Diagnoses are not really helpful in understanding how to best train an individual. We are more interested in categories of physiological dysregulation that relate to our neurofeedback options of electrode placement and training frequency. Our categories of dysregulation include physiological arousal regulation, instabilities, disinhibition, localized dysfunctions, and learned fears and habits. We use specific symptoms as indicators of modes of dysregulation. So we are not really treating symptoms with neurofeedback, but rather using symptoms to help us understand how the nervous system is dysregulated.

Our assessment leads to an overall neurofeedback treatment plan. We want to know as much as possible about the client's function and dysfunction, from which we develop an understanding and expectation of what specific modes of training might be most helpful for that individual. Later we will implement this plan as we are guided each step of the way by the observed and reported effects of training. Beginning by optimizing a starting electrode placement and training frequency, we then add basic sites, other sites, Alpha-Theta and Synchrony as needed.

Neurofeedback produces strong and specific effects. It makes a significant difference where we put electrodes and what frequencies we feed back to the brain. We need a model of brain function and dysfunction that will allow us to think about how to train and how to understand the specific effects of training. This working model will support our decision making throughout the neurofeedback process. The model is shaped by our clinical experience over many years, as our ideas are tested daily in clinical practice.

The central nervous system (CNS) is an incredibly complicated network of billions of neurons plus other supporting cells. It includes many different functional levels from the cerebral cortex at the top down through subcortical structures, brainstem and spinal cord. We put our electrodes on the scalp, where they pick up electrical activity from groups of neurons in the cortex. These neurons are aligned in a way that allows their electrical potentials to add together so that they can be measured at the scalp. Our EEG signal comes from the cortex, but we understand that training on the cortical EEG impacts broader brain circuits involving subcortical and brainstem areas as well.

It is helpful to have a simplified model of the brain to help us understand brain function and dysfunction and how we might best target the neurofeedback training.

Input and output functions are organized at each level of the central nervous system such that input comes into the back and output goes out from the front. Understanding both the type of information and how it is being processed at these different levels can help us understand where and how dysfunction is occurring.

At a spinal cord level input comes from our bodies, which may be sent to higher levels for processing and response. Output from the spinal cord allows us to move our bodies reflexively or according to instructions from higher levels of the central nervous system. There is also local coordination of sensory input and motor output. Dysfunction at a spinal cord level is far from our scalp electrodes, but can still be influenced by changing top-down influence on spinal cord function.

The brainstem is involved in processing sensory input and controlling motor output to orient us to the environment. It regulates vital functions essential for life – breathing, sleep/wake cycle, body temperature, etc. Brainstem dysfunction with a traumatic brain injury, for example, can have a severe impact on basic life-supporting functions. Neurofeedback can be helpful in reorganizing and recovering these brainstem functions.

Subcortical nuclei are involved in rapid assessment of danger and opportunity and rapid response to keep us safe and well. These survival responses are more rapid than the detailed analysis and response at a cortical level. They constantly shape our perception and behavior below our conscious awareness or control. This will be a frequent target for neurofeedback to reestablish some balance between automatic life-preserving reactions and deliberate conscious actions.

The cortex mediates detailed analysis of sensory input and the selection and control of behavioral output. Good cortical function allows us to carefully consider options and deliberately control our actions. The verbal narrative of our conscious experience occurs at a cortical level.

Input and output functions are not sequential, but rather simultaneous. Perception guides action, and action also guides perception. Our needs and desires guide both. Back and front areas of the central nervous system work together. Parietal and frontal cortical areas, for example, work together to guide movement, while prefrontal areas hold the plan, and limbic areas set priorities. Perception, then, should be seen as a directed, purposeful process that is driven by the brain's needs and expectations. This realization is central to our understanding of the process of neurofeedback.

How does the brain select and organize its input and output functions? How does it control its readiness to attend and respond? And how does it activate areas needed for the function at hand?

This brings us to regulation of brain states. How are the brain's resources managed to achieve the current goals? Physiological arousal and activation are key contributors to this brain state regulation. First the brainstem manages physiological arousal level – the general tone of the central nervous system. Subcortical nuclei are then involved in more specific control of activation. Specific brain areas are activated to allow specific functions, preparing for specific perception and response.

The next question is what states of arousal and activation are needed. How does the brain choose a state of readiness and specific functions to activate? This brings us to drives and emotions and the limbic system.

The limbic system manages drives and emotions, which in turn motivate our perception, behavior and physiological regulation. We engage with the world seeking safety and rewards. Limbic function allows us to judge dangers and opportunities, and motivates behaviors that will maximize our wellbeing.

We will focus on subcortical and subconscious limbic areas that play a significant role in rapidly assessing internal and external danger and rewards, and then motivating reactions that keep us alive. We understand that drives and emotions are also distributed functions that involve brainstem control of emotional tone, and cortical management of conscious plans and goals. Cortical limbic areas also provide top-down regulation of immune, endocrine and autonomic functions.

Limbic function is critically important for our ongoing survival, but it can become a problem when out of balance. In life-threatening situations we learn life-preserving behaviors, which sometimes continue after the danger has passed. Those with Post Traumatic Stress Disorder (PTSD), for example, continue to react to their environments in a way that is no longer appropriate. They are unable to inhibit the subconscious reaction even though they understand consciously that it is no longer needed. With neurofeedback for PTSD we calm the agitation and hyper-vigilance with infralow frequency training and then allow resolution of traumatic memories with Alpha-Theta training.

Inhibitory control is another important factor in how different levels of the central nervous system work together. Cortical areas have inhibitory control over lower brain regions and their automatic reactions. This allows time for detailed sensory analysis and consideration of priorities and possible consequences before selecting and executing a response. The prefrontal cortex is the highest level, with inhibitory control over all lower areas of the central nervous system. Good prefrontal function is essential for self-control and mature behavior.

Self-regulation is an important concept in thinking about neurofeedback. We will use the term selfregulation to refer to automatic, unconscious regulation of physiological functions. Good selfregulation underlies efficient and effective functioning of brain and body. Neurofeedback can be understood as a process that promotes good self-regulation, enhancing flexibility and stability of state. It thereby improves health and well-being, and also reduces dysregulation and suffering.

We can now use this simplified model of central nervous system building blocks and interactions to understand basic categories of brain regulation and dysregulation. These basic categories correlate with how and where we need to train with infra-low frequency and Alpha-Theta neurofeedback.

These modes of dysregulation form the basis for the rest of the Protocol Guide. They are key to assessment and to understanding the effects of training, and for decision making throughout the neurofeedback process.

1. Indicators of physiological arousal help us understand the effect of training frequency on arousal level for each individual. During training we expect to use symptoms related to shifts in arousal level to adjust training frequency. For high arousal symptoms, we start with a T4-P4 placement for right brain calming.
2. Instabilities result in paroxysmal symptoms as the brain loses control with migraines, panic, seizures, etc. The presence of instabilities at any time in a person's life suggests nervous system hyper-excitability, for which we include inter-hemispheric stabilization with a T3-T4 placement.
3. Disinhibition relates to loss of prefrontal self-control with stress or boredom, as with tics or impulsivity. This calls for training with placements for calming agitation and also increasing prefrontal inhibitory control.
4. Localized dysfunctions might be indicated by report of symptoms, or by testing or brain imaging. This information suggests potentially useful training sites.
5. Learned fears and habits that interfere with good behavioral control and well-being indicate that Alpha-Theta might be an important part of a total neurofeedback program. Subcortical survival or reward strategies can continue to shape behavior in ways that outlive their usefulness. After physiological calming and stabilizing with infra-low frequency neurofeedback, Alpha-Theta training can then allow needed processing and resolution of traumatic experiences.

These are our basic categories for assessment and for understanding responses to training. We will look at these five categories in more detail since they are fundamental to our understanding of neurofeedback.

Physiological arousal is our first category of central nervous system regulation and dysregulation. It is the most basic component of brain state regulation. Arousal is managed by brainstem nuclei that project widely throughout the central nervous system. This is part of the Reticular Activating System that manages wakefulness and alertness. Wherever we place electrodes on the scalp we will be impacting this arousal system, so it is always an issue in training. However, physiological arousal becomes a special focus when we start a new client with history of developmental trauma. Then right brain calming (with T4-P4) becomes the priority for sufficient calming of these traumatized and reactive nervous systems.

We think of physiological arousal as being under brainstem control. The brainstem sets the tone of the whole central nervous system. The brainstem component is rather nonspecific – just how awake the person is. How people actually experience a shift in arousal level will be individually specific. It might affect attention, mood, physical tension, thinking, etc., which involve other more specific brain functions. For the sake of neurofeedback training, we are interested in shifts in core physiological arousal level as a guide to finding the optimal training frequency for each individual.

When starting a new neurofeedback client, the first question is whether we are dealing with a dysregulation of arousal or excitability. Arousal dysregulation generally results from developmental trauma, and responds best to right-side (T4-P4) training. Hyper-excitability (instability) symptoms are more often genetic and/or related to brain injury, and respond best to inter-hemispheric (T3-T4) training.

Arousal level has a strong impact on our overall level of functioning. We each live on our own individual arousal and performance curve. We move up and down this curve over the course of the day. With a well-regulated nervous system there is a good middle range of normal function. This allows us to use our higher cognitive abilities to manage our daily lives. At the end of the day we should be tired and drift off to sleep through low arousal. And, at the high end of the arousal curve, we should be able to respond quickly to emergencies without freezing, and without taking time to stop and consciously analyze the situation.

Good self-regulation means both flexibility and stability of state. High arousal is useful in emergencies, but getting stuck there can lead to significant problems. In emergency mode we hyper-focus on the emergency and ignore our bodies and our future plans. Low arousal states are essential for rest and sleep, but can interfere with good alert functioning during the day. Our goal with neurofeedback is to improve flexibility and stability of state regulation, not just to move the person's arousal level.

We can map this same performance curve with training frequency rather than arousal level on the x axis. Adjusting the training frequency up or down has the effect of shifting arousal level up or down. It is our job clinically to read the signs of arousal shifts and use that information to optimize the effect of training. The optimal training frequency is individually specific, so we need to find the training frequency that works best for each person. This process of observing and interpreting training effects related to training frequency is a key component of effective neurofeedback training.

Another important distinction for the sake of neurofeedback is that between arousal and reward deficits. Reward deficits relate to deficiencies in interest, pleasure and engagement, while arousal relates to core wakefulness. Reward deficiency is not the same as low arousal.

Those with reward deficiency might lack interest and engagement in normal activities, presenting as depression. Or they might escalate to thrill-seeking behavior in order to feel alive, seeking reward rather than wakefulness. We all need rewards to stay alive. Rewards satisfy drives, either to achieve pleasure or to escape from suffering, or both. Those who experience unrelenting misery and lack feelings of pleasure, safety or self-worth will take great risks for moments of peace, security or pleasure. Those with reward deficiency are vulnerable to addictive substances and behaviors, which turn on their reward systems that were not responding to more normal stimuli.

For reward deficits we want to target limbic function, not just brainstem arousal. We target limbic function most directly with temporal lobe and prefrontal placements. There are left and right brain aspects of the reward system.

We might target the right hemisphere when rewards satisfy basic needs for safety and comfort, and for excitement and exploration. And we might target the left hemisphere when rewards follow completion of repetitive behaviors.

Rewards are a normal and essential part of our lives. They allow us to learn from our experience and gain useful skills and habits. People with healthy nervous systems generally find behaviors and substances that support their own good physiological function and provide adequate rewards.

People with less well regulated nervous systems might find it necessary to use substances like alcohol or marijuana to manage their brain states and support normal brain function. They might be dependent on the use of those substances or on prescription drugs. Some people live with significant reward deficits, such that they never feel peaceful, safe or happy. They might resort to self-destructive habits for even moments of relief from their suffering.

For those with self-destructive addictive behaviors, infra-low frequency neurofeedback provides physiological calming and stability and more effective self-control. With the newer infra-low frequency HD applications and lower training frequencies, we now expect to reduce cravings significantly, along with symptoms of anxiety and depression, within the first 20 sessions. This is an important first step before adding Alpha-Theta neurofeedback. Alpha-Theta then allows resolution of early trauma and suffering, which drives addictive behavior.

Our second category of dysregulation is instability of state. Symptoms of instability such as headaches, mood swings, panic attacks, seizures, etc. are paroxysmal events that arise suddenly and dramatically. Symptoms are usually very uncomfortable and disabling until they subside on their own. Panic attacks, for example, involve sudden feelings of terror and fear of dying. This is quite different from chronic anxiety which involves more constant high arousal and feelings of agitation, fear, etc. Rapid shifts in arousal can sometimes trigger unstable events, but instability of state is not the same as high arousal.

