First, Do No Harm:Adverse Effects and the Need

for Practice Standards in Neurofeedback

D. Corydon Hammond, PhD, ECNS, QEEG-D, BCIA-EEGLynda Kirk, MA, LPC, QEEG-D, BCIA-EEG

ABSTRACT. Adverse and iatrogenic effects associated with psychotherapy have beensubstantiated in research for more than 40 years. Controlled research also exists in the fieldof neurofeedback (electroencephalographic biofeedback) that documents that negative effectscan occur from inappropriate training. This article presents accumulating evidence, takendirectly from acknowledgments by neurofeedback practitioners of the existence of bothtransient side effects and of more serious adverse reactions that have occurred. Unlicensedand unqualified practitioners pose a risk to the public and to the integrity and future of the pro-fession. It is vitally important that both professionals and professional societies emphasizestandards of practice and that the public be protected from individuals seeking to use neurofeed-back to work with medical, psychiatric, and psychological conditions for which they are notqualified and licensed to work. Some in the field propose pursuing biofeedback or psychophy-siology licensure as a means to establish standards of practice and address ethical concerns. Thisis a reasonable option to consider, although it may take many years to implement in variousstates. In the meantime it is vitally important that individuals offering neurofeedback servicesfor clinical diagnostic conditions be licensed to lawfully provide services for such conditions.

KEYWORDS. Adverse effects, consumer protection, EEG biofeedback, iatrogenic effects,neurofeedback

INTRODUCTION

Bergin (1971) reported 30 research studiesthat documented deterioration in a pro-portion of patients who underwent psycho-therapy. Within 6 years there were morethan 40 studies identified that demonstrated

negative effects from therapy (Lambert,Bergin, & Collins, 1977). Bergin andLambert (1978) defined such iatrogeniceffects in these words:

Deterioration implies an impairmentof vigor, resilience, or usefulness from

D. Corydon Hammond is affiliated with the University of Utah School of Medicine.Lynda Kirk is affiliated with the Austin Biofeedback & EEG Neurofeedback Center.Address correspondence to: D. Corydon Hammond, PhD, University of Utah School of Medicine, PM&R,

30 North 1900 East, Salt Lake City, UT 84132–2119 (E-mail: D.C.Hammond@utah.edu).This article is adapted from an original article in the publication Biofeedback (Vol. 35, No. 4, 2007) with the

permission of the Association for Applied Psychophysiology and Biofeedback, and Allen Press.

Journal of Neurotherapy, Vol. 12(1) 2008Available online at http://jn.haworthpress.com

# 2008 by The Haworth Press. All rights reserved.doi: 10.1080/10874200802219947 79

a previously higher state. Generally, ithas been regarded as a worsening ofthe patient’s symptomatic picture, theexaggeration of existing symptoms, orthe development of new symptoms, asassessed before and after treatment.(p. 152)

Clinical experience and research has foundthat neurofeedback has great therapeuticvalue (e.g., Hammond, 2006; Monastra,Monastra, & George, 2002; Peniston &Kulkosky, 1990, 1991; Sterman, 2000). How-ever, it has been noted previously that sideeffects and adverse reactions can occur inassociation with neurofeedback treatmentof various conditions (Hammond, Stockdale,Hoffman, Ayers, & Nash, 2001).

An abundance of evidence has demon-strated that there is a heterogeneity in theelectroencephalography (EEG) patternsassociated with various symptom complexesand diagnoses, whether it is a more commondiagnosis such as attention deficit disor-der=attention deficit hyperactivity disorder(ADD=ADHD; e.g., Monastra, 2005) ormore complex and difficult to treat con-ditions such as obsessive–compulsive dis-order (Prichep et al., 1993), schizophrenia(e.g., John, Prichep, & Alper, 1994), orautism (Sutton et al., 2005). Consequently,when treatment is not individualized fol-lowing a conscientious assessment of notonly symptoms but also of the brain’selectrophysiological functioning, we believethat there is a greater risk posed of eitherbeing ineffective or of producing an iatro-genic effect. Everyone does not benefit fromthe same treatment or need the same thing,and in fact psychotherapy studies have longsuggested that failure to individualize treat-ment is a significant risk factor for causingharm (e.g., Lieberman, Yalom, & Miles,1973).

