Neurofeedback Is Training, Not Treatment

The terms training and treatment are often confused, and their meanings and definitions vary depending on the context. The distinction between training and treatment, however, is not merely semantics but has significance for how biofeedback and neurofeedback providers think about what they do, how they do, how they represent their services to recipients, and how well those recipients can engage with the feedback process and subsequently apply what they have learned. This post defines and contrasts treatment and training approaches, presents the implications of the two general approaches, and suggests that biofeedback and neurofeedback are best considered training rather than treatment.

Treatment in Medicine

A simple example of treatment is the use of aspirin or other analgesics to "treat" pain. The analgesic may or may not remove the cause of the pain, but it does provide relief from the pain sensation. The analgesic is a palliative treatment that acts without effort by the recipient. (Gueven & Dietis, 2021).

Because analgesics directly reduce pain, they are considered a pain treatment. Similarly, the occasional application of ice to a bruise during the first 24 hours after injury directly reduces the leakage of blood into the tissues from injured capillaries, thus reducing swelling and attendant pain. Again, this is an example of a treatment for the injury that doesn't repair the injured tissues but reduces the effects and the experience of pain and discomfort (Bleakley et al., 2004).

In medical practice, certain medications are used to treat illnesses, such as antibiotics for bacterial infections, medications to reduce high blood pressure, and other medications to treat migraine. Medications may treat an illness's effects or causes (James et al., 2014).

These examples of treatment interventions follow a pattern. They represent something done to the patient rather than something the patient learns to do, such as skill acquisition.

Other examples of treatments include some physical therapy interventions such as massage, application of hot and/or cold packs, application of vibration or other types of stimulation, and more. Conversely, physical therapy interventions often include instruction in body mechanics (sitting, standing, or lifting) and general stretching and strengthening. These, however, might be thought of as learning experiences and fall under the general umbrella of training that allows the recipient to gradually and consciously acquire or strengthen skills over a series of learning sessions (Brosseau et al., 2005).

Confusing Training and Treatment in Biofeedback

When we consider the field of applied psychophysiology and biofeedback, we find that both terms, training, and treatment are often used interchangeably. Each of these terms may be combined with the terms client and patient. The use of these terms, to some extent, follows the core discipline of the provider. Patient and treatment are often used if the biofeedback practitioner is a medical professional such as a physician or nurse practitioner. Mental health professionals such as counselors, licensed psychologists (LP), and licensed clinical social workers (LCSW) often use client and treatment. Medical professionals treat diseases, and mental health professionals treat mental health disorders. Individuals providing biofeedback without a clinical license often identify themselves as coaches and use the terms training and client (Moss, 2020). This can lead to nontrivial confusion about what is being provided and the expectations for the person in either a patient or client role. In turn, the necessary collaboration between the provider and recipient of biofeedback or neurofeedback may be jeopardized, and beneficial outcomes may be reduced.

Most new clients are naïve about neurofeedback and benefit from sometimes repeated education about what to expect regarding the experience and what they can do to maximize its effect (Huang & Huang, 2022). Whereas information about experiences to expect is often given when providing treatment, informing the client about what they can do to maximize outcome falls more in the category of training.

A client's attributions about training or treatment may contribute to the durability of gains. For example, if a client attributes her/his good outcome, at least in part, to their own efforts, they are more likely to persist in skill application and enjoy long-term benefits once training has ceased. They may achieve better outcomes if their trainer progressively educates or "socializes" them about their roles (Zimmerman, 2000). By contrast, a patient who sees themself as a passive recipient of treatment may attribute good outcome to the presence of the treatment, this being the case for conditions that cannot be decisively cured, for example, some mental health problems, chronic health issues, and peak performance.

When researching the term treatment in a mental health context, one finds information on treatment for substance use and abuse disorder as well as inpatient treatment for severe, acute mental health problems such as suicidality with active plans or attempts, self-harm or harming others, extreme withdrawal from life tasks with self-neglect or due to psychotic episodes (Drake et al., 2004).

Other sources list various therapeutic approaches in counseling and psychotherapy, such as psychoanalysis and psychodynamic therapies, behavior therapy, cognitive therapy, humanistic therapies such as client-centered therapy, Gestalt therapy and existential therapy, and various integrative or holistic therapy approaches (Short & Thomas, 2014).

However, this categorization of therapeutic approaches appears to involve less in applying a treatment to the client and more of a collaborative process where the client is involved in self-exploration, learning new thinking or behavioral strategies, and/or experiencing the effects of the therapeutic relationship. These approaches seem to be more in the realm of training, although they could also be termed experiential. The patient/client doesn't learn to change their body/mind when taking an aspirin, but the goal of many other interventions seems to be learning in some form.

Biofeedback is Training

In all its aspects, biofeedback, from simple hand temperature training to the most complex 19-channel swLORETA neurofeedback, is all about training. Clinicians providing any biofeedback are involved as teachers or coaches, providing an opportunity to re-think the terminology we use. The concept of coaching vs therapy is one place to start. Coaching is not government-regulated. There is no current licensure for behavioral, life, performance, relationship, or other types of coaching. As such, coaches are not qualified by licensure to provide mental health therapy or counseling (Aboujaoude et al., 2020). However, much of what a coach may do involves motivation to change, similar to what a therapist does. A therapist may also engage in behaviors that may seem like coaching.