Selecting a starting placement for a new neurofeedback client involves this important disfunction between arousal and excitability deficits. High arousal typically results from developmental trauma, and responds best to right-side calming (T4-P4). Hyper-excitability is generally a genetic trait or the consequence of brain injury, which responds best to inter-hemispheric stabilizing (T3-T4).

For the sake of neurofeedback there is also an important difference between instability and reactivity. Instability reflects an internal loss of stability and control as for example with mood swings. Reactivity reflects over-reaction to external triggers as with reactive anger outbursts. Reactivity falls under our category of disinhibition rather than instability of state.

The central nervous system is highly interconnected and therefore inherently excitable. Since each neuron connects with thousands of other neurons, activity could easily spiral out of control.

Significant inhibitory control is required to maintain stability. Most central nervous system connections are in fact inhibitory. Injury or loss of these inhibitory connections can lead to hyperexcitability and lack of inhibitory control. Incoming excitation may then set off an explosion of nerve activity rather than contained processing of the input.

Depending on where this occurs in the CNS, different symptoms of instability can result – seizure, panic, mood swings, migraine, vertigo, etc.

Nervous system hyper-excitability is generally related to genetic vulnerability and/or physical injury to the nervous system.

With infra-low frequency neurofeedback we address instabilities most effectively with left-right temporal lobe placements (T3-T4). This gives the most stabilizing effect across the whole brain. It also addresses the particular vulnerability of the temporal lobes to hyper-excitability.

T3-T4 is the best starting site for those with instability symptoms, which are typically related to genetic vulnerability and/or brain injury. By contrast, T4-P4 is the best starting site to calm high arousal for those with a history of developmental trauma.

Many of these symptoms of instability are best treated medically with anticonvulsants. When treating mood swings, anticonvulsants are often called mood stabilizers. We might think of them generally as state stabilizers. The effectiveness of anticonvulsant medications for any symptom is a good indication for T3-T4 as an effective electrode placement with infra-low frequency training.

We have been focused on central nervous system regulation and dysregulation to understand the specific effects of neurofeedback. Meanwhile, we have also been impacting autonomic nervous system function. The autonomic nervous system regulates internal organs and glands - for example heart, bladder, intestines, and breathing. It also regulates endocrine and immune function.

Self-regulation of the autonomic nervous system involves issues of arousal and stability, as does the central nervous system. And autonomic dysfunction can result from genetic vulnerability or neurological disease or toxins.

The autonomic nervous system has three branches - sympathetic, parasympathetic, and enteric. The sympathetic branch activates and prepares our physiology for fight or flight. The effect is fast and widespread. The parasympathetic branch calms and stabilizes our physiology so that it can rest and restore. The enteric branch of the autonomic nervous system lies entirely within the gastrointestinal tract, where it regulates autonomic gut function.

Targeting central nervous system self-regulation, we start with T4-P4 to calm arousal, and with T3-T4 to calm excitability and promote stability. The autonomic nervous system responds similarly to T4-P4 to calm sympathetic arousal, and T3-T4 to promote calm parasympathetic balance.

We are seeing an increasing number of neurofeedback clients with symptoms and diagnoses related to autonomic nervous system dysregulation. They include dizziness, exercise intolerance, chronic fatigue, low blood pressure, ortho-static hypotension, and tachycardia.

Dysautonomia, or autonomic dysfunction, refers to autonomic nervous system dysregulation. Symptoms may occur with autoimmune diseases, fibromyalgia, irritable bowel, HIV/AIDS, lyme disease, or Parkinson's. With autonomic dysfunction we see the importance of T3-T4 for balance, sometimes along with T4-P4 for calming. It may be necessary in some cases to start with T3-T4 alone.

The third category of dysregulation is disinhibition. Disinhibition arises from a combination of agitation and lack of prefrontal self-control. Stress can increase agitation and thereby increase symptoms. Fatigue or sedatives can reduce prefrontal self-control and thereby increase symptoms as well. Symptoms such as tics and hyperactivity can increase with both high and low arousal - or stress and boredom. This is the situation with ADHD for example. Excitement can increase hyperactivity and impulsivity. Likewise, sedatives, fatigue or low blood sugar can decrease prefrontal self-control and release those same ADHD behaviors.

Good brain function depends on sufficient top-down inhibitory control from the highest level of our central nervous system. If we lack good inhibitory control genetically or due to injury, illness or sedating substances, then we become disinhibited, with release of immature or primitive behaviors.

The cortex is the highest level within our central nervous system, and the prefrontal cortex is the highest level within the cortex. For each individual the prefrontal cortex develops over many years as we achieve maturity and increased self-control. With infra-low frequency neurofeedback we target mature control of function by training prefrontally.

Infra-low frequency neurofeedback for disinhibition involves left and/or right prefrontal training for increased self-control and also parietal training for physical calming. Right parietal (T4-P4) training most effectively calms agitation. Right parietal (T4-P4) training most effectively calms agitation.

Right prefrontal (T4-Fp2) training increases control of emotional reactivity. Lack of emotional control can lead to angry, fearful, oppositional or aggressive behavior. Left prefrontal (T3-Fp1) training increases control of thinking and acting. Lack of control can lead to impulsive and compulsive behavior.

Medication management for symptoms of disinhibition involves calming medications to lower arousal level and reduce agitation, plus activating medications to improve focus and self-control.

Stimulants like Ritalin both calm the body and focus the mind. They are not given to ADHD people to increase arousal level; they are given for increased self-control. Of course stimulants can also increase arousal in some people, who then might require further calming with a more sedating medication such as Clonidine.

Localized dysfunctions are the fourth neurofeedback category of dysregulation. Specific symptoms give us clues about where the brain is dysregulated. We can then target brain circuits related to specific functional deficits. It is clear from our clinical experience over many years that different placements can lead to very specific effects on brain function. It is remarkable how quickly the brain can shift its response with a shift in electrode placement. When trying a new placement to address a specific symptom it is usually obvious within a session or two whether the new site will be useful.

Do we need to engage circuits involved in sensory processing in the back of the brain? Or do we need to engage circuits involved in creating output in the front of the brain?

Should we target right hemisphere big picture awareness or left hemisphere processing of detail?

Electrodes on the scalp pick up cortical EEG activity, which is regulated by subcortical and brainstem circuits projecting to the cortex. We can target specific functional deficits by specific placement of our electrodes during infra-low frequency neurofeedback. Calming and stabilizing brain function then leads to better cortical regulation and better brain function.

The back of the brain processes input – sensory information regarding the outside world and also from inside our bodies. Training the back of the brain impacts sensory processing and sensory integration. It impacts body awareness and awareness of our body in space. It also impacts spatial attention – attention to our environment in response to sensory input.

The front of the brain processes output – moving, speaking, singing, thinking, planning, etc. Training the front of the brain impacts executive function and self-control. We can influence the initiation and sequencing of behaviors. And we can impact the ability to inhibit impulsive, compulsive, immature and reactive behaviors so that we have time to consider and decide how to act. Frontal training can also impact internally motivated and goal-directed attention.

We have two brains in our head that function quite differently. It is important that the left and right hemispheres do their separate and distinct jobs well, but also that they communicate and cooperate with each other. Efficiency lies in dividing and specializing roles before sharing the results.

Right brain function is the more integrative. The right brain looks at the big picture in the moment – in the context of its prior history – and helps us navigate through the world while keeping us safe and well. Left brain function is more analytical and sequential. The left brain sees details and helps us organize our behavior to achieve our goals. We might think of left and right brain function as text (L) and context (R).

We will look at symptoms for clues about relative strengths and weaknesses of left versus right brain function. It is important to know that sensory input and motor output from the brain cross over between left and right side. Input from the left side of the body projects to the right brain, and the right side projects to the left brain. Likewise, output to the muscles is controlled by the opposite side of the brain. With brain injury we might see weakness or paralysis on one side of the body and correlate that with injury to the opposite side of the brain.

Auditory input from the ears largely crosses over so that most of the input from the left ear goes to the right auditory cortex. This could be useful to know when dealing with a person with unilateral tinnitus. We might want to target the contralateral sensory areas. Visual input from our eyes partially crosses over such that the right visual field of both eyes projects to the left visual cortex, and the left visual field projects to the right visual cortex. This might help us think about where to train when people report loss or distortion of part of their visual field.

The effects of infra-low frequency training with left or right side placements are very different and need to be carefully managed for each client. As we consider symptoms and life history, it is critical that we sort indicators for left side versus right side training.

The right hemisphere is aware of and responsive to the environment – where we are and how we are. The right brain assesses what is expected of us and how we might fit in. It helps us explore new situations and acquire new skills and knowledge. Its job is to keep us alive and safe. Importantly it allows us to feel safe and comfortable in ourselves so that we can be open to others.

Right brain exploration is important in our early lives as we are learning about the world. It is also important later in our lives to support flexibility and creativity.

Early development of the right brain allows development of good self-regulation. We learn in the first few years of life to organize our sensory input, and how to self-soothe and to connect with others. When this early stage of development is disrupted by circumstances or by the childs own temperament, there can be a life-long difficulty with core self-regulation. And this can result in chronic dysregulation and chronic disorders. It is truly remarkable that neurofeedback can impact this core self-regulationv – even many years later.

For people with a history of developmental trauma, infra-low frequency neurofeedback begins with right parietal (T4-P4) placement for physical calming. Right prefrontal (T4-Fp2) generally comes next for calming emotional reactivity. Sometimes T3-T4 is required for migraines, panic or other instabilities, but more frequently we need to stay strictly on the right side for some time.

Moving quickly to the left side (even T3-T4) may increase agitation and emotional reactivity.

We understand that developmental trauma interferes with learned self-regulation in early life. This leads to a lack of core resilience and to chronic dysregulation. These are the people who do not recover from injuries, losses or traumatic events that occur in most lives. Later stress or trauma can overwhelm and reactivate unresolved earlier trauma. We see this for example in PTSD. The healthy nervous system can often recover from even severe traumas. Those who remain chronically impacted are usually those with pre-existing trauma.

We find that infra-low frequency neurofeedback is very effective in physical and emotional calming with right side placements for PTSD. Later Alpha-Theta is added for resolution of specific traumatic memories.

The left hemisphere is specialized for detailed sensory processing, and organization and execution of skilled behaviors. Our left brain knows the rules and organizes the steps to achieve the goal. It manages the top-down control of attention to our goal-directed task. This is different from right brain spatial awareness which keeps us alert to our surroundings. Left brain attention is obviously important for school performance, where organization and follow-through are essential. We also target the left brain to improve verbal expression, as well as reading, writing and arithmetic.

Left brain function develops later as language and explicit memory come on line. Our left hemisphere manages the conscious, verbal interpretation and narration of our lives. It often feels the need to be in conscious control of everything we do. This can be a challenge in session when we are trying to calm right hemisphere function while the left hemisphere demands a verbal explanation of what is happening.

We can divide both left and right cortex into different more specific functional areas. Primary sensory areas receive and process information from our eyes, ears, joints, muscle and skin. This is the first and most basic cortical representation of sensory input. Primary motor areas are the final cortical output stage directing the body to move.

Modality-specific association areas represent a higher level of sensory (input) processing and organization of motor output. More information is extracted from each incoming sensory stream, but still separately.

The multimodal association areas are where we put it all together – sensory integration across sensory modalities and organization of behavioral output.

We will look at these functional areas in more detail starting with primary sensory and motor areas. Sensory processing occurs in the back of the brain, output and executive control in the front. Primary sensory and motor areas occupy a relatively small amount of our total cortex. They are involved in the first stage of sensory processing and final stage of motor output.

Somatosensory input from skin, joints and muscles provides information regarding touch and body position from the opposite side of the body. The primary somatosensory cortex lies just posterior to the central sulcus dividing front and back halves of the brain.

Auditory input from the ears to the primary auditory cortex provides basic sound frequency and intensity information mostly from the opposite side of the head.

Visual input from the eyes to primary visual cortex provides basic motion, shape and color information to each hemisphere from the opposite visual field.

The primary motor area has direct output to lower motor neurons in the spinal cord that instruct the opposite side of the body to move.

We might target these primary sensory and motor areas when there are symptoms related to basic sensory processing and motor control. This is more likely with cases of specific brain injury. Visual deficits, for example, might result from traumatic brain injury when the occipital cortex impacts the skull. Or a stroke involving the primary motor cortex might leave the opposite side of the body weak or paralyzed.

Adjacent to the primary sensory and motor areas are the corresponding modality-specific association areas. Further processing of sensory information and extraction of more complicated properties of the input occur within each sensory modality. We might, for example, target higher level visual processing with posterior temporal placements for reading on the left side and pattern and facial recognition on the right.

The premotor cortex manages higher level organization of motor output, including initiation and sequencing of movements. We might target Broca's area on the left side to improve speech articulation and word finding. Broca's area sits directly in front of the primary motor cortex area controlling movement of face and mouth. We sometimes target the frontal eye fields near the midline, where the brain controls eye movements to orient to stimuli in the environment.