Ethical guidelines against trying to exper-imentally induce iatrogenic effects have lim-ited the amount of research that we haveavailable on adverse reactions. However,some hard evidence does exist. Lubar et al.(1981) published a reversal double-blind con-trolled study with epilepsy in which theydocumented that uncontrolled epilepsy could

either be improved with neurofeedback or bemade worse if the wrong kind of neurofeed-back training was done. It was likewisedemonstrated by Lubar and Shouse (1976,1977) that ADD=ADHD symptoms couldboth improve but also be made worse ifinappropriate neurofeedback treatment wasprovided. This study used an A-B-A reversaldesign and established that when theta (4–7Hz) was inhibited and the sensorimotorrhythm reinforced, improvements occurredin ADHD symptoms. However, when thetawas reinforced, there was a deteriorationand reversal of the positive improvements.

A double-blind, A-B-A crossover designstudy was conducted by Whitsett, Lubar,Holder, Pamplin, and Shabsin (1982) withuncontrolled epilepsy patients. This is oneof the studies that importantly substantiatedthat neurofeedback does not teach thepatient voluntary self-regulation of brain-wave activity but rather actually recondi-tions the manner in which the brain isfunctioning. Clinicians familiar with epilepsyare aware that there is more epileptiformactivity found in the sleep EEG than in awaking EEG. In the Whitsett et al. (1982)study, sleep EEG was evaluated, and it wasdetermined that training to inhibit thetaactivity and to enhance the sensorimotorrhythm (SMR). resulted in an 18% decreasein paroxysmal activity from a baseline of72%. However, when the reward contingen-cies were reversed, there was a 29% increasein epileptiform activity (which, of course,was concluded to be detrimental to thepatients), and then following a reinstatementof the appropriate treatment, there was adecrease of more than 60% in paroxysmalactivity. These findings reinforce once againthat inappropriate neurofeedback trainingcan cause negative effects.

Incorrect assumptions about the mostefficacious treatment protocols can certainlysometimes be made, particularly by lesseducated neurofeedback practitioners. Wehave heard some individuals express to thepublic that neurofeedback never results inadverse effects. As we have pointed out, thissimply cannot be said. We have also seenpractitioners assume that because quanti-tative EEG research has reported that

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alcoholics commonly have an excess of betaactivity and a deficiency of alpha and thetaactivity (e.g., John, Prichep, Fridman, &Easton, 1988) that, therefore, neurofeed-back training to inhibit beta activity andreinforce alpha and theta is the treatmentof choice for this population. The problemis that such an assumption rests on general-ities and group averages that do not alwaysapply to individual cases.

In the real world of clinical practice,comorbidities are common and patientscan be unique. For example, Figure 1 dis-plays the quantitative EEG (QEEG) mapfrom the NxLink database for a 25-year-old chronic alcoholic patient. As can be seen,she displays an extreme excess of theta, notbeta activity. This patient fits a subtype of24% of alcoholics who have a diagnosisof ADHD (Schubiner et al., 2000). A lack

of individualization and use of an alpha=theta protocol in such a case could be anti-cipated to have the potential to seriouslycompromise cognitive function and resultin even greater problems with impulse andemotional control. As we note later in thisarticle, alpha=theta training, or perhaps weshould say inappropriately applied alpha=theta training, has particularly seemed proneto producing some adverse effects.

We should similarly note that about 10to 15% of ADHD patients have anexcess of beta rather than theta activity(Chabot, Merkin, Wood, Davenport, &Serfontein, 1996; Clarke, Barry, McCarthy,& Selikowitz, 1998, 2001a, 2001b). Somepractitioners, without having conducted indi-vidualized assessments, have simply assumedthat ADHD patients will usually have anexcess of theta activity and a deficit of beta.