Because of the potential for confusion, Jasper (2015) suggests the following: "The practice of coaching and the practice of psychotherapy are distinct and, as such, it is recommended the practices be advertised separately to avoid confusing and/or misleading clients regarding the scope of work performed as a coach and/or psychotherapist. When practicing both professions, the best practice would be to have different business names, separate letterhead, business cards, promotional materials, and websites."

This may seem extreme since many biofeedback practitioners have a mental health license and provide therapy services along with biofeedback in an integrated format. Biofeedback exists within an educational format, while therapy may follow a different format. However, the two together provide useful tools that benefit the client in many ways that may not occur when used separately.

Kleinbub and colleagues (2020) suggest that integrating biofeedback information can be helpful when used as part of the therapeutic process. Monitoring galvanic skin response (GSR) and heart rate (HR) information can reveal hidden anxiety or stress reactivity in the client, which can help identify both emotional and psychological triggers and improve interpersonal feedback between clinician and client. Kleinbub quotes Carl Jung regarding GSR, where he states, "Aha, a looking glass into the unconscious!"

Even more pertinent to this discussion is the statement by Sebern Fisher in her paper on integrating neurofeedback training with psychotherapy (2007). "When reporting outcomes with the use of neurofeedback, it is especially important to make a distinction between training and treatment. Although initially Lyle wanted nothing to do with psychotherapy, he was fully engaged in treatment within 50 sessions of training. Ultimately, it isn't easy to know how to attribute his success. Both Lyle and his therapist agree, however, that for him, neurofeedback made psychotherapy possible. Operant conditioning of his brain waves provided him with the capacity to regulate his affect in a way that prior therapy and medications had not. The psychotherapy then offered him the expansive opportunity to talk about what he was experiencing as fear drained away. The experience of greatest importance to him was stepping into the interpersonal world through empathic engagement with himself and others."

Biofeedback and neurofeedback involve learning through feedback, whether termed treatment or training. A clinician uses devices to measure physiological functions such as muscle activity (EMG), skin temperature, GSR, brain activity (EEG), heart rate, and more. These devices and software provide feedback to the client, and the clinician coaches or instructs the client on strategies to modify these functions. When applied to purely physical issues like post-injury rehabilitation, psychotherapy is typically not involved. However, recovery from injuries has emotional and psychological components, similar to managing blood pressure. Emotional self-regulation and relaxation are crucial for blood pressure control, so addressing anger, stress, and emotional suppression is vital. This raises the question: when does coaching become therapy, and is there a clear distinction between the two?

Merriam-Webster's Definitions

Merriam-Webster (2024) defines treatment as the action or method of managing and caring for a patient or condition medically or surgically to prevent, cure, ameliorate, or slow the progression of a medical issue. It includes specific therapeutic agents, therapies, or procedures for treating medical conditions. The term also encompasses products or techniques to enhance or improve performance, condition, or appearance.

Training is defined as the act, process, or method of one that trains, encompassing the skill, knowledge, or experience acquired through training. It also refers to the state of being trained.

This fairly simple definition defines training as something an individual does to acquire a skill or skills. Why is this important? Why do we care whether our work with our clients/patients is called treatment or training? Our language distinguishes the services provided by licensed and non-licensed providers. Licensed providers who use the term treatment may find that the term training facilitates an optimal attitude for the client/patient.

Patients/clients seeking biofeedback providers may initially think about treatment interventions where the biofeedback device fixes the presenting problem. This is a common attitude among clients (personal experience), and they can often be somewhat anxious about what the device is doing to them. This concern allows the clinician to correct such misconceptions and explain that the biofeedback device does nothing to the client but provides information and encouragement through a rewarding feedback display that helps the client learn new physiological self-regulation skills.

AAPB and ISNR Definitions

However, many clinicians and even professional societies continue to use the term treatment. The first sentence in the About BioFeedback section of the Association for Applied Psychophysiology and Biofeedback (AAPB) website is: "Biofeedback has evolved from a fascination in the 1960s and 70s to a mainstream methodology today for treating certain medical conditions and improving human performance ..."Biofeedback has been shown to be an effective treatment for migraine and tension type headache, urinary incontinence, high blood pressure, anxiety, and a number of other conditions. A growing body of research indicates that neurofeedback, (also known as EEG biofeedback) is an effective treatment for attention deficit hyperactivity disorder and can help manage the symptoms of autistic spectrum disorders, brain injury, posttraumatic stress, seizures, and depression."

Again, the term treatment is frequently used, even though other paragraphs contain descriptions more in line with a training paradigm, such as "Biofeedback is a process that enables an individual to learn how to change physiological activity for the purposes of improving health and performance."