There are large areas of the cortex that are not engaged in specific sensory or motor tasks. These areas include inferior parietal, mid temporal and prefrontal cortex. They are involved in the highest level of integration and abstraction of both input and output. They also receive input from limbic areas that provide information on where to direct perception and action in order to survive and achieve our goals.

There are two separate high level sensory processing areas that handle different aspects of the incoming information. First the dorsal stream of sensory processing concentrates input to the inferior parietal area from all sensory modalities. Here the brain extracts how and where information – how loud, how fast, how bright, how many, and also where in space and where in relation to body position. Operating in parallel the ventral stream of sensory processing brings input to the mid temporal lobes. Here the brain identifies what things are – object and pattern recognition.

The highest level of organization of behavioral output occurs in the prefrontal cortex. It is also the area that manages self-control. This is where we hold our intentions and execute needed steps to reach our goals, while not reacting immediately and impulsively.

In addition to sensory input and motor output, we need to consider limbic processing of our internal states and external threats and rewards. The limbic system directs our input and output functions to help us stay alive and achieve our goals. We think of limbic function as primarily subcortical, but there are also cortical limbic areas, which are largely folded under and out of sight. Pulling back the temporal and frontal lobes exposes limbic cortex extending from the orbitofrontal cortex, through the insula, to the temporal pole.

We target limbic areas and limbic function with prefrontal (Fp1 and Fp2) and temporal (T3 and T4) sites.

In discussing input and output function, it is important to remember that our needs and goals drive all of our brain processing and behavior. We see what we are looking for, and what we have learned how to recognize. And of course we act according to our short-term and long-term needs and goals.

Cortical and subcortical limbic areas communicate strongly with the multimodal association areas. This allows coordination of drives and emotions, plus physiological regulation of visceral state, endocrine balance and immune regulation.

We have been shaped through clinical experience over many years to focus on these multimodal association areas as the most effective training sites. We can understand now that the multimodal association areas are managing the highest level of input and output processing, and therefore give us the broadest training effects.

These areas are the most newly evolved parts of our brains and also the last to develop over a lifetime. They are the first to lose function with dementia or normal aging.

There are times when we want to target more specific functions, but we should always begin with the high level organization and function of the multimodal association areas.

We target these multimodal association areas across the lifespan for maximum clinical effect:

• To aid development of good high level function when that is not developing appropriately, as with developmental disorders.
• To optimize good functioning and improve performance with a mature nervous system. It is generally possible to get more from the nervous system we have by increasing efficiency of functioning with neurofeedback.
• To counter the loss of function with normal aging or dementia. Neurofeedback is very helpful in maintaining good brain function and physiological self-regulation as we age. Even with severe dementia, we typically see significantly better function with training. With degenerative disorders like Alzheimer's, we might need to keep training indefinitely to maintain gains.

Our basic neurofeedback sites target these multimodal association areas – inferior parietal (P3, P4), mid temporal (T3, T4) and prefrontal (Fp1, Fp2). These are the most effective training sites for most people most of the time. We will target these sites first and then add other sites later, but only as needed for more specific training effects.

Considering first these basic sites, parietal training impacts high level sensory processing. Specifically this is the target of the dorsal stream of sensory information. This is where we impact the perception of how big, loud, bright, fast, etc. things are, and how they relate spatially to us and to each other.

The right brain looks at the big picture and at the whole body in space. With right parietal training we can impact body awareness and body relaxation. We impact the ability to interpret our sensory input and thereby relate to our environment (sensory integration). And we can calm overall reactivity to sensory stimuli.

The left brain processes detail. With left parietal training we can impact timing and attention to detail. We can impact awareness of left and right and fine control of the dominant hand. Left parietal training can improve ability to calculate with numbers. And it can calm light sensitivity while reading.

The mid temporal lobe is the target of the ventral stream of sensory processing. This is an area of high level sensory integration regarding what things are – object and pattern recognition. With left temporal lobe training we can impact recognition of objects and symbols including letters in reading. Right temporal training can impact recognition of patterns and faces.

Temporal lobe training can also impact auditory processing, since this is where the primary and modality specific auditory areas are located. This is different from targeting auditory sensitivity with parietal training.

Temporal placements have always been strong sites for impacting emotional and physiological regulation as well.

Prefrontal placements allow us to impact the highest level of output organization. Good prefrontal function allows us to hold information in our minds, while we plan and execute appropriate sequences of actions so as to achieve our goals. It also allows us to inhibit more primitive and immature reactions while we consider how to act. This is a key issue in ADHD where the person might act impulsively before he has time to consider the possible consequences of his actions.

Good prefrontal function is the key to good self-control (of thinking, acting and feeling). As the brain develops, prefrontal function gradually matures. This allows us to behave in a more mature fashion with greater self control. Symptoms of disinhibition such as OCD, tics, impulsivity, emotional reactivity, etc. all argue for prefrontal training. Whether that is left or right prefrontal depends on exactly what symptoms and who has the symptoms.

The right hemisphere regulates core emotions that keep us alive and safe in the world. Right prefrontal training impacts control of emotional reactivity. Right prefrontal training can reduce anger, fear, impatience, despair, etc. The left hemisphere regulates conscious planning and executing of goal directed behavior. Left prefrontal training impacts control of thinking and acting.

Our last category of brain dysregulation relates to learned fears and habits. Learning occurs throughout the central nervous system. We tend to focus on explicit, conscious memories that can be recalled within the story line of our lives, but this system only comes on line when we are a few years old. An older and deeper learning results in implicit memories. This learning shapes how we perceive and respond to the world, and how we understand ourselves. Some of these memories are formed in our early pre-verbal life experience, while some may relate to later traumatic experiences.

Our subcortical and subconscious brain function is designed to keep us alive and safe. It can learn well in one traumatic event that a situation is life-threatening and to be avoided at all costs. Later attempts to talk ourselves out of this belief and reaction can be ineffective. The combat veteran might know that he is no longer on the battle field, but his brain remains hyper-vigilant and hyperreactive. A sight, a sound, or a smell can trigger a flashback of the life-threatening and traumatizing event.

These learned fears and habits indicate that Alpha-Theta training will be an important component of our neurofeedback program. Alpha-Theta allows people to internally access and resolve traumatic experiences while in a safely relaxed witness state.

Alpha-Theta neurofeedback involves relaxing cortical control and allowing subcortical processing of subconscious memories. We support a low arousal state in session with reduced sensory input. Training is typically done eyes-closed in a dark room with headphones and a comfortable chair, blanket and pillows for maximum physical comfort. This reduces external distractions and frees the brain to process its own internal material.

Feeding back alpha and theta EEG activity promotes synchronous low frequency brain waves and a disengaged cortex. This allows memories to surface and be processed in a deeply relaxed state. The memories may or may not reach conscious awareness during this process. In either case, traumatic memories are stripped of their emotional charge and filed away as memories that can later be consciously recalled without reactivating the trauma.

Alpha-Theta training is especially helpful in resolving fears and attachment issues resulting from trauma in early development, or in later traumatic situations. It is helpful with habits formed through addictive experiences, where an addictive substance or behavior gives profound relief from unrelenting pain or misery. And it is helpful with habitual behaviors such as smoking that might no longer serve a useful purpose, but are maintained by long-term associations.

Before Alpha-Theta training we always start with infra-low frequency training for physiological calming and stabilizing. This allows a more successful Alpha-Theta experience and training effect. With PTSD for example, infra-low frequency training resolves the physiological consequences of trauma – agitation, hyper-vigilance, reactivity, sleep disturbance, etc. Alpha-Theta training then addresses unresolved traumas and emotional triggers. Together these two approaches are remarkably effective with PTSD.

In the assessment section we discussed a clinical model of brain regulation and dysregulation relevant to neurofeedback. This gives us a language and basic neurofeedback tool-kit for addressing specific modes of dysregulation. In this symptom profiles section we will map specific symptoms to our basic categories of dysregulation.

We are not treating these symptoms with specific protocols, but rather using the symptoms to guide our understanding of how the nervous system is dysregulated. Then the categories of dysregulation give us ideas on how to craft an effective neurofeedback program for each individual.

For each symptom profile, we will indicate starting site options followed by common sequences of basic sites, synchrony and Alpha-Theta.

Reviewing the basic categories:

• Arousal indicators help us read the impact of training frequency choice on arousal level – whether to adjust training frequency higher or lower for comfort in session and optimal effectiveness.
• Instabilities result in symptoms that arise paroxysmally, such as migraines or seizures, and require stabilization with T3-T4 training.
• Disinhibition results in immature or primitive behaviors that are released by insufficient prefrontal inhibitory self-control and exacerbated by increased agitation. Parietal calming and improved prefrontal control are indicated.
• Localized dysfunctions are indicated by symptoms, or by known details of brain trauma or brain imaging that point to dysfunction of specific brain circuits that can be targeted with specific placements.
• Learned fears and habits that trigger dysfunction suggest Alpha-Theta training.

Mapping symptoms to these categories helps us understand a client's responses to training and helps us make decisions on how to adjust training over time for best effect.

In the following symptom profiles we will map specific symptoms to our basic categories of dysregulation and basic electrode placements. First putting together the understanding of front versus back and left versus right brain function, we can look at the specific training effects of the four brain quadrants.

Training the right back promotes physical calming and body awareness. We impact sensory processing of the big picture – how I am and where I am in space and time. We also impact sensory integration – the ability to make sense of our environment and how our bodies interact with it.

Right front training calms emotional reactivity. This is how we impact core emotional regulation, which allows an internal sense of safety and comfort. Core emotional regulation results in less emotional reactivity since people feel less threatened by others. Right front training can enhance emotional expression and the desire to connect with others. It can also impact common sense, understanding how the world works and basic cause and effect thinking (as opposed to left brain logic).

Left front training can produce mental calming, which allows clearer, faster, more organized thinking and goal-directed behavior. It can impact verbal and written expression and logical thinking.

Left back training can impact awareness and processing of detail. This means symbolic processing as in reading, writing and arithmetic. Left back training can improve awareness of left and right and dominant hand awareness, which allows control and timing of skilled movements. Here we can impact access to stored knowledge and skills.

We need to add one more piece to the four quadrants just considered. Inter-hemispheric training (left minus right – or equivalently, right minus left) has the effect of stabilizing brain function. T3-T4 is our strongest placement for symptoms of instability such as headaches, seizures, panic, mood swings, etc. Instability symptoms are usually very unpleasant and disabling. It is difficult to function when the brain is going out of control. Neurofeedback is particularly effective with instability symptoms. A very slight change in the brain's ability to maintain stability can make a very significant change in the incidence and intensity of symptoms. It is necessary to carefully optimize training frequency with instabilities. The consequence of training a less than optimal training frequency can be increased symptoms and significant discomfort.

This is now the basic template for deciding where to train. Whatever the symptom category, we need to ask the same questions. Do we need physical calming, calming of emotional reactivity, mental calming, awareness and processing of detail and/or stabilizing? We will now apply this template to different symptom categories, always with the same core categories of where to train in mind.

For each symptom profile, we will also consider where to start and how to add other ILF placements as well as Alpha-Theta and Synchrony.

STARTING PLACEMENTS

The first step is to find the best starting placement or placements for each client.

RIGHT SIDE (T4-P4) is calming for those with developmental trauma. Related symptoms include agitation, hypervigilance, emotional reactivity, insomnia, etc.

INTER-HEMISPHERIC (T3-T4) is stabilizing for hyper-excitable nervous systems, related to genetic vulnerability and/or brain injury. Symptoms include instabilities such as migraine, panic, mood swings, etc.

BOTH (T4-P4 and T3-T4) are calming and stabilizing for those with significant reasons to include both options. Sometimes the need for both sites is exposed during the first few sessions. Continue from that point with both starting sites.

ADDING BASIC SITES

Prefrontal and parietal as needed

AFTER STARTING T4-P4, stay right-side to avoid agitation. Next site is T4-Fp2.

AFTER STARTING T3-T4, need to balance left and right-side placements to maintain stability. Right parietal (T4-P4) and left prefrontal (T3-Fp1) add more specific impact on spatial awareness and executive function.

AFTER STARTING BOTH T4-P4 AND T3-T4, continue focus on calming and stabilizing. Add next T4-Fp2, and avoid other left-side placements.

STARTING PLACEMENTS

RIGHT SIDE (T4-P4) - for people with high arousal symptoms related to early life trauma. T4-P4 specifically calms physical tension and allows people to be more comfortable in their bodies.

INTER-HEMISPHERIC (T3-T4) - for some clients with anxiety unrelated to developmental trauma. This might be obsessive worry or panic attacks. The presence of other instabilities like migraine, ADD, etc. suggest genetic vulnerability, and starting T3-T4.