FIGURE 1. Eyes closed EEG power of a chronic alcoholic patient who may also have ADHD as evidenced byabnormally elevated theta activity.

Clinical Corner 81

If the clinician then uses a canned protocolto increase beta activity in such a patient(who already has excess beta and corticalirritability), the patient could very wellexperience a seizure, anxiety, or tic activity.

THE NEED FOR MORE VIGOROUSSTANDARDS OF PRACTICE

The authors have become increasinglyalarmed about risks of iatrogenic harm andadverse reactions for two reasons. First,there have come to be an increasing numberof dealers, manufacturers, and trainerswho have been supplying EEG biofeedbackequipment directly to laypersons. Theseindividuals have no advanced degrees orhealth care licenses for independent practice,and yet many of them are opening practicesand advertising to the public that they havecompetency to work with serious medical,psychiatric, and psychological problems,including depression, bipolar disorder,uncontrolled epilepsy, obsessive-compulsivedisorder, traumatic brain injuries, stroke,autism, alcoholism, and drug abuse, aswell as ADD=ADHD and learning dis-abilities. Some equipment and softwaremanufacturers are seeking to ‘‘fly under theradar’’ of the Food and Drug Administra-tion (FDA) and are evading registrationof their equipment, whereas others areviolating FDA regulations against the saleof biofeedback equipment to unlicensed indi-viduals (or without the written prescriptionof a licensed practitioner).

Second, we have been impressed with thenumber of reports on public and pro-fessional internet list groups about sideeffects and adverse reactions. These effectsrange from very mild, transient symptomssuch as fatigue or headache to muchmore serious conditions such as exacerbationof depression, manic episodes, emotionallability, seizures, and deterioration incognitive functioning. Consequently, webelieve that it is vitally important for legit-imate and legally licensed practitionersto be aware of potential risks and for practi-tioners as well as professional societies toemphasize standards of practice. We also

believe that it is important that futureneurofeedback research not only monitorrates of improvement and lack of changebut also report the frequency of side effects,adverse reactions, and deterioration infunctioning.

NEW DATA ABOUTADVERSE REACTIONS FROMNEUROFEEDBACK TRAINING

Because research on negative effects ofneurofeedback is difficult to conduct, theauthors have compiled information fromat least seven internet list groups wherethere have been reports on these forumsof side effects and adverse reactions. Inthe material that follows we describe, and insome cases directly quote, from these reports.In every case, the identity of the list groups,equipment being used, and individual mak-ing the report have been left anonymous.We emphasize that these are actual reportsof individuals using neurofeedback. The onlychanges made were in spelling out abbrevia-tions or in punctuation. Headings have beenadded for the convenience of the reader inidentifying types of adverse effects.

Emotional Lability and Vocal Tics

One practitioner ‘‘did eyes closed alphatheta’’ training and discovered that thepatient became ‘‘very emotionally labile’’after returning home. Another practitionerdescribed a 7-year-old patient who camefor help with developmental articulation.They began by training beta at C3 and aftertwo sessions added training at C4 becausehis sleep was being disturbed by the training.They then shifted training to C3-C4, butafter several sessions the mother commentedthat she did not notice any improvements.The practitioner added bipolar training atC4-PZ, and after two sessions the mothersaid that her son was crying very easily.Therefore, the practitioner changed trainingto F3 ‘‘for the articulation and to reversecrying,’’ but instead of improving articu-lation the two sessions of training at F3

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created a vocal tic. At this point the prac-titioner admitted that treatment endedbecause the mother was ‘‘afraid to bringhim back,’’ but her son continued to havethe iatrogenically developed tic. After all ofthis trial-and-error guesswork, the prac-titioner asked for advice in the event thechild returned.