The International Society for Neuroregulation and Research (ISNR), in its website section on What is Neurofeedback, uses more training-based terminology to describe neurofeedback training (NFT) such as: "Based on this feedback, various principles of learning, and practitioner guidance, changes in brain patterns occur and are associated with positive changes in physical, emotional, and cognitive states ... Being a self-regulation method, NFT differs from other accepted research-consistent neuro-modulatory approaches such as audio-visual entrainment (AVE) and repetitive transcranial magnetic stimulation (rTMS) that provoke an automatic brain response by presenting a specific signal. Nor is NFT based on deliberate changes in breathing patterns such as respiratory sinus arrhythmia (RSA) that can result in changes in brain waves. At a neuronal level, NFT teaches the brain to modulate excitatory and inhibitory patterns of specific neuronal assemblies and pathways based upon the details of the sensor placement and the feedback algorithms used thereby increasing flexibility and self-regulation of relaxation and activation patterns."

The Participant's Role

The primary difference between the concepts of treatment and training is the participant's role. If they are receiving treatment, then their role is essentially passive. Practitioners instruct the patient to report changes experienced, either positive or negative. The patient is not empowered to effect change but is provided with an intervention that hopefully reduces symptoms.

Training, on the other hand, is a learning process. Learning requires repetition, client participation and engagement, reinforcement, consistency, and attention to outcomes. Additionally, the intensity of the reward, the ability to generalize skills learned to everyday situations and tasks, and the degree of meaning or importance to the client's life are all crucial to attaining mastery. Self-regulation training can increase a client's internal locus of control, the belief that one can influence events and outcomes through one's own actions and decisions (Culbert et al., 1996). An internal locus of control is important in self-regulation training because it empowers individuals to believe they have control over their behaviors and outcomes. This belief enhances motivation, persistence, and the ability to effectively implement and maintain self-regulatory strategies (Ryan & Deci, 2000).

New clients are often naive about self-regulation training and what to expect of their providers. A client must become a willing and engaged participant in the training and learn to accept responsibility for their change process. This also extends to accepting credit for the positive changes. When clients talk about improvements, they may try to credit the practitioner for these changes. The practitioner needs to reflect this back to the client, reinforcing that these changes resulted from the client's efforts, willingness, and ability to engage in the change process. To quote Jay Gunkelman's 2024 AAPB Lifetime Achievement Award acceptance speech, "Don't blame me for your damn success!"

Similarly, clients must become knowledgeable about and engaged in the training process. Because this is training, the clinician needs participation and, most importantly, feedback from the client. Clients sometimes resist telling the provider about the negative effects of the training, believing incorrectly that these are necessary side effects and have to be endured for the sake of the hoped-for improvement or that the therapist knows what they are doing and, therefore, doesn’t need any input from the client.

Of course, the opposite is necessary to the process. The provider must hear about any positive or negative responses so that training can be adjusted for optimum results. A negative effect generally means the client has used the feedback and experienced a change. Because that change is negative, the training needs to be altered, possibly only slightly, to shift that change to a positive one. Again, this requires the client's active involvement in fine-tuning the training process.

This is like any other learning process, such as playing a musical instrument. This involves practice and feedback – one hits a key on the piano keyboard and hears the note (feedback). Hitting another key or combination of keys results in additional feedback – possibly discordant- and this provides the information needed to correct the placement of the fingers on the keyboard. One hears a progression of notes and begins learning about scales, intervals, timing, rhythm, volume, and intensity. Frequent repetition results in improvement, and progress is directly related to how much time, care, and interest the budding musician is willing to invest. Biofeedback is similar, but the learning is about one's own physiology, and the results are greater self-mastery, greater integration, and improved performance.

Below is a table that summarizes the characteristics of treatment and training with artificial dichotomies. Some characteristics overlap, and there are many instances when biofeedback or neurofeedback training may take on treatment characteristics. For example, neurofeedback for migraine headaches may essentially eliminate signs and symptoms of migraine to the degree that the condition is durably cured. However, this, too, is the result of training the client to correct the dysregulation that results in the migraine event and is not the result of any active input from the neurofeedback training system. Conversely, treatment may often take on training qualities, as when range-of-motion exercises are provided to a passive patient and then later trained for self-administration through a collaborative therapeutic interaction. Or, in the case of medicine, a somatic treatment, which may have effects on both the body and mind.

Although a provider may be licensed to provide medicinal treatment, for example, they may also provide biofeedback training in isolation or combination with treatment. However, the provider must understand that the expectations and change processes differ between treatment and training approaches so that they can intentionally engage the client in the learning processes involved in training to optimize the outcome.

Conclusion

Although these may seem like small and unimportant distinctions, they speak to the heart of biofeedback. Biofeedback of all types involves learning and education, skill development, acquisition, and mastery. The clinician is a guide, a provider of equipment, software, expertise, support, and encouragement, and ultimately, a coach, cheering on successes and ensuring credit is given where credit is due.

Glossary

internal locus of control: the belief that one can influence events and outcomes in one's life through one's own actions and decisions.

training: the act, process, or method of one that trains, encompassing the skill, knowledge, or experience acquired through training.

treatment: the action or method of managing and caring for a patient or condition medically or surgically to prevent, cure, ameliorate, or slow the progression of a medical issue.

References

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