BOTH (T4-P4 and T3-T4) - for anxious people with strong symptoms of high arousal and also significant symptoms of hyper-excitability. This might be, for example, a combination of developmental trauma and attachment issues, along with panic attacks or dissociation.

ADDING BASIC SITES

AFTER STARTING T4-P4 - people who respond positively to T4-P4 alone will probably do best by staying with right-side placements. That means adding T4-Fp2 next. That should provide emotional calming and reduced reactivity. If adding T4-Fp2 increases instabilities, then add T3-T4 for stabilizing. If T4-Fp2 increases emotional reactivity, first re-optimize training frequency. Sometimes more time is needed at starting sites before adding prefrontal.

AFTER STARTING T3-T4 - add left and right side sites to keep balance and stability. Adding T4-P4 alone can be sedating and disinhibiting. Usually it is better to add T3-Fp1 along with T4-P4.

AFTER STARTING BOTH T4-P4 AND T3-T4 - both starting sites should promote calming and stabilizing for those with both arousal and excitability issues. T4-Fp2 is generally the next basic site to add. This more specifically promotes emotional calming along with T4-P4 physical calming.

ADDING OTHER SITES

T4-O2 is another right-side placement for people with a history of trauma. T4-P4 is more physically calming. T4-O2 calms hypervigilance for people who are keeping a look-out for danger.

ADDING ALPHA-THETA OR SYNCHRONY

Synchrony can be effective in calming anxiety. 0.05 Hz synchrony can move people to a calm and safe core self. 10 Hz is mentally calming in a way similar to meditation. Synchrony is often helpful to prepare the way for Alpha-Theta.

STARTING PLACEMENTS

RIGHT SIDE (T4-P4) - for people with early life trauma that leaves them with chronic dysregulation and agitated depression. T4-P4 calms physical tension and promotes body awareness.

INTER-HEMISPHERIC (T3-T4) - for people with unstable nervous systems related to genetic vulnerability and/or brain injury. This includes mood swings and depressive episodes.

BOTH (T4-P4 and T3-T4) - for people with significant trauma-related agitation and also significant instabilities. This might include emotional reactivity and rage and also mood swings. Starting with T4-P4 calming alone might provoke instabilities such as mood swings or headaches. Starting T3-T4 alone can cause increased agitation, such as anger or aggression.

For those with bipolar mood swings, we always start with both calming and stabilizing.

ADDING BASIC SITES

AFTER STARTING T4-P4 - when a right-side placement is effective in calming mood without stirring up instabilities, then we stay on the right side with T4-Fp2. This is a very important site for calming despair and overwhelm, anger and aggression.

AFTER STARTING T3-T4 - when T3-T4 positively impacts mood swings and other instabilities, and does not increase agitation, then we might add Left and right side placements to maintain stability. T4-P4 improves body awareness and physical calming. T3-Fp1 can calm obsessive worries and allow optimism and planning for the future.

AFTER STARTING BOTH T4-P4 AND T3-T4 - for those who need both calming and stabilizing, the next step is to add T4-Fp2. This adds emotional calming and self-control to the T4-P4 physical calming. For those with bipolar mood swings or atiachment disorders, we avoid T3-Fp1. It is very likely that these people will become manic and/or aggressive with T3-Fp1.

ADDING OTHER SITES

T4-O2 is generally emotionally soothing for those with a trauma history. It can be a useful addition to established basic sites. Left frontal T3-F3 can be energizing and motivating. It also can be over-stimulating for some, creating agitation.

ADDING ALPHA-THETA OR SYNCHRONY

Synchrony can be useful by itself and also as a step toward Alpha-Theta. Unresolved traumatic experiences contributing to depression can be resolved with Alpha-Theta. Care should be taken with Synchrony or Alpha-Theta for those with instabilities. Some ILF may be necessary to maintain stability.

STARTING PLACEMENTS

RIGHT SIDE (T4-P4) - for those with attention deficits related to early trauma. These are people with behavioral problems - oppositional, controlling, fearful, aggressive, etc. T4-P4 should calm agitation.

INTER-HEMISPHERIC (T3-T4) - for ADD (or ADHD) people without developmental trauma or emotional reactivity. ADD people can be unaware of others around them and have difficulty staying on task, but they are generally not angry or aggressive. ADD generally relates to genetic vulnerability and/or brain injury. Instability symptoms are common in ADD people and their near relatives.

BOTH (T4-P4 and T3-T4) - for those with agitation related to early trauma, and also genetic ADD or brain injury.

ADDING BASIC SITES

AFTER STARTING T4-P4 - for those who respond well to right side alone, we stay on the right side with T4-Fp2. The prefrontal training can improve executive function, even though it is not working directly on the left side. Calming right brain agitation can sometimes free the left brain to function better. Training left side or even T3-T4 can cause agitation in these clients.

AFTER STARTING T3-T4 - we start T3-T4 to find a good training frequency before adding more attention-specific sites. ADD people are a challenge because they are generally poor reporters of how they feel. We might then add left and right sites for a more specific response before we have completely optimized the frequency. Adding T4-P4 should help body and spatial awareness. And T3-Fp1 should help goal-directed attention and impulse control.

AFTER STARTING BOTH T4-P4 AND T3-T4 - for those who need calming and stabilizing to improve attention, we expect to stay on the right side by adding T4-Fp2.

ADDING OTHER SITES

T3-P3 can help with attention to detail and sequential processing.

ADDING ALPHA-THETA OR SYNCHRONY

People with trauma-related attention deficits will benefit from Alpha-Theta to process unresolved traumas. Straight-forward ADD people have difficulty staying awake without excitement. They will tend to fall asleep with Synchrony or Alpha-Theta. We do see some good effects, however, with 40 Hz synchrony prefrontally improving organization for ADD clients.

STARTING PLACEMENTS

RIGHT SIDE (T4-P4) - for people who need right brain calming for insomnia. That means difficulty falling asleep or falling back to sleep after waking during the night. T4-P4 should be physically calming, allowing an easier transition to sleep.

INTER-HEMISPHERIC (T3-T4) - for people who need better regulation of sleep states, to provide adequate deep sleep and to avoid instabilities such as sleep walking or night terrors.

BOTH (T4-P4 and T3-T4) - for people with early trauma who have difficulty getting to sleep, and also have dysregulated sleep that interferes with restorative rest.

ADDING BASIC SITES

AFTER STARTING T4-P4 - for those who benefit from T4-P4 alone, we expect to add T4-Fp2 next. T4-Fp2 calms hypervigilance and fears that might interfere with falling asleep.

AFTER STARTING T3-T4 - for those who benefit from T3-T4 alone, there may be benefit in continuing with T3-T4 long enough to address a number of symptoms related to hyper-excitability. This includes, night terrors, sleep paralysis, sleep walking, night sweats and restless leg syndrome. Over time there may be benefit also with T3-Fp1 for mental calming, and T4-P4 for physical calming.

AFTER STARTING BOTH T4-P4 AND T3-T4 - for those who need both calming and stabilizing, insomnia may be challenging. In addition to both starting sites, we expect to add T4-Fp2 for more emotional calming.

ADDING OTHER SITES

ADDING ALPHA-THETA OR SYNCHRONY

10 Hz or .05 Hz Synchrony can be very calming and therefore helpful with sleep regulation by itself, or by preparing for Alpha-Theta. Unprocessed traumas can result in significant sleep problems. after calming and stabilizing with ILF training, Alpha-Theta can be very helpful.

STARTING PLACEMENTS

RIGHT SIDE (T4-P4) - Typically people with developmental disorders such as Autism do best with right side training. If instabilities are a significant issue, then T3-T4 will also be needed as a starting site. T4-P4 promotes physical calming and sensory integration.

INTER-HEMISPHERIC (T3-T4) - Symptoms related to genetic vulnerability or brain injury respond best to T3-T4 stabilization. This includes vertigo, motion sickness and auditory processing.

BOTH (T4-P4 and T3-T4) - for people with significant right brain processing deficits such a non-verbal learning disabilities, and also significant instabilities such as vertigo.

ADDING BASIC SITES

AFTER STARTING T4-P4 - for those who respond well to right side alone, the next site to add is T4-Fp2. This helps with deficits around emotional expression and common sense.

AFTER STARTING T3-T4 - for those who do well with T3-T4 alone, other sites might help with more specific cognitive deficits. T4-P4 should help with spatial awareness and visual-spatial skills. T3-Fp1 should strengthen executive function and verbal expression. T3-P3 can also improve sequential and symbolic processing - reading, writing and arithmetic.

AFTER STARTING BOTH T4-P4 AND T3-T4 - those who need both calming and stabilizing from the start generally do best with T4-Fp2 for additional calming and self-control.

For those with cognitive deficits related to cognitive decline with age or dementia, training all basic sites can be very effective in improving brain function.

ADDING OTHER SITES

More specific sites are often helpful with sensory and cognitive symptoms. On the right side, T4-T6 helps recognition of facial expression and body language, which eases social awareness. In the front, T4-F8 promotes early language, often an issue with autistic children. Frontal sites can be too activating. If that occurs, drop T4-F8 for while. On the leti side T3-F7 can help word finding and articulation. And T3-T5 targets object recognition, including letiers, words and numbers. T3-P3 and/or T3-T5 can be helpful with dyslexia.

ADDING ALPHA-THETA OR SYNCHRONY

After sufficient ILF calming and stabilizing, 0.05 Hz Synchrony can be deeply settling and helpful with atiachment issues. For those with a trauma history, Alpha-Theta helps resolution of unresolved issues.

STARTING PLACEMENTS

RIGHT SIDE (T4-P4) - physical and behavioral problems related to developmental trauma do best with right side training. T4-P4 impacts physical calming and coordination. If T4-P4 provokes a headache, mood swings or other instability, T3-T4 should be added to the starting site.

INTER-HEMISPHERIC (T3-T4) - uncomplicated ADHD should start with T3-T4, but most physical and behavioral problems will require some or all right-side training.

BOTH (T4-P4 and T3-T4) - those with right-side physical and emotional problems might also require T3-T4 as a starting site for significant instabilities

ADDING BASIC SITES

AFTER STARTING T4-P4 - those who start successfully with right side training, add T4-FP2 as the next site. T4-Fp2 is the key site to address emotional reactivity, oppositional and aggressive behavior.

AFTER STARTING T3-T4 - uncomplicated ADHD clients will respond best to T3-T4, and then the addition of T4-P4 and T3-Fp1 to address attention, impulse control and hyperactivity.

AFTER STARTING BOTH T4-P4 AND T3-T4 - after both starting sites, the next placement should be T4-Fp2 for emotional and behavioral control.

Tics and OCD require some calming and/or stabilizing, plus prefrontal control. This could be an ADHD person with tics (T3-T4 plus T4-P4 and T3-Fp1), or a developmental trauma person with tics (T4-P4 plus T4-Fp2).

ADDING OTHER SITES

ADDING ALPHA-THETA OR SYNCHRONY

Symptoms related to developmental trauma might benefit from calming with Synchrony, and also resolving traumatic memories with Alpha-Theta.

STARTING PLACEMENTS

RIGHT SIDE (T4-P4) - chronic physiological (autonomic) dysregulation may benefit from right side calming of sympathetic arousal, and its fight or flight symptoms. Constipation, for example, is a common symptom of high arousal and responds well to T4-P4. Emergency mode over-rides attention to one's bodily needs or planning for the future.

Irritable bowel symptoms, on the other hand, respond best to T3-T4. Most people with autonomic dysfunction will also need T3-T4, which promotes parasympathetic rest and recovery.

INTER-HEMISPHERIC (T3-T4) - T3-T4 is most effective in promoting calm self-regulation of the autonomic nervous system. Sometimes this requires more sessions of T3-T4 alone than usual.

BOTH (T4-P4 and T3-T4) - both starting sites might be necessary to both calm and stabilize the autonomic nervous system, and related immune and endocrine regulation.

ADDING BASIC SITES

AFTER STARTING T4-P4 - for those who benefit from right side calming, the next placement to add is usually T4-Fp2. This provides further calming emotionally and behaviorally. It is possible that the addition of T4-Fp2 might expose the need to add T3-T4 stabilizing.

AFTER STARTING T3-T4 - for those who benefit from T3-T4 alone, there might still be need for T4-P4 for sympathetic calming. And there might be benefit with T3-Fp1 for mental focus and motivation.

AFTER STARTING BOTH T4-P4 AND T3-T4 - after beginning with both starting sites, the next site to add is typically T4- Fp2 for emotional calming.

ADDING OTHER SITES

ADDING ALPHA-THETA OR SYNCHRONY

With both Synchrony and Alpha-Theta, there is risk of destabilizing the nervous system and provoking symptoms of instability. Prepare the client with adequate T3-T4 ILF training. Some T3-T4 atier Synchrony or Alpha-Theta might also be useful.