Deterioration and Loss of Improvements

‘‘Most of the meth addicts with whomI have worked have had excessive alpha. Inthe past, when working with people withexcessive alpha, I have not had good resultswith alpha=theta training, even after doing20–30 eyes open training [sessions withanother protocol] prior to the alpha=thetatraining. This group did well with the eyesopen [training], but as soon as I switchedto alpha=theta training, they lost most ofthe gains they had made. I then trained thealpha down and they quickly returned tothe level of function prior to the alpha=thetatheta training. As a result, I have avoideddoing alpha=theta training with the addictswho have excessive alpha. Instead, whenworking with meth addicts I have done a lotof eyes open suppressing alpha, often overCz, with excellent results.’’

Regression

A mother doing home training with herautistic child acknowledged, ‘‘Adverse eventshappen from neurofeedback—at least in myhome. My son regressed dramatically fromthe wrong training when we started 4 yearsago.’’ This smart mother then continued,‘‘But even with 3 years of home training,I would never train him without super-vision.’’ Nash has also noted a case ofdecompensation in a borderline or fragilepatient (Hammond et al., 2001).

Somatic Symptoms

A mother described an experience whereinterhemispheric training was done, withdominant electrocardiogram artifact present.

Immediately following the session he‘‘became very ill, sick to his stomach and ter-rible headache within an hour of leaving.’’Another practitioner reported that followinga session a patient experienced nausea, a verybad headache, worsening of tinnitus, anddisturbed equilibrium. Examples have alsobeen given of patients where frontal betauptraining has resulted in their increasingtheir facial muscle activity with a resultingincrease in headaches.

Muscle Twitches

Another practitioner described that after aperiod where a 6-year-old child seemed tohave calmed down, he then began ‘‘exhibit-ing jerking and a progression of muscletwitches, going rhythmically through thebody.’’ A different highly experienced (butunlicensed) practitioner replied, ‘‘I believeyou might have increased this reactivity. Hesounds like the bipolar children I deal with.Definitely training too high [a reward fre-quency] can increase muscle twitches.’’

Emotional Lability and Explosiveness

An experienced practitioner indicatedhaving found that with right prefrontal neu-rofeedback training where they ‘‘rewardedbeta and SMR frequencies’’ (e.g., at T4-Fp2) that it had precipitated ‘‘emotionalmeltdowns or explosions.’’

Tics

In response to a question about whetherneurofeedback could cause or worsen tics,a practitioner responded, ‘‘I suggest beingvery careful with left side training asI have seen tics increase and come backwith [neurofeedback].’’ Another practitionerdescribed reducing tics in a patient, butthen after two to three training sessions atCz, the tics were exacerbated, but furthertraining reduced them again. Still anotherpractitioner described the development oftics that consisted of mouth movements(such as licking his lips) after training that

Clinical Corner 83

reinforced a low frequency. There have alsobeen cases of Tourette’s where tics haveincreased.

A case of tics=Tourette’s and inadequatehistory gathering. A practitioner describedtreating a 13-year-old boy who started‘‘clearing his throat’’ and ‘‘making a sniffingsound’’ in combination shortly after he wasput on Adderall. After he was taken offthe medication, the tics continued. After 18neurofeedback sessions the tics haddecreased, and then the practitioner changedthe protocol for another 8 to 10 sessions,resulting in still further improvement. ‘‘Forsome reason, I added [training at site] CZto the mix,’’ and tic frequency increased.The practitioner then learned that ‘‘the boywas born without a soft spot in his skulland that he had seizures as a child. He alsowould sway his head from side to side as achild and did so until the last few years.After treatment with a CZ [placement], hestarted doing this as he walked out of theoffice.’’

Incontinence

A highly experienced practitioner wrote,‘‘I have had good results with stress inconti-nence with NF [neurofeedback]. This isimportant for all of us doing NF becausetraining too low [a reward frequency] in vul-nerable people can increase stress inconti-nence. We need to track this post-stroke orin older clients.’’ Another practitioner admit-ted, ‘‘I caused bedwetting by going too low[in the reinforcement band].’’

