falling asleep
• Staying asleep
• Predominant Mood
• Genal progress
• Attention since
• Other reactions
The BrainMaster Atlantis EEG is used which is cleared by the FDA for relaxation. BrainPaint is the clinical software system. Both can only be obtained by licensed health care professionals.
Conditions That Respond to EEG Biofeedback
Research on EEG biofeedback has been conducted since the late 1960s and has been reported in various books, journals, at conferences and within practitioners’ offices. A consensus has emerged from those conducting EEG biofeedback on a regular basis that EEG biofeedback is or may be beneficial for the following categories:
Optimal functioning: students, meditators, performing artists, athletes, soldiers, executives. Everybody: IQ, sleep, mental focus, memory, emotional health, personality factors.
Brain: seizures, stroke, traumatic brain injury, coma, migraine.
Lifestyle: drug & alcohol abuse, criminality, eating disorders.
Arousal: stress, anxiety, headache, obsessionality, anger, PTSD, psychological trauma.
Chronic: asthma, IBS, TMJ, chronic fatigue, immune suppression, fibromyalgia.
Not just kids: ADHD, autism, Asperger’s, Tourette’s, tics, learning disorders.
Women: PMS, menopause, hot flashes, infertility.
Major: cancer, obesity, diabetes, hypertension, chronic pain, depression.
Most research studies on any of these conditions typically show an 80% success rate. There is little consensus on why 20% of people competing a course of EEG biofeedback training do not respond. Possible causes for non-responding include nutrition and other external constraints such as family dynamics. Experienced clinicians tend to perform better with their clients than research subjects in laboratory conditions constrained by experimental trials with rigid protocols.
A more conservative list of conditions affected by EEG biofeedback depends on the evaluator’s level of rigor. Many academics and nearly all insurance companies who are asked to pay for EEG biofeedback say that it is experimental for all conditions. They do not consider any conference presentations, certain journals, some research conditions, particular research paradigms, small sample sizes, and other factors that cause them to completely ignore those results.
For several decades the neurofeedback community published their research in the Journal of Neurotherapy hoping to get that journal elevated to high status including being listed in PubMed. But certain technical publication conditions were not met by the volunteer editors (such as 4 publications per year) and now all those hundreds of articles are hard to find.
EEG biofeedback has been shown to help a variety of conditions at more conservative levels of rigor. Much research shows that attention deficit/hyperactivity disorder (ADD/ADHD) responds well to this approach. https://www.ncbi.nlm.nih.gov/pubmed/29445867
Neurofeedback has been found to be effective with all kinds of epilepsy, on average producing a 70% reduction in seizures. https://www.ncbi.nlm.nih.gov/pubmed/19715180
Chronic alcoholics tend to have lower levels of alpha and theta waves with more fast beta waves. Neurofeedback training can achieve up to 80% success in creating long term abstinence. http://polysubstance-abuse.com/evidence-based-treatment-addiction several studies.
Using alpha-theta training, studies have shown that people who have Post Traumatic Stress Disorder (PTSD) have significant reductions in symptoms as well as a reduction in medication.
Other strong evidence of effectiveness exists for depression, anxiety, migraine, chronic pain, and minor traumatic brain injury. Here is a comprehensive bibliography of research: https://www.isnr.org/isnr-comprehensive-bibliography.
Use Google or Google Scholar with the search terms (neurofeedback or EEG biofeedback) plus any term of interest.
Some sites of interest:
You could read that neurofeedback may reduce ADHD symptoms it doesn’t do better than sham treatment or other forms of therapy. This is wrong. Pharmaceutical companies have billions of reasons to discredit a method that has their patients reduce or eliminate medications. They have sponsored studies that do neurofeedback badly and support research with sham treatments that have positive effects. Then they claim no benefit. There are plenty of conference presentations, research studies and published articles that show significant and enduring benefits to neurofeedback. See: The Fallacy of Sham-Controlled Neurofeedback Trials: A Reply to Thibault and Colleagues (2018)
Despite substantial research and considerable clinical experience, conservatively speaking, EEG biofeedback is not considered a medical device or a treatment for any disorder.
How it Works
Nothing is more complex than the brain. Neurons are firing trillions of times per second in your brain. There are many ways to describe what happens with biofeedback.
More complex. When researchers use the Hurst exponent to look at changes in the stream of EEG before and after a batch of sessions they find greater complexity. Think of your symptoms as being ruts in the road. You keep falling into repeated patterns that are hard to escape. With greater complexity come more useful options.
Flexible and Resilient. This is a concept from chaos theory. Think of carrying the ball down a football field. You want to find creative ways to move around obstacles. You want to maintain your balance even when grabbed. You want to move through your day fully capable without internal distractions.
Enhanced dopamine This is a feel good neurotransmitter. Neurofeedback seems to enhance bio-availability of dopamine.