STARTING PLACEMENTS

RIGHT SIDE (T4-P4) - chronic muscle-tension or nerve pain usually respond best to T4-P4. With Complex Regional Pain Syndrome (CRPS) we expect to start with T4-P4 alone. If that gives rise to a headache or other instability, then T3-T4 should be added as a second starting site.

INTER-HEMISPHERIC (T3-T4) - headache and other migraine symptoms respond best to T3-T4. Other pain instabilities include trigeminal neuralgia, arthritis and fibromyalgia.

BOTH (T4-P4 and T3-T4) - for clients with significant need for nervous system calming and stabilizing. With more severe and complicated headache clients, it is likely that both starting sites will be needed.

ADDING BASIC SITES

AFTER STARTING T4-P4 - when right-side T4-P4 training is helpful, then further calming with T4-Fp2 is usually the next site to add. Chronic pain is often related to developmental trauma, which gives reason to add T4-FP2. Chronic pain also promotes emotional reactivity, which is calmed with T4-Fp2.

AFTER STARTING T3-T4 - with instabilities such as migraine, T3-T4 might be the best placement for some while. Over time it might be helpful to add T4-P4 for body calming and awareness, and also T3-Fp1 for mental clarity and positive mood.

AFTER STARTING BOTH T4-P4 AND T3-T4 - complicated pain patients often respond best to a combination of T4-P4 and T4-Fp2 calming, plus T3-T4 stabilizing.

ADDING OTHER SITES

T4-O2 can be calming for pain patients with a trauma history.

ADDING ALPHA-THETA OR SYNCHRONY

Synchrony can be calming for people with chronic pain. Alpha-Theta is expected to help with resolution of early trauma, or for the on-going trauma of chronic pain. Significant ILF calming and stabilizing is necessary before synchrony or Alpha-Theta.

STARTING PLACEMENTS

RIGHT SIDE (T4-P4) - T4-P4 impacts body awareness and appetite awareness, which can be effective in normalizing appetite. For people with a history of trauma and addiction, right side training is necessary.

INTER-HEMISPHERIC (T3-T4) - T3-T4 usually stabilizes blood sugar, which reduces sugar craving.

BOTH (T4-P4 and T3-T4) - when both calming and stabilizing are required to normalize appetite and behavior.

ADDING BASIC SITES

AFTER STARTING T4-P4 - for those who benefit from T4-P4 alone, the next step is T4-Fp2. This could be a child with a developmental disorder such as Autism, or an adult with an eating disorder. Eating for reward or punishment, as with anorexia or bulimia, responds best to T4-Fp2.

AFTER STARTING T3-T4 - for a person with genetic instabilities such as migraine or ADD, we might add T4-P4 for appetite awareness and T3-Fp1 to calm eating when bored or stressed.

AFTER STARTING BOTH T4-P4 AND T3-T4 - for more complicated clients with compulsive and addictive eating behaviors we expect to add T4-FP2 to both starting sites.

ADDING OTHER SITES

T4-O2 is another site to consider for clients with a trauma history.

ADDING ALPHA-THETA OR SYNCHRONY

For eating disorders related to developmental trauma and ttachment issues, Alpha-Theta should be helpful with unresolved traumatic memories. Synchrony is also calming and might be useful to prepare for Alpha-Theta.

STARTING PLACEMENTS

RIGHT SIDE (T4-P4) - attachment and personality disorders relate primarily to developmental trauma. Right side calming with T4-P4 is necessary for physical calming and emotional awareness. If T4-P4 alone sets off mood swings or other instabilities, then T3-T4 should be added as a second starting site.

INTER-HEMISPHERIC (T3-T4) - instabilities such as panic, dissociation, migraine or mood swings might suggest the inclusion of T3-T4 from the beginning of training. However, it is expected that right side training will also be required along with T3-T4.

BOTH (T4-P4 and T3-T4) - Both right side calming and T3-T4 stabilizing are most likely the best starting placements for this group.

ADDING BASIC SITES

AFTER STARTING T4-P4 - those who do well with right side alone, will also benefit from T4-Fp2 to calm hyper-vigilance and emotional reactivity.

AFTER STARTING T3-T4 - while a person with attachment issues might need T3-T4 to stabilize mood and other symptoms of instability, it is expected that they will also require right side calming in addition to T3-T4.

right-back, right front, and inter-hemispheric T3-T4 is the most common site combination for people with attachment and personality disorders. T3-Fp1 should be avoided since it can precipitate mania or aggressive behavior.

ADDING OTHER SITES

T4-O2 is often useful for emotional calming with people with a trauma history.

ADDING ALPHA-THETA OR SYNCHRONY

0.05 Hz Sychrony can be very calming with attachment disorders, and can help prepare for Alpha-Theta.

STARTING PLACEMENTS

RIGHT SIDE (T4-P4) - the usual starting site for physical calming and sensory integration. Developmental disorders mostly require right-side placements to promote core self-regulation.

INTER-HEMISPHERIC (T3-T4) - some genetic developmental disorders disrupt autonomic function or central nervous system excitability. T3-T4 might then be the core starting site.

BOTH (T4-P4 and T3-T4) - developmental disorders such as Autism require staying on the right side in most cases. There are some individuals who also need T3-T4 for serious instabilities such as seizures or migraines.

ADDING BASIC SITES

AFTER STARTING T4-P4 - most people with developmental disorders require strictly right side training. Any left side training, even T3-T4, can lead to agitation and less emotional connection. After starting successfully with T4-P4, the next site is T4-Fp2 for emotional reactivity and improved emotional connection.

AFTER STARTING T3-T4 - when the core issue is central and autonomic nervous system excitability, T3-T4 alone may be needed for some time. Eventually some T4-P4 for body awareness and T3-Fp1 for excutive function might be useful.

AFTER STARTING BOTH T4-P4 AND T3-T4 - the next site should be T4-Fp2 for emotional self-control. We avoid T3-Fp1, which often causes mania or aggressive behavior in Autism or other developmental disorders. People with Asperger's, on the other hand, often do well with T3-Fp1 for ADD and OCD symptoms.

ADDING OTHER SITES

T4-T6 can be a useful addition to basic right-side training for Autistic individuals. T4-T6 improves ability to read facial expressions and understand the intentions of others. T4-F8 promotes early language ability in those with delayed speech. Frontal sites can be too activating, so for some the T4-F8 should be set aside for later.

ADDING ALPHA-THETA OR SYNCHRONY

STARTING PLACEMENTS

RIGHT SIDE (T4-P4) - indicated by pre-existing symptoms related to developmental trauma and/or right brain injury, such as a right brain stroke impacting the left side of the body.

INTER-HEMISPHERIC (T3-T4) - for injured brains that require stabilization of mood, headaches, etc., following traumatic brain injury. Concussion causes hyper-excitability, which often requires rest to heal. We might need to reduce neurofeedback session length or frequency of sessions to avoid stressing the injured brain. Bright visual feedback display might also be too stressful. Eyes-closed might be easier using game with strong auditory feedback of training signal.

BOTH (T4-P4 and T3-T4) - when strong reasons for both starting sites. With brain injury it is often helpful to work on body awareness and body in space with T4-P4. That may need balancing with T3-T4 to avoid instabilities.

ADDING BASIC SITES

AFTER STARTING T4-P4 - starting with physical calming, T4-Fp2 is probably the next site to calm emotional self-control. We might need to add other basic sites, depending on specifics of the injury and pre-existing symptoms. Traumatic brain injury can have wide-spread impact throughout the nervous system. Adding all basic sites may be useful.

AFTER STARTING T3-T4 - stay with T3-T4 alone as necessary to maintain stability. Then carefully add T4-P4 for right- brain calming and spatial awareness, and T3-Fp1 for improved executive function.

AFTER STARTING BOTH T4-P4 AND T3-T4 - add T4-FP2 next to continue combination of right-side calming and T3-T4 stabilizing.

ADDING OTHER SITES

More specific sites are often useful with specific brain injuries. This might be left-side T3-F7 for word finding and articulation, or right-side T4-F8 for emotional expression. T4-T6 might help understanding of facial expression and body language. While T4-P4 is generally most helpful for balance and coordination issues, T4-O2 is sometimes more effective when there is a visual field deficit contributing to the problem.

ADDING ALPHA-THETA OR SYNCHRONY

Alpha-Theta might help brain-injured clients cope with traumatic memories or life-changing disabilities, but care should be taken to avoid provoking instabilities.

STARTING PLACEMENTS

RIGHT SIDE (T4-P4) - Peak performers are skilled and driven to excel. T4-P4 promotes physical and emotional calming that allows even betier performance.

INTER-HEMISPHERIC (T3-T4) - for peak performers whose success might be limited by disabling instabilities. Migraines, panic attacks, asthma attack, etc. can derail a successful performance. Peak performers in sports often have a history of concussion, which adds to brain excitability and need for stabilizing training.

BOTH (T4-P4 and T3-T4) - often needed to promote calming and stabilizing throughout training.

ADDING BASIC SITES

AFTER STARTING T4-P4 - after physical calming with T4-P4, the next site should be T4-Fp2 for calming emotional reactivity, an important skill for peak performers. Other basic sites can be added in time for more specific effects. It is often necessary to stay on the right side with those with a history of developmental trauma.

AFTER STARTING T3-T4 - after sufficient stabilizing, right side T4-P4 can be added for body and spatial awareness. Then left side T3-Fp1 and T3-P3, as tolerated for executive function and fine motor skills. Clients with bipolar mood swings should not train left side, since that will likely produce mania.

AFTER STARTING BOTH T4-P4 AND T3-T4 - when right-side calming and T3-T4 stabilizing are necessary to start, the next site should be T4-Fp2 for emotional calming.

ADDING OTHER SITES

Other more specific sites might be useful for enhancing specific skills.

ADDING ALPHA-THETA OR SYNCHRONY

Both Synchrony and Alpha-Theta should be helpful for peak performers. They may promote a calm focus and/or allow resolution of traumatic memories that interfere with their performance.

STARTING PLACEMENTS

RIGHT SIDE (T4-P4) - for people who feel better and function better with sedating medications or therapies.

INTER-HEMISPHERIC (T3-T4) - for people who benefit from anticonvulsant medications or marijuana.

BOTH (T4-P4 and T3-T4) - for those who do well with a combination of sedating and stabilizing medications.

Effective neurofeedback training should decrease the need for medication to control symptoms. Formerly optimal dose of medication might start to feel like too much, or side-effects of medication might increase.

ADDING BASIC SITES

AFTER STARTING T4-P4 - add T4-Fp2 for addictive behaviors

AFTER STARTING T3-T4 - for ADHD and other instabilities add T4-P4 and T3-Fp1 for specific impact on attention and body calming.

AFTER STARTING BOTH T4-P4 AND T3-T4 - add T4Fp2 for emotional calming

ADDING OTHER SITES

ADDING ALPHA-THETA OR SYNCHRONY

For those with addictive behaviors or substances, Alpha-Theta should be helpful in resolving traumatic experiences and self-destructive behaviors.

Neurofeedback assessment leads us to an understanding of how our client's brain does and does not function well. We consider symptoms, test results and other information to identify modes of dysregulation that relate to our specific training options. We develop an overall treatment plan, which includes how and where we expect to train over time - right side, left side, front, back, Synchrony or Alpha-Theta.

Then we begin the training process and gradually and systematically implement our training plan. Every step of the way, we are open to modifying our plan and our understanding of the client based on the response to each change in training frequency or addition of training site. We do not start right away with all sites that are expected to be useful. We need to start with one site, optimize the training frequency at that starting site, and see exactly what effects are achieved with training at that site. We might need to shift starting site if the results are not positive. We then add other sites, one at a time, as needed and as tolerated. This is the heart of the clinical process. What are we doing, and what else do we need to do? Our understanding of the client, our model of their functioning and understanding of how we need to train, changes and grows as we progress with training.

In this section we will discuss the neurofeedback process beginning with 1 channel or 2 channel infra-low frequency training. We will discuss factors in selecting a starting site and finding an optimal training frequency.

Then we will look at the process of adding basic sites, other sites when necessary and finally Alpha-Theta or Synchrony when appropriate.

A neurofeedback program begins with infra-low frequency training to achieve physiological selfregulation. The 1 channel and 2 channel ILF HD applications in Cygnet is optimized for signal processing and feedback presentation in the infra-low frequency range.

1 channel bipolar placements for ILF training involve both plus and minus (signal and reference) electrodes recording EEG activity at the scalp. The difference signal (signal minus reference, or equivalently reference minus signal) is displayed as 1 channel EEG and spectral. This is the EEG signal from which the feedback to the client is derived. What is generally called the ground electrode does not contribute directly to the training signal and can be placed anywhere on the head. In fact, for safety reasons the client is always isolated from actual system ground. Bipolar placement is distinguished from referential placement, in which the difference signal is derived primarily from one electrode on the scalp with reference to a quasi-neutral site such as the ear.