Enuresis

A practitioner described working with a7-year-old boy with a previous history ofbedwetting but who had not experiencedenuresis in 1 year. After about 10 neuro-feedback sessions he began having enuresisagain. The protocol used prior to theresumption of bedwetting was a broad(‘‘squash’’) protocol inhibiting 15 to 38 Hzat C3 and F3, which also resulted in whinybehavior. After his most recent neurofeed-back session, the little boy awakened

the next morning and asked his mother,‘‘Why do I always wet the bed after braintraining?’’

Mental Fogginess and Cognitive Inefficiency

‘‘One reason a practitioner might have todeviate from just doing T3–T4 [training] isbecause of people who respond to that sitelike I do—at any frequency, just too disor-ienting and I have brain fog for two days.’’Another experienced practitioner utilizinga ‘‘one-size-fits-all’’ neurofeedback systemin its default mode reported, ‘‘[The neuro-feedback system] is supposed to make peopleaware of the present moment. But I, andmost clients, get zoned out. Semi-conscious.It takes people a little while to recover frombeing groggy. We ask, ‘Are you okay todrive?’’’ This posttreatment sedation symp-tom has been previously reported in theliterature with Stockdale noting cases ofpatients where alpha=theta training had cre-ated ‘‘spacey’’ feelings or evoked traumaticmemories (Hammond et al., 2001).

Further examples of mental fogginess andcognitive disorientation. Yet another well-known practitioner in the neurofeedbackfield reported the following after alpha=theta training: ‘‘In one case a client drovethe car up on a curb after leaving theoffice; another drove through a red light;another slid through a stop sign at an inter-section; and a fourth ran into a lightpole only one block from his therapist’soffice following his first A=T session. Oh,yes, and a fifth went home and could notput two threaded pipes together, beingmomentarily spatially disoriented. In eachof these cases the people involved saidin retrospect that it was unlike them tobehave that way.’’ Imagine the potentialliability! Yet another advanced practitionerdescribed how he experimented on himself,rewarding delta activity. The result wasthe development of significant cognitiveimpairments that required a considerablenumber of neurofeedback sessions toremediate.

Another clinician described experimentingon himself with LORETA neurofeedback

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for a problem with chronic pain. He decidedto train the dorsal anterior cingulate and=orthe right insula. ‘‘I tried rewarding differentfrequencies. There was some indicationfrom a research study that one might traintheta. When I tried this, my thinking gothorribly foggy and I had to stop. I triedtraining 12 to 15 Hz, and could get no learn-ing curve. I did best with 14 to 18 Hz, andthat improved my attention back to normal,but I didn’t notice any difference in pain.’’

Another case of cognitive inefficiency.A practitioner asked for help with a clientwith presenting complaints of insomnia andanxiety, which was assumed to mean ‘‘over-arousal’’ Following an ‘‘optimum frequencyevaluation’’ at T3–T4, ‘‘we began trainingat 3 to 6 Hz [reinforcement] which seemedto be the most positive, but she seemed tobe very sensitive and not have a lot ofemotional involvement so we trained at C3–C4 instead of T3–T4, and I removed the inhi-bits. Initially, this seemed to be decreasingher anxiety and she began sleeping better.This week however, she complains of groggi-ness and lethargy, forgetfulness, so I movedup in frequency and at 18 to 21 Hz she feltmore alert. Today she’s still groggy, forgetful,so I replaced the inhibits and gave her a littletraining at F7 F8 to help with memory. Sheleft still feeling groggy.’’ The practitionerreported that the woman was not ADD and‘‘her forgetfulness does not seem to be relatedto inattention issues.’’ Rather, she was an‘‘extremely busy, productive person’’ whocould not stand the ‘‘grogginess’’ that train-ing had produced.

Sleep Disturbance

‘‘I would appreciate some feedback inregards to a youngster I am currentlyworking with. He has been diagnosed withmild to moderate autism. I have used neuro-feedback with this population before withpretty good success. With this individualI have been training up SMR on the rightside. The problem is his mother says his sleeppatterns have become disturbed, i.e., wakingup in the middle of the night and not goingback to sleep for one or two hours. This

was not a pattern before neurofeedback.’’There have been other reports that an excess-ive amount of training with a disentrainmenttype of neurofeedback has sometimesresulted in a patient feeling ‘‘wired’’ andhaving difficulty falling asleep. In one casea patient was up all night without being ableto sleep.