Exercise or Conditioning The biofeedback training is practicing using certain brain wave frequencies. People with problems have some parts of their brains that are over-active and some parts are under-active. During training you are both encouraged toward and discouraged from moving along 8 thresholds at the same time. Think of driving down the middle of the lane without running over the lines. Or think of riding a bike without wobbling. Neurofeedback is skill building. Practice more sane brain waves and you get more sanity in your life.
Efficiency We can see from fMRI research that the ADHD brain finds a quicker, more direct path to activation and inhibition.
Learning Biofeedback is a training procedure where you monitor a biological signal, such as finger temperature or brain waves with an EEG. The signal is processed and feed back to the eyes and ears for the purpose of self-correction. This is ‘look and learn’ or trial and error learning called operant conditioning. In some biofeedback, the learner must intend to make the numbers go up. With BrainPaint, the musical tones cue the brain toward or away from desired patterns on multiple thresholds.
Non-linear dynamical self-regulation Adding feedback to a dysregulated complex system promotes self-organization. Think of a population census or economic activity data that is used to make public policy. Just watching fractals images that respond to the morphology of your brain waves dozens of times per second helps the central nervous system understand itself and work better.
Balance and harmony We see from QEEG brain maps that the intensity of certain brain wave frequencies are abnormally high or low at various sites in the brain before training. After training these maps show more normal ranges of both frequency and connectivity between sites. These pictures look like re-wiring brain patterns toward normalization of activity and internal communication.
Perceptual instincts Science studies normal EEG reactions when first receiving a stimulus called event-related potentials. There are EEG patterns of response within a split second that depend on the sound, picture or task. There is a predictable slowness in those with ADHD. EEG biofeedback normalizes these instinctual reactions and processes. https://www.ncbi.nlm.nih.gov/pubmed/20843737
Autonomic normalization. There is the central nervous system (brain and spinal cord) and the autonomic (peripheral) nervous system for the rest of the body that regulates activation and relaxation. You’ve heard of fright, fight flight. The opposite is rest and digest. These systems are constantly shifting balance throughout your body and regulating you in the world. Training the brain normalizes the ebb and flow of the body’s nervous system. Biofeedback enhances the range and flexibility of the nervous system.
There are no adverse effects or contraindications reported in the scientific literature. If you are taking prescription medication, it is important to remain in close communication with your prescribing physician.
Some EEG Biofeedback trainers notice that the effects of medications become stronger early in a course of training. Then as the underlying condition is resolved within the brain, the same dose of medication will become an overdose and produce more side effects. In some cases, a person will experience increased side effects of the medications unless they reduce the dosage.
In many cases, the need for some or all of your medications may decrease after a series of neurofeedback sessions. Let your prescribing physician know so they can make any changes to your medications. Do not make changes without seeking medical advice. Many EEG Biofeedback trainers have noticed that benzodiazepines (Xanax, Klonopin, Adavan, Valium, etc.) may slow or prevent progress in about 40% of clients.
HIPAA stands for the Health Insurance Portability and Accountability Act. The system I use is called BrainPaint. It uses HIPPA compliant protocols. Confidentiality is treated seriously. Your data is kept anonymous as much as possible with codes used to transfer protocols. The system keeps a record of dates of service, progress on goals and protocols used plus any additional notes and assessments within the system. These can only be seen locally.
Gary Ames is a masters level psychologist with an MBA. Mr. Ames has been practicing EEG Biofeedback since 2002. He is or has been a member and/or Board Member of several national and regional biofeedback societies. Since 2007 he has fulfilled the bulk of his continuing education requirements from neurofeedback conference presentations.
Gary Ames, 28 Rock Hill Road, Bala Cynwyd, PA 19004. Office 610.668-3223, or Email GaryAmes at comcast.net. Fax 610.668-3223
When insurance is not involved, the average cost of EEG biofeedback sessions in America is $125 per session. Thus, for a course of 25 sessions the total is $3125. Many other neurofeedback systems require 40 sessions as their standard. I charge based on a sliding scale between $80-135 per session, depending on where you are economically. There are quantity discounts when purchasing a block of sessions.
I accept some, but not all insurances for partial payment. Insurance may have co-pays, deductibles and limits. It is rare for an insurance plan to cover neurofeedback. For us, insurance only covers the clinical session, not the neurofeedback. Using the neurofeedback technology requires a separate additional fee between $35-85 per session, this is on a sliding scale, depending on your capacity to pay. Let’s discuss. I do want to make this possible for you.
I feel sufficiently informed about EEG Biofeedback, Assessment, Confidentiality, Frequency of Training, Medication Interactions, Therapeutic Indications, Right to Discontinue Training, Cost, Qualifications of the Trainer and my Duty to Detect and Report. I have had the opportunity to ask questions and I am satisfied in my level of understanding. I am willing to participate in the success of this neurotherapy program.