EEG history graphs show average amplitudes within different frequency bands over the course of a session. These graphs might indicate some changes over time in muscle tension, closed eyes, sleep or movement. But caution should be used in interpretation of these signals that are highly corrupted by artifacts as people blink, speak, and move during the session.

Other physiological measures are now available as additional information to the clinician. Heart rate, skin conductance, and hand temperature can be measured with a combination sensor on the finger. EMG (muscle tension) is also measured as high frequency activity from the EEG sensors.

1 channel bipolar placements involve three electrodes – plus, minus and ground. The placements are labelled as the plus and minus electrode sites, for example T3-T4. For 1 channel training it does not matter which site is plus or minus. T3-T4, for example, is equivalent to T4-T3. The ground electrode can go anywhere on the head and does not contribute directly to the difference signal. All three electrodes must always be attached, however, since the ground serves as common reference for the plus and minus electrodes.

Bipolar placements can involve both plus and minus electrodes on the same side of the brain, for example T4-P4. Or plus and minus electrodes can be on opposite hemispheres, for example T3-T4.

With the Neuroamp EEG amplifier, 1 channel bipolar placements require that electrodes be connected to channel 1 plus and minus inputs, and the common ground. Electrodes plugged into channel 2 inputs will not be seen by a 1 channel application.

For infra-low frequency training we use silver/silver chloride electrodes, which give us a more stable signal in the infra-low frequency range. The brain is amazingly good at separating signal from noise, but we want to give it the best information that we can. Some care is required in handling these electrodes, since they will be damaged by exposure to any substances other than distilled water and electrode paste. They should be cleaned with distilled water to remove residual paste before they are allowed to dry.

The 1 channel ILF HD display shows a 10-second sweep of the EEG signal, which is the difference signal between the channel 1 plus and minus electrodes. This includes activity in the conventional EEG frequency range from delta to high beta. Infra-low frequency activity is filtered out for this display to maintain a stable baseline.

The spectral display shows the distribution of amplitudes across the same frequency range. The current values are displayed in front, which then scroll to the back over 10 seconds until they disappear. When we see some transient or rhythmic activity in the EEG trace, we can look at the spectral and see that activity represented in terms of frequency. Infra-low frequency activity is also filtered out for the spectral display. Artifacts and infra-low frequency EEG would dominate the spectral display if they were not attenuated.

Training signal and inhibit bars show the feedback information that is represented in the games for the client. The infra-low frequency training signal is selected by moving the slider along the infralow frequency range of 0.001 to 10 millihertz. The most recent update of Cygnet has expanded the lower training frequency limit from 0.01 to 0.001 millihertz. The inhibit bar shows the combined activity of multiple inhibit bands across the usual range from delta to high beta.

2 channel Cygnet applications involve two separate EEG signals that are combined by adding or subtracting. The feedback is then determined by the combined sum or difference signals. For 2 Channel ILF HD the training signal is derived from the difference between the two channels. If we use a common reference for the 2 channels, this gives us exactly the same training signal feedback as 1 channel ILF HD. Working with the difference signal promotes differentiation and control of cortical function. The inhibits, on the other hand, are set on the sum of the two channels. Since dysregulated EEG activity is more likely to be seen in the sum than in the difference of channels, we have more effective inhibit information with the 2 channel application. We find that this enhanced inhibit feedback increases the overall effectiveness of the program.

For both 2 Channel Alpha-Theta and 2 Channel Synchrony the two channels of EEG are added together for training and inhibit feedback. Deriving the training signal from the sum of channels promotes synchronous activity at the two training sites. This leads to deactivation of cortical function and release of deeper states of consciousness.

The 2 channel ILF HD Cygnet screen shows EEG and spectral displays for channel 1 and channel 2 separately.

The one yellow training bar shows the signal level at the selected training frequency. The training signal is derived from the difference between the two channels of input. This is the same training signal that we would have with 1 channel ILF HD, assuming that we use a common reference site.

The one gray inhibit bar is a combination of the multiple inhibits set on the sum of the two channels. This is different from, and stronger than, the inhibits in 1 channel ILF HD.

For 2 channel ILF HD we can use four electrodes on the head by linking the two reference inputs. A short jumper cable can be used to connect channel 1 reference (minus) to channel 2 reference (minus). Then one electrode can be plugged into the combined reference input and attached to the head at Cz. A separate ground electrode can go anywhere on the head - shown here on the forehead.

The other two electrodes become signal (plus) inputs for channel 1 and channel 2. They are moved around during a session for different training sites. The session report shows the training placement as T4-P4 with a blue (difference) line connecting them. In this case Cz is circled since it serves here as reference for both channels. Cz is typically used as the common reference for 2 channel ILF HD. The activity at Cz will be part of the displayed EEG signals, but it will be subtracted out for the training signal. For the difference signal, (T4-Cz) - (P4-Cz) = T4-P4. Meanwhile Cz will contribute to the inhibit signal which might add to the strength of the inhibit and that might be helpful. For inhibits on the sum of channels (T4-Cz) + (P4-Cz) = T4+P4-2Cz, abnormal amplitudes at Cz are a reasonable target for down training.

History graphs show the amplitudes of the conventional EEG frequency bands over the whole session. These trend lines are highly smoothed, so they do not show the rapid changes that are represented in the feedback display. They can show gradual trends over the session. They also show a considerable amount of artifact, reflecting movements during session, particularly in the delta band.

A new combination sensor for Cygnet allows monitoring of additional physiological variables during the session. The time scale can be adjusted to show changes over a shorter or longer time frame. This physiological monitoring option is available with all Cygnet applications including ILF HD, Alpha-Theta and Synchrony. For the clinician these measures provide more information about the physiological state and stress level of the client during a neurofeedback session. We expect this to be useful in detecting otherwise unreported state shifts.

Muscle tension (EMG) is derived from a high frequency range measured by the EEG electrodes. This is well above the normal EEG range, although some EMG activity can also be seen in the higher frequency end of the EEG spectral display. Since the EEG electrodes are on the head, the EMG measurement will relate primarily to muscle tension in the jaw, neck or face.

Heart rate tracks the average heart rate which might increase with sympathetic arousal. We also expect to see normal fluctuations in heart rate with the breath. When people are quiet and still, we expect to see a rhythmic variation in heart rate, increasing while breathing in and decreasing while breathing out. The lack of a normal heart rate variability is a sign of physiological dysregulation.

Galvanic skin response (GSR) is a measure of the ease of electrical conduction through the skin. Skin conductance relates to sweat gland activity, which increases with sympathetic arousal. GSR increases rapidly in response to emotional triggers, and then settles gradually with relaxation.

Hand temperature is related to peripheral blood flow. In stressful situations blood flow is usually decreased in the extremities and increased in the vital organs and major muscles of the body. This is useful in reacting to danger in a fight or flight situation. When people feel calmer and less stressed, their hands and feet are often warmer.

Our understanding of neurofeedback has evolved significantly over the past 30 years of clinical experience and instrument development. We all believed initially that we were doing operant conditioning on brain waves. If we rewarded the brain for making better brain waves, we would get better brain waves and better brain function. That model however fails to explain the effects we now see, particularly with infra-low frequency training.

We now understand neurofeedback as a process of allowing the brain to see its own activity and self-correct. Increasing awareness of one's internal state allows improved self-regulation and better function. This is somewhat similar to the practice of mindfulness while focusing on the breath. We don't need to reward the brain for doing it "right." And we don't need to fix the brain waves. We let the brain see what it is doing in the moment, which allows it to let go of dysfunction and function more optimally. Neurofeedback is not treating symptoms or curing disease. It is simply promoting healthy self-regulation and good brain function.

Our EEG feedback has two components – a selected infra-low frequency training band and the standard multiple inhibit bands. The inhibits show the brain when it has gone off track. The multiple inhibits respond to rapid increases in amplitude at any frequency from delta to high beta. All the individual inhibit bands are combined into an overall inhibit amplitude that influences the feedback game display. The effect of the inhibit is to disrupt or limit the game display in some way. A black fog, for example, enters the tunnel in Inner Tube, or the picture whites out in Advanced Media Player. These are usually brief and mild disruptions that inform the brain without punishing it.

Artifacts can also trigger inhibits. Cygnet automatically removes most artifacts in real time, but some may slip by and trigger the inhibits. This is not a significant problem since our brains are good at separating signal from noise. And our brains certainly know when we are blinking or moving.

Individual inhibit bands contributing to the combined inhibit bar are usually hidden, but can be displayed when selected from the measurement menu. Inhibit frequency bands and thresholds are all set automatically. It is possible, but not usually necessary, to change the overall strength of the inhibits with a slider on the inhibit window.

Sudden increases in amplitude at any frequency are seen in the movement of the corresponding inhibit bar. The movement of all of the inhibit bars in relationship to their individual thresholds are combined into one overall inhibit bar. The height of the combined inhibit bar then controls the inhibit function in the feedback display.

Training frequency selection is an important part of clinical decision making in infra-low frequency bipolar training. The brain is surprisingly responsive to the specific choice of training frequency. It is necessary to carefully adjust training frequency for best effect with each brain.

This is the frequency we select to show back to the brain through its impact on the feedback display. We want to make the brain aware of this signal. We are not asking the brain to make it bigger, but simply to engage with the signal and witness its slowly changing level.

We can draw no conclusion from the training signal itself as to the status of the trainee, or regarding trends. Nor can we tell from the signal itself whether the training is being conducted at the optimal frequency.

The ILF HD application in Cygnet shows the training signal level as the height of the yellow bar in the signal window. The range (or height of the window containing the training frequency bar) is adjusted automatically to optimize feedback to the brain. We expect to see the training bar change very slowly when we are working in this infra-low frequency range. The training frequency signal level controls the speed or size of the feedback display, so we also expect the feedback related to the training signal to change very slowly in session.

The training frequency is selected by adjusting the slider across the infra-low frequency range. This is a logarithmic scale from 0.001 mHz to 10 mHz. One millihertz (mHz) is one thousandth of a Hertz, or one cycle per 1000 seconds.

What exactly do we mean by signal level and amplitude? And how do they control feedback in different frequency ranges?

At higher frequencies we track the overall amplitude of the wave form as seen here for 10 Hz activity. The signal completes 10 cycles each second, which would be much too fast for direct feedback. The amplitude, however, rises and falls more slowly, providing a more comfortable feedback display.

With infra-low frequencies we track the raw signal level, not the amplitude. We are not interested in the overall height of the wave (the amplitude), which we might not even know within the duration of one session. Instead we are interested in where we are on the wave in the moment (the magnitude of the actual signal at that moment). This is something like attending to your own breath. Your brain tracks the rhythm as you breathe in and breathe out, not just the overall volume of the breath. Similarly in our case of infra-low frequency training, the self-regulating brain is only interested in its behavior in the present moment. At 0.1 Hz (or 100 mHz), one full cycle takes 10 seconds. With our usual infra-low training frequencies, we are far below 0.1 Hz, which gives us a very slowly changing signal level. We find that this is actually more direct and more useful information for the brain, which gives us stronger training effects than at higher training frequencies.

An increasing training signal translates into more speed with the car, train, rocket or jet ski. That might be more fun, but it does not mean one is doing anything better. We are just tracking the rising and falling wave form. Just like breathing in and breathing out are equally useful, one is not better than the other. Here the information is in the dynamics of the signal as it goes up and down, not how far it ultimately goes.

Training frequency effects are surprisingly specific. There can be a huge change in training effect with one small step in training frequency. As we adjust training frequency we need to track both short-term and long-term effects. Short-term effects reflect state shifts in session which might last a few hours to days. Of course, we are most interested in the long-term effects – the improved regulation of state that becomes permanent. We find that good effects in session are usually a good indicator of good long-term outcome. Whatever keeps people in a comfortable state in session is likely to produce the best outcome over multiple sessions.

As we work with an individual client, we learn what symptoms shift with a higher or lower training frequency. During a sequence of sessions, we adjust electrode placements and training frequency as needed for optimum effect.

With infra-low frequency feedback most people are able to notice and report state shifts in session. This might be a change in physical relaxation, alertness, emotional state, head or body pain, heart rate, etc. The general rule is that shifting to a higher training frequency invites the brain to shift to a state of higher physiological arousal. Similarly shifting down in training frequency leads to a lower state of physiological arousal. We are looking for the optimal training frequency which results in a state of relaxed alertness. Often we can observe changes in body posture, breathing, speech, etc. for clues as to how the person is feeling. Or we might see changes in our physiological measures, although we cannot rely on measurements entirely to guide our selection of the optimal training frequency. The person's experience is the most useful information in guiding the choice of optimal training frequency.

Short-term state shifts within a session help guide us to a comfortable training frequency that is not too agitating or too sedating. But shifting to a new brain state is not the goal of neurofeedback. The exercise of shifting state repeatedly over a number of sessions leads to improved flexibility and stability of state. We are working toward improved self-regulation of brain function. A calmer and more stable brain is then capable of better function.

The first decision is whether to start with right side training (T4-P4 for calming), left-right (T3-T4 for stabilizing), or a combination of the two. We plan to stay with the starting placement long enough to optimize the training frequency and to see what symptoms it is and is not impacting. We would like to see how the effects develop over a few sessions, not just the effect within the first session. Then we gradually add more placements as needed. If we can see where the current placements are taking us, we have a clearer idea of what else is needed.

After carefully selecting the best starting placement, or placements, it still might become necessary to change starting placements within the first session or the first few sessions. Our understanding of the client changes and grows as we observe the specific effects of training. Sometimes we have to revise our approach as we go.

How do we decide whether to start training right side or left-right? Developmental trauma is the key issue in deciding whether right brain calming needs to come first before any left brain training. During early development our nervous system is learning physiological and emotional selfregulation. If that step is missed due to the child's own temperament or due to external circumstances, we then have a nervous system that lacks resilience. A healthy nervous system recovers over time from the injuries, losses and traumas of life. People who lack resilience often develop chronic symptoms of dysregulation. People with chronic pain, chronic mood disorders, chronic insomnia, chronic addictions, etc. generally respond best to T4-P4 as a starting placement for physical calming. If we train the left hemisphere without sufficient right-brain calming, the consequence is increased agitation. Even when there is no report of developmental trauma, we should consider chronic dysregulation as indication of lack of resilience and a good reason to start training right side.

Nervous system excitability (or instability of state) is a separate issue from physiological arousal. Excitability generally relates to genetic vulnerability and/or brain injury. Instability symptoms are typically explosive and disabling. Starting with right-side calming (T4-P4) can be destabilizing and promote more headaches, panic, asthma, etc.

Instability symptoms indicate the need for T3-T4 as starting site - before or in combination with T4-P4.

The choice of starting placement is fundamental for the whole training process. It is important to get this choice right for each individual. Sometimes that might take a few sessions to completely sort out.

There are people who have strong reasons to start right side (T4-P4), and also strong reasons to start with left-right (T3-T4). Sometimes we need both placements within the first session or first few sessions. The issue is not just how to get the best positive effect, but also how to avoid a negative effect. We want to avoid increased agitation in people with early trauma, so we want to stay on the right side. But we also want to avoid precipitating significant instabilities such as seizures, migraines, panic or dissociation, which might happen if we do not include T3-T4.

This comes down to clinical judgment in deciding which placement to start with. At which site do we want to start finding the optimal training frequency in the first session? We might start with T4-P4 in the first session with someone with a trauma history and panic attacks. We would be adjusting the training frequency at T4-P4 for optimal calming. Then we might take that optimal training frequency to T3-T4 within the first session or the first few sessions to see how the person responds. If the effect is positive and calming, then we can continue with both starting sites. If the effect is too activating, we back off to T4- P4 alone. Some brains do best with right side training even when symptoms of instability suggest otherwise.

There are times when we might start T3-T4 with a person who has seizures and also a developmental disorder. If we can find a good training frequency at T3-T4, then we might try adding T4-P4 in early sessions. If that is destabilizing rather than calming, we can safely go back to T3-T4 alone.

We expect to impact brain state within the first few minutes of training, although people differ in terms of their self-awareness and ability to report changes. We need to inquire about changes and give some guidance in what to look for. It is useful to ask about changes in body relaxation and mental alertness. Always give options - more, less or just the same. All options are equally valid and useful. It is important to encourage feedback without suggesting a desired response. We should also observe clients for changes in physical tension or activity, alertness, mood, facial expression, tone of voice, posture, etc. Basically we are working toward physical relaxation and mental alertness.

After selecting an appropriate starting frequency, start moving the frequency down every two or three minutes to explore the range down to 0.01 mHz. If the person shows signs of low arousal like uncomfortable sedation, nausea or inexplicable sadness in session, then move back up gradually as far as necessary for good effect. If the person feels agitated or feels no effect, keep moving down to 0.01 mHz and stay there for the rest of the first session. There is nothing better or worse about training higher or lower. Our job clinically is to find what works best for the individual.

Very few people train higher than 0.5 mHz, so that is a reasonable starting frequency for people with no obvious need for a strong calming effect. Moving down through the range 0.5 to 0.01 mHz gives the brain an opportunity to judge the difference in effect with each step down. This might include people with instabilities like migraines and seizures.

Clients with high arousal symptoms such as anxiety and insomnia are expected to optimize in a lower frequency range. Starting with 0.1 mHz and working down from there should reach a comfortable training frequency more quickly.

People with extreme arousal symptoms such as those associated with developmental and attachment disorders are expected to train with a very low training frequency. We want to avoid increasing agitation with these clients and we may not get good feedback during the session. For all those reasons, it makes sense to start at 0.01 mHz and stay there for the full first session, unless there is good reason to change.

We try to make a good choice regarding starting placement – T4-P4 or T3-T4, but sometimes it is not the right choice. How do we know when to change starting placement, or add a second placement as we start training?

We might find T3-T4 too activating at any training frequency in the first session or first few sessions. That is usually an indication that we need to move to right side training (T4-P4). Left side training, even T3-T4, can be too activating for some people. Then we move to right side training with T4-P4.

Starting with T4-P4 might set off symptoms of instability, typically headaches, nausea or dizziness. We should try adjusting the training frequency first. If that is not effective, then move to T3-T4 and try optimizing the training frequency there. Some brains need stabilizing first before tolerating right side training.

Starting with T4-P4 also might set off symptoms of disinhibition. Disinhibition means loss of selfcontrol. This might look like immature, impulsive behavior. Or it might involve loss of emotional control. Training right back (T4-P4) is very calming, which can be a problem for some people when it is not balanced with prefrontal training for control. So there is a left/right issue and also a front/back issue.

When the response to T4-P4 is more like ADHD immaturity and impulsivity, we can move to T3-T4 as a stepping stone toward T3-Fp1. Training both sides with T3-T4 is usually enough of a left side effect to eliminate the disinhibition. When the response is loss of emotional control, we might need to add T4-Fp2 to reduce emotional reactivity.

Some people need both starting sites, T4-P4 and T3-T4 right away. In that case we continue to divide each session into two parts. Both starting sites should optimize at the same training frequency, so any adjustment of the training frequency at one site should also be applied at the other site.

In the first session we plan to explore training frequencies down to 0.01 mHz. If more calming is still needed in later sessions, we can gradually and carefully explore the range from 0.01 down to 0.001 mHz. It is best to move down through this lower range very gradually and carefully. We want to see the effect of each move, before shifting lower.

It is usually helpful to stay with the starting placement or placements for a few sessions. This will be the foundation of everything else we do, so we want to get it right. We want to see what effects it does and does not produce. We may be tempted to add other sites quickly, but that can confuse and complicate the process of figuring out what works best.

Throughout infra-low frequency training our decisions will be which training sites with what training frequencies. The key is to know what specific effects relate to training at each site and what it looks like when we are too high or too low with the training frequency. Our first step in the process is the starting site and training frequency. All along the way we will optimize sites and training frequency based on training effects in session and also changes from session to session.

We continue to monitor and adjust the training frequency throughout training, but our focus shifts in time to selection of effective training sites. After some sessions to establish the most effective starting site and training frequency, we are ready to add more training sites to target specific symptoms that are not responding to the starting site or sites alone. The effect of training each new site should be observable against the baseline of starting site training effects.

If adding a new site has a good effect, then we keep it in the mix for as long as we continue infralow frequency training. If the new site makes things worse, it could be a training frequency issue, and adjustment of the training frequency might yield a better effect. More typically a bad effect means that we should not train that site – at least not yet. If we expect a site to be useful and it is not, then we might need to rethink our understanding of the dysregulation involved. Sometimes a new site is not tolerated, but then later it is useful. This is common with PTSD, for example, where we need to start with right side training only. Once the right brain calms sufficiently, we can often add in left side sites that were not tolerated earlier in training.

We always start by gradually adding some combination of the basic sites discussed earlier in the assessment section.

Basic sites include temporal (T3 and T4), parietal (P3 and P4) and prefrontal (Fp1 and Fp2) areas. These are the areas involved in the highest level of input and output functioning of the central nervous system. The basic sites give us the broadest effects in developing and maintaining good high level brain function for most people. Most of our clients complete infra-low frequency neurofeedback training with some subset of these basic sites.

After exploring the effects of training at these basic sites, we sometimes need to add other more specific sites. Starting with the basic sites, many specific symptoms are impacted. That then clarifies what still remains to be done and simplifies the decision of what to do next.

Finding the best training frequency at the starting site helps us predict the optimal training frequency at other training sites to be added. There is a strong expectation that the training frequency at other sites will follow some simple rules. Of course we should always do what is comfortable and effective for the client, but we expect that things will sort out in time according to these rules. The rules have emerged from our clinical experience and are quite robust.

First, all right-side bipolar sites should train with the same training frequency, which should be the same as for T3-T4. This includes both starting site options, T4-P4 and T3-T4.

All left side bipolar sites should train with the same training frequency, which is higher than the optimal right side training frequency. The simple rule about left and right side training frequencies is that the left side training frequency is expected to be two times the right. So a right side training frequency of 0.25 mHz, for example, translates to a left side training frequency of 0.5 mHz. This doubling only applies to the infra-low frequency range.

We always train basic sites first and see how far that goes in resolving symptoms for each individual. For the majority of clients, the general effects of these high level sites give us what we need for a satisfactory training outcome. But sometimes there are specific symptoms that are not sufficiently addressed with basic site training. There are other less frequently used sites that can be helpful in these specific situations. This is more common with brain injuries or specific learning disabilities.

Other sites include frontal (F3, F7, F4, F8), central (C3, C4), posterior temporal (T5, T6) and occipital (O1, O2).

Other right side sites can be useful with autism and other developmental disorders. This includes T4-F8 for acquisition of language and emotional expression, and T4-T6 for the ability to read the facial expressions and body language of others. T4-O2 is sometimes an emotionally calming placement for those with trauma or developmental disorders. Occipital placements might also be helpful with visual deficits related to TBI or premature birth.

Other left side sites can be useful with brain injury or processing deficits. T3-F7 can be helpful for word finding and improved verbal articulation. T3-T5 can be helpful with decoding words when reading. T3-F3 can have a strong antidepressant and energizing effect.

Frontal and prefrontal training have very different effects. Prefrontal training improves planning, organization and self-control. This is like the brakes and steering in brain function. Frontal training is more activating – like stepping on the gas. Frontal training impacts the initiation and sequencing of output – moving and talking. On the left side Broca's area controls motor speech. Training here with T3-F7 can have a strong impact on articulation and word finding. The comparable area on the right side (T4-F8) is often helpful with acquisition of language and emotional expression in developmental disorders.

The frontal eye fields control our visual orientation to new stimuli. Targeting the frontal eye fields by training frontally (T3-F3 or T4-F4) can be quite helpful with strabismus, where the two eyes do not track together to focus on input. T3-F3 can get people energized and motivated, but can also be too activating for many people.

Because frontal training is activating, it is important to do sufficient prefrontal training first. We want brakes and steering in place before we step on the gas. Some people never tolerate frontal training because it is too activating and agitating for them.

The central strip straddles the anterior parietal and posterior frontal cortical areas. This is where the brain processes somatosensory input and executes motor output. Although central sites have been used historically in a number of published neurofeedback studies, we now achieve stronger training effects on most common symptoms with our basic sites. Central sites are still useful for impacting more specific symptoms related to primary somatosensory or motor function. On the input side, this might be an inability to feel what we touch, or seizures precipitated by touching some part of the body. On the output side, this might be weakness or paralysis after brain injury, or seizures that start with a particular movement of the body.

We can target dysfunction of specific parts of the body with specific placements along the central strip. Both the somatosensory (input) and motor (output) cortex map the opposite side of the body in a predictable fashion. Areas of the body that are more sensitive to touch or have finer motor control have a larger cortical representation. Hands, face and mouth, for example, have much larger representations than trunk or legs.

With motor seizures or deficits in feeling or moving, it is clearly helpful to target the specific area related to the involved body part. C3 and C4 are close to the areas related to the left and right hands. So we might, for example, target post stroke paralysis of the right hand and arm with T3-C3.

We use central strip placements for deficits in feeling and moving. We do not generally use central strip placements for deficits in sensory integration, coordination, spasticity, tremor or sensory hypersensitivity. Those are all indicators for parietal training.

With posterior temporal placements we are targeting high level visual processing in the ventral stream. On the left side (T3-T5) we might impact reading by improving the ability to decode letters and words. On the right side (T4-T6) we might impact the ability to read facial expressions and body language. This can lead to more comfort in social situations, which can be helpful for those on the autistic spectrum.

We can target basic visual processing with occipital lobe training. This is sometimes useful with traumatic brain injury when the brain has impacted the front and back of the skull. We might improve double vision, visual acuity, color vision or depth perception. Projections to the primary visual cortex partially cross over so that each hemisphere processes input from the contralateral visual field of both eyes, not from the opposite eye ball.

We have also seen very significant improvement in visual deficits related to premature birth. Premature birth and exposure to oxygen while in intensive care can lead to abnormal development of the primary visual areas and abnormal visual cortical activity.

Right hemisphere occipital (T4-O2) training can be profoundly calming emotionally. This is different from the physical calming effect of T4-P4. We have specifically observed this in people with emotional trauma. It is sometimes also helpful with autistic individuals.

Once we have left and right side training frequencies optimized for the basic sites, we also know what the optimal training frequency should be at other training sites.

All right side placements with reference to T4 train with the same optimal training frequency, which is the same for T3-T4. All left side placements with reference to T3 also train with the same optimal training frequency, which is two times the right side training frequency (in the infra-low frequency range). If we know what training frequencies are effective at left and right side basic sites, we can simply extend those training frequencies to the other sites.

There are some people who do not tolerate our usual basic placements. They might do well with T3-T4, but then respond badly to left and right side placements as we try to incorporate parietal or prefrontal sites. Sometimes this is a matter of further optimizing the training frequency or waiting a while longer, but these clients might also do better with inter-hemispheric training by combining T3-T4 with P3-P4 and Fp1-Fp2.

Training frequency rules for inter-hemispheric placements are a little more complicated, but very important for optimizing training effects. The optimal training frequency is first established at T3- T4. Moving forward to Fp1-Fp2 requires that we divide the T3-T4 training frequency by 2. Moving back to P3-P4 requires that we divide the T3-T4 training frequency by 4.

It is important to remember that going from right to left with our usual basic placements means increasing the training frequency. Moving front or back with inter-hemispheric training means a lower training frequency.

For those who do better with inter-hemispheric training sites, we might want to add other sites beyond the basics. We should already know the optimal training frequencies at the basic interhemispheric sites. Then we need to know which other sites train with the same training frequencies.

Other inter-hemispheric placements on the central strip (C3-C4) and posterior temporal area (T5- T6) train with the same training frequency as T3-T4.

Inter-hemispheric frontal sites (F3-F4 and F7-F8) train with the same training frequency as prefrontal (Fp1-Fp2).

Inter-hemispheric occipital (O1-O2) and parietal (P3-P4) train with the same training frequency.

Training frequencies require continued attention throughout training. Some people need a training frequency adjustment after their brains have settled in with a number of sessions. Some people are enormously sensitive to training and require frequent small adjustments of training frequency over the course of training. This is often the case for people with fibromyalgia.

Sometimes we uncover the need to adjust training frequency when adding a new site. Prefrontal training, for example, is especially powerful and can cause discomfort when the training frequency is not adequately optimized. If we do need to adjust the training frequency at a new site, then we should go back and adjust for other sites accordingly. The optimal training frequency at T3-T4 might seem to be 0.2 mHz, for example, but then T3-Fp1 at 0.4 mHz results in a headache.

Readjusting the training frequency at T3-Fp1 down to 0.3 mHz in order to reduce headache symptoms then indicates a readjustment at T3-T4 to 0.15 mHz, which should be more effective as well.

We use common arousal indicators to understand symptom changes with training, which helps us adjust the training frequency for optimal effects. Increasing the training frequency results in increased arousal. Decreasing the training frequency results in decreased arousal.

If we train with too high a frequency, the brain responds by getting too speeded up. Training too high results in increased agitation – physical, emotional, mental or physiological. This is usually distressing to the client and sometimes to those around him. Training too high can produce increased muscle tension or spasms, hyperactivity or impulsivity, tics or OCD symptoms, and sometimes heart palpitations or increased heart rate. Emotional agitation might show as increased anxiety, fear, anger, despair or emotional reactivity. Sleep can be disturbed with difficulty falling asleep or increased nightmares.

High arousal is appropriate in emergency mode, but not as a long-term state. In an emergency we need to focus on and respond to the emergency. We do not pay attention to our long-term needs to take care of our bodies or plan for the future. Hence constipation is a common symptom for people who live in emergency mode, and increased constipation can be a marker of training too high.

If we train with too low a frequency, the brain responds by getting too slowed down. This is usually very unpleasant for the client. Being sedated might cause people to feel dizzy, nauseous, heavy, groggy or sad. Too low can cause emo-onal sensi-vity, which is different from emo-onal reac-vity related to training too high. Too low can cause excessive sleepiness and also lack of deep sleep.

Training too low might cause people to fall asleep and back to sleep easily, but wake frequently and not feel rested in the morning, despite many hours in bed. This is different from waking during the night and having difficulty falling back to sleep, which might be related to training too high. Too low can cause people with an asthma vulnerability to have difficulty taking a deep breath. This is different from the chest tension with increased anxiety when training too high. Too low can also precipitate symptoms of low blood sugar.

Sleepiness in session is a tricky issue. It often confuses our interpretation of training effects in session and the search for an optimal training frequency. Training optimally is very relaxing for most people. And for some people relaxation leads to sleepiness. Many people are significantly sleep deprived and are running on adrenaline and caffeine. They will, of course, feel sleepy when they relax. ADHD people tend to run at high speed and then fall asleep as soon as they are bored or still. A quiet relaxing neurofeedback session puts them to sleep as would a movie without enough action scenes. A comfortably relaxed sleepiness is probably a good effect and does not require a training frequency adjustment. We don't want to over-stimulate people in an attempt to keep them awake, when they really need to calm down and sleep better.

We want to calm people with training, but not sedate them. Feeling sedated is not comfortable. Feeling groggy or slowed-down in session or after a session does suggest that the training frequency is too low. If that is so, a higher training frequency should immediately feel better.

It is also possible that training with too high a training frequency can make people feel exhausted, and may cause difficulty keeping eyes open. This feels different from sleepiness. Lowering the training frequency quickly reduces the discomfort. If we do change the frequency appropriately in session to address grogginess or exhaustion, there should be an immediate benefit. If not, go back to the starting training frequency and judge the training effect by what happens after the session.

We are typically training 2 to 5 sites in each session. It is usually sufficient to divide the total training time equally among the selected sites. For example, a 30-minute session might be 2 sites at 15 minutes each, 3 sites at 10 minutes each, 4 sites at 7.5 minutes each or 5 sites at 6 minutes each. There are times when we want more focus on one training one site, so it might make sense to spend more training time at that site.

We can also adjust order of sites to maximize overall training effect. We might start right back for physical calming as the first placement in session and work toward left front to end with mental alertness when that is part of the mix. Training all basic sites would then be in the following order: T4-P4, T4-Fp2, T3-T4, T3-P3, T3-Fp1. Sometimes it is more effective to work in the reverse order, ending with T4-P4 in order to leave the client in a more calm and relaxed state. It is also possible to start a session with T4-P4 and also end with it for physical calming as the first and last step.

It is best to train all useful sites in each session. We might completely eliminate a symptom, but that does not mean we have eliminated the vulnerability. Not including a needed site in sessions can, in fact, set off symptoms. This means that we need to be efficient in our selection of training sites. We want to keep training only those sites that give a positive effect. Sometimes the number of training sites becomes inconveniently large, which is possible for example with the specific deficits of brain injury. Then we might divide the placements into 2 or more groups and alternate training groups over sessions.

Infra-low frequency bipolar training is helpful in normalizing physiological self-regulation. That is the first step in our training process for everyone. And that might be all that is needed for some individuals. Others have unresolved traumatic experiences, fears and habits that continue to trigger uncomfortable feelings and behaviors. For these people we also include Alpha-Theta training.

With PTSD for example, we might succeed in physiological calming and stabilizing with infra-low frequency training, significantly reducing flashbacks, hyper-vigilance, insomnia, anger, etc. But there might still be triggers related to the traumatic experience that set off uncomfortable reactions.

Alpha-Theta feedback holds the person in a deeply relaxed state in which the traumatic memories can safely surface and be processed, with or without conscious awareness. Memories are then put into long-term storage from which they can be recalled without the accompanying emotional state.

Infra-low frequency training prior to Alpha-Theta provides time for the client to become comfortable with the neurofeedback process. We are asking people to relax deeply with eyes closed during the Alpha-Theta session. This requires some level of comfort and trust. We might typically add Alpha-Theta training after 10 or 20 sessions of infra-low frequency training, but that can be sooner or later depending on the individual.

When people successfully begin Alpha-Theta training, most will also continue some infra-low frequency sessions along with the Alpha-Theta. The client can usually judge which kind of training would be most helpful on a given day. Infra-low frequency training calms and stabilizes the person's state. Alpha-Theta allows the client to work through unresolved issues.

Alpha-Theta should be useful for any adult since we all have unresolved emotional experiences. Children can also benefit from Alpha-Theta, but it is less frequently used for them.

1-Channel Alpha-Theta involves a referential placement with plus and minus electrodes at Pz and A1 or A2, on the ear lobe or mastoid bone behind the ear. The ground electrode can go anywhere on the head. It is shown here on the top of the forehead. So the placement is Pz-A2.

Silver/silver chloride electrodes are recommended for all clinical work. Metal (gold or silver) electrodes are also adequate for Alpha-Theta sessions, but it is important to have all electrodes of the same material. Do not mix electrodes types. Ear clips can be used for the reference electrode on one ear and also for the ground on the other ear.

The 1 channel Alpha-Theta Cygnet screen shows the 1 channel EEG trace and also the spectral display. We typically see rhythmic alpha activity in the EEG during eyes-closed sessions. This activity appears as peaks in the spectral display around 10 Hz. The dominant frequency is displayed digitally and also by the small ball that moves along the frequency scale. Dominant frequency is only meaningful when there is some frequency that stands out above the rest. When alpha spindles subside and there is no peak frequency, the dominant frequency indicator wanders down to lower frequencies. That doesn't mean that there is a lower peak frequency, but just the lack of any clear dominant frequency. Most of what you see on the clinician screen in session relates to the ebb and flow of rhythmic alpha activity.

Alpha and theta bars show changes in amplitude within the alpha and theta training bands. Thresholds for training bands are set automatically by the software. Adjustments can be made to the alpha and theta frequency bands with the sliders on the frequency scale. We sometimes move the Alpha frequency up to 10.5 Hz for a less sedating effect, but the default frequencies are effective for most people.

Automatic artifact rejection removes artifacts sometimes caused by movements during a session.

The 2 channel Alpha-Theta clinician screen shows three EEG traces - channel 1, channel 2 and channel 1 + channel 2. At the bottom of the screen are separate spectral displays for channel 1 and channel 2. The larger spectral display in the middle is for the sum (channel 1 + channel 2). We can often see rhythmic activity around 10 Hz in the EEG and in the spectral displays. Synchronous activity in the two channels will add together to give a larger EEG trace and a larger spectral peak.

Alpha and theta training bars and feedback relate to the sum of channels signal. All feedback options are the same as for 1 channel Alpha-Theta.

With 2 channel ILF HD the training signal is derived from the difference of the two channels. That subtracts out the combined reference signal input, so we have a clean training signal, e.g. T3-T4. With 2 channel Alpha-Theta and synchrony we derive our training signals from the sum of two channels. That means we have input from both reference electrodes in our training signal - in addition to our Fz+Pz signal.

Reducing the amplitude of those reference signals gives us a cleaner training signal. First we can select A1 and A2 as reference sites, which should be lower amplitude than placements higher on the scalp. And then we can use a jumper cable to connect the two reference inputs to the Neuroamp - further reducing the combined reference signal.

The session report shows the sum of channels as a red line connecting Fz and Pz. A1 and A2 are circled to indicate their use as reference inputs. The ground electrode is shown on Cz, but it is not indicated on the session report.

Here we see the alpha and theta history graphs over the course of a typical session. Alpha rises quickly at the start of the session with eyes closed. With deeper relaxation, we see a drop in the alpha amplitude. Early in the session or early in training, there may be an excitement or fear with going deeper. We then see the alpha amplitude jump back up again. Eventually relaxation is tolerated and the alpha amplitude stays lower for a while. That is often the time of internal imagery and processing. Toward the end of the session, we might see the alpha rise again as the client is ready to be done.

We should avoid disrupting the session when a person is in a deep state. We should also give the client time to slowly reorient to the external world as we remove the blanket, headphones, electrodes, etc.

2 channel synchrony provides feedback on synchronous activity within one frