A man is in a reclining chair with small flat metal discs attached to his scalp. His eyes are fixed on a liquid crystal display screen, either watching a movie, listening to music or playing a game. Meanwhile, a neurofeedback practitioner sits by his side, studying his brain activity with an electroencephalography (EEG) device.
While this may sound like a scene right out of a movie, it is, in fact, an ongoing therapy session known as neurofeedback. The technique is used to treat clinical disorders such as depression, anxiety, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD) and sleep disorders. In neurofeedback, the practitioner gets real-time feedback on the client’s brain activity while he helps the client reach optimum brainwave frequency.
Neurofeedback has been around for more than 50 years and countless hours of research have been done to prove its effectiveness. According to a recent study published in the Biological Psychiatry journal, neurofeedback can be used to help people regulate their emotions. It suggests that people would be able to control the activity of their amygdala, or the part of the brain associated with emotions, with the technique.
Vernice Si Toh, a psychologist at Spectrum of Life Sdn Bhd, says neurofeedback is still a new concept in Malaysia and there are only a few practitioners offering it. Additionally, they may be using different devices and a different name for the treatment such as brain training, brain activation or brain exercise. Nevertheless, the number of people using the therapy has grown as more and more people become aware of its benefits.
Dr Shu Lit Gen, a medical practitioner at Shu Healthcare, says he started offering neurofeedback in 2012 after seeing patients with problems he could not help, such as ADHD and OCD. “I wanted to help these patients, but back then, I did not have a way to do so. One day, I attended a talk in Singapore and learnt how neurofeedback is used to help people with such clinical disorders. I did my training there and started to offer neurofeedback here.”
He adds that a growing number of adults are seeking such treatments, especially those with high stress levels, depression and anxiety. “There are also those who seek peak brain performance; they want to achieve optimal productivity and enhance their well-being. Neurofeedback can help with that as well.”
Reading brainwaves
The neurofeedback practitioner assesses the client’s goals before choosing a suitable brainwave frequency to help him meet those goals, says Si Toh. “Once a goal has been set, different types of training can be done to reach that goal. Electrodes are attached to specific points of the brain throughout the sessions [to achieve the desired brainwave frequency].”
Brainwaves are divided into five frequencies — delta, theta, alpha, beta and gamma. Each frequency is then divided into three bands, such as lo-beta, beta and hi-beta. Delta, theta and alpha are slow brainwaves (associated with dreaming, sleep and meditation) while beta and gamma are fast brainwaves (associated with attentiveness and alertness).
Si Toh assesses and analyses a client’s brainwaves before each brain training session. She does this by attaching active electrodes to the client’s left and right frontal cortex and earlobes and recording his brain activity four times — with his eyes open, eyes closed and during two tasks — for three minutes each.
The tasks are usually watching a movie while the brainwaves are recorded, but they can also be listening to music or playing a game. “During the process, the client is expected to have more fast brainwaves, such as beta and hi-beta. However, if they are too high, it may indicate that the client is having high levels of stress and anxiety. If it is too low, he may be having low motivation levels and tends to feel very tired after certain physical activities,” she says.
“Sometimes, during the task, the client’s brainwaves may suddenly drop. This happens because some people tend to shut down their brain when they are doing something they do not want to be engaged in. So, we suggest activation training and train a specific point of their head to help them raise their beta brainwaves so that they are able to perform tasks better or put in more effort,” she says.
For the training sessions, Si Toh determines the location of 19 “trainable” points on the client’s scalp. This is internationally known as the 10-20 system. It is based on the relationship between the location of an electrode and the underlying area of the cerebral cortex.
She works with five electrodes during the training sessions — two serve as reference points, one as a ground point and two as active points. “We do not train the whole brain; only two points at a time. And we train the areas according to the client’s need. For example, if he is suffering from speech delay, we only train the two points that are related to the issue.”
Si Toh says the desired brainwave frequency depends on the client’s needs. Gradually as the brain is trained, the threshold becomes narrower until it reaches the optimal frequency. Her clients usually undergo one session a week, which lasts about 30 minutes to an hour.
The approach used — movies, music or games —
depends on the kind of feedback the practitioner aims to achieve during the session.
“For example, if we are using a movie, it will only play if the client’s brainwaves are at the desired frequency. If they are not, the movie will pause. It is the same with music; it will only play if the brainwaves are at the desired threshold,” says Si Toh.
The games, however, work a little differently. For example, in a game where the client is in control of a fish shooting bubbles at insects, the bubbles can only be shot when his brainwaves are at the desired length.
Si Toh says she realises that some clients may become frustrated with the training, but she actively monitors and sets the frequency so that the training proceeds with ease. “Adult clients know that it is a training, so it is very easy to get them to cooperate. For young clients, however, we set the training accordingly. Sometimes, if they are getting uncomfortable, what we do is ‘force play’ the movie until they are able to control their brainwaves.”
Shu actively observes the client’s behaviour during the training session. “Gradually, after the training sessions, we notice that they no longer have problems paying attention and can sit quietly for the sessions. These are indications that the training is working.”
He adds that for adult clients, he asks them how they are feeling during the session to better understand their state and help them recover faster. “For clients with anxiety, for example, I ask them if there are signs of headache or if they are feeling more anxious. The subjective response I get from the client during the session will help me adjust the frequency to speed up the whole process.”
The number of sessions needed depends on the clients’ needs. For example, Si Toh recommends that clients who suffer sleep deprivation undergo 10 sessions. “For a more complex case such as anxiety, we will have to see the client’s progress. If he progresses quickly, then we can probably move on to another type of training very quickly. If the progress is slow, then we might need to drag on. It may take 30 to 60 sessions,” she says.
A neurofeedback session at Spectrum of Life costs RM190 while at Shu Healthcare, it costs RM100.
Lasting effects
Once a client has undergone the required sessions and reached his goals, he may stop the sessions completely. Shu says unlike other types of treatment, neurofeedback allows one to retain the effects for a long time, even without regular brain exercise.
Si Toh says the treatment is akin to learning how to ride a bicycle in a particular manner. “We like to use the analogy of riding a bicycle. I will restrict the lines for you to ride your bicycle in and you need to learn how to ride the bicycle and feel the balance to stay within the lines. Gradually, you will master the skill. Later, you can still ride the bicycle even though it has been a few years since you learnt it. This is more or less how the brain training works.”
While there are studies that have hailed the benefits of this therapy, others have found its effects to be inconclusive or showing no positive outcomes. Some even state that the effects of neurofeedback are merely the result of the placebo effect.
However, Si Toh says once the clients see their improvements, they will not say it is just a placebo effect. “You need to understand, research-based settings and clinical settings are very different. In a research-based setting, the researchers use the same protocols on a lot of individuals, whereas in a clinical setting, we use a customised protocol for each client. After each session, you are shown reports on how your brainwaves are gradually progressing. You are able to see how the trainings have benefited you thus far.”
She adds that all of the neurofeedback practitioners at Spectrum of Life are certified by the Spectrum Biofeedback Certification Institute of Asia, a Singapore-based institute for clinical neurofeedback.
Although neurofeedback is a safe, non-invasive treatment, Si Toh says there are people who are wary of electrodes. “Some people, especially parents, may have a problem cooperating because they are concerned about the electrodes attached to their children’s heads. We explain to them that it is safe and they can even try it on themselves to ensure that it does not hurt.”
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