OCD Symptoms

‘‘Has anyone seen OCD-like behaviorresult from downtraining 3–7 (Hz)? A boyI met recently had about 40 sessions of thattraining at F3, F4, CZ, T4, FP1, and FP2(referential montages). He came with aQEEG that indicated the training I listed.His main reason for training prior to hisrecent issues was ADD, which still seemsevident. He is 13 years old, above-averageintelligence, psychological testing indicatesADD inattentive [type]; no significantlearning disabilities. His mother feels hisOCD-like stuff resulted from his training.’’Another seasoned practitioner reportedseeing patients who had been trained by otherpractitioners for a lengthy period with a sin-gle protocol focused on beta activation whobecame very single-focused and obsessive.

Fatigue

A considerable number of practitionershave reported transient fatigue, lasting upto the remainder of the day following aneurofeedback session.

Seizure

An experienced practitioner, using neuro-feedback with a reinforcement band in thetheta or delta range, had a patient with noprior seizure history experience a seizureduring training.

Anxiety, Agitation, Irritability, Rage,Depression, or Manic Reactions

Excessive reinforcement of beta duringneurofeedback has been reported to cause

Clinical Corner 85

temporary irritability, anxiety, and sleepdisturbance until the level of beta reinforce-ment was lowered. Recently an OCD patientcontacted one of the authors. She had gonethrough 33 sessions of neurofeedback witha chiropractor, and not only did OCD symp-toms not improve, but now she indicatedthat she was experiencing anger and ragereactions. One autistic boy experiencing adisentrainment type of neurofeedback was‘‘wired,’’ running around the house for2 hours following a session. Another prac-titioner noted cases where SMR training cre-ated agitation and where ‘‘overtraining’’exacerbated manic or depressive symptomsin bipolar disorder patients. One practitio-ner described inhibiting SMR in himself,which resulted in hyperactivity. Increaseddepression has also been reported.

Slurred Speech

An individual who described themselvesas ‘‘articulate,’’ reported that although theyslept better, they were now experiencingslurred speech following neurofeedback.

DISCUSSION AND CONCLUSIONS

The reports we have cited are uncontrolledcase reports from which, first, we cannotknow the degree to which other confoundingevents in the patients’ lives may have con-tributed to these negative symptoms and,second, we do not know whether the adversesymptoms were short lived or more endur-ing. After our review of descriptions ofadverse reactions, it is our impression thata large percentage of negative effects andtransient side effects may result fromapproaches to training that seek to reinforceand increase various bands of EEG activity(whether it is alpha, theta, beta, or delta),as opposed to focusing more on inhibitingor disentraining problematic EEG activity.Some individuals have also begun reinforc-ing very slow brainwave activity, which webelieve may pose greater risks of sideeffects and which we hypothesize may pro-duce more transient state changes that

appear calming in the short term, ratherthan enduring positive (trait) changes inthe EEG. It has also been reported thatcoherence training has potential to createadverse reactions if not carefully monitored.The authors further believe that hometraining that is not regularly supervised byqualified professionals also increases the riskof negative effects.

Neurofeedback is an exceptionally valu-able therapeutic modality, but this reviewhas shown that it can also occasionally resultin side effects, and when improperly donemay in fact sometimes result in more signif-icant iatrogenic reactions and an exacer-bation of symptoms. Adverse effects thathave been reported by clinicians includeincreased anxiety and agitation, panicattacks, manic-like behavior, headaches,nausea, fatigue, sleep disturbance, angerand irritability, crying and emotional lability,incontinence, enuresis, an increase indepression, decline in cognitive functioning(decreased concentration, mental fogginess),increase in obsessional rumination andOCD symptoms, increase in somatic symp-toms (including tics and twitches), vocal tics,seizures, slurred speech, loss of previoussymptomatic improvements, and temporarydisorientation or dissociation that could putsomeone at risk for an accident or injury.

It is apparent that neurofeedback is atherapeutic modality that requires cliniciansto be vigilant in watching for occasional sideeffects. Legitimate professionals shouldacknowledge to patients in an informed con-sent process that a side effect can occasion-ally occur, and less frequently that adversereactions have occurred. Thus patientsshould be told that it is vitally important toreport any side effects immediately shouldthey occur so that training may be modified.We have found it useful to ask patients dur-ing and after sessions, and at the beginningof each new session, about any side effects(even though they may not be extremelyfrequent) and to have the patient rate symp-toms on a 0 to 10 scale at the beginning ofeach session to facilitate discussion and thetracking of progress. When such carefulmonitoring is done, side effects are usuallyminor and infrequent because the clinician

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can immediately modify training protocolsbefore any negative effects escalate.

When clinicians are conducting alpha=theta or other types of deep relaxation train-ing, we also consider it very important toensure at the end of the session that patientsfeel sufficiently clear-headed to drive andfunction prior to allowing them to leave theoffice. The possibility of negative effectswill also undoubtedly be minimized whenpractitioners obtain a thorough history ofpsychological and medical symptoms andemploy assessment procedures prior to treat-ment, thus allowing for individualization.Ethical standards also require that one seeksconsultation when problems arise and thereis uncertainty about how to address them.

We strongly believe that the field of neu-rofeedback is at risk. Increasing numbers oflay persons are inappropriately and illegallyobtaining neurofeedback equipment. A sig-nificant number of such persons are presum-ing that they are qualified to put electrodeson someone’s head and to seek to alter thebrain functioning of individuals with seriousmedical and psychological conditions. Ser-ious consumer protection issues are involved.Not only do such lay practitioners have thepotential to harm members of the public,as well as to be ineffective, but such individ-uals also place in jeopardy the future of theneurofeedback profession because such prac-tices will undoubtedly result in legal actionsfor harm done (one current case is pending)and the disparagement of the field by physi-cians, psychologists, other licensed profes-sionals, and the public at large in reactionto unqualified practitioners.

We therefore believe that is incumbentupon licensed professionals to report laypractitioners to state regulatory bodies aspracticing psychology and medicine with-out a license when they are found to beoffering services for medical, psychiatric,and psychological conditions. Likewise ourprofessional societies and members ofthose societies should not be admitting indi-viduals to clinical training workshops unlessthey are licensed for independent practice,have a letter from their graduate schooladvisers in accredited institutions, or canverify through a letter from their employer

that they are a technician whose work isbeing supervised by a licensed professional.Similarly, allowing lay practitioners to belisted under ‘‘provider’’ sections of societywebsites places professional societies in theposition of implicitly sanctioning and in asense recommending to the public theunlawful practice of such individuals. It isimperative for both clinicians and pro-fessional societies to more actively educatethe public about how to select qualifiedneurofeedback practitioners. One of theauthors recently published such an articleciting the value of neurofeedback, the needfor licensed professionals to be adequatelytrained and certified, and importance ofconsumer protection (Hammond, 2008).Providing members of the public with copiesof Hammond (2006) can be helpful in regardto public education.

Competency and continuing educationmust likewise be encouraged. Licensed clini-cians should be strongly encouraged toobtain certification in neurofeedback (e.g.,from the Biofeedback Certification Instituteof America), and when they are analyzingtheir own quantitative EEG’s, to pursuecertification from the EEG and ClinicalNeuroscience Society or the QuantitativeElectroencephalography Certification Boardor a credential from the Society for theAdvancement of Brain Analysis. The protec-tion of the public and of our professionrequires that we more vigorously emphasizestandards of practice. It is our opinion thatit is unethical for practitioners to useneurofeedback to work with any medical,psychiatric, or psychological symptoms andconditions that they are not qualified towork with through both their training inother therapeutic modalities and by virtueof their licensure within their state orprovince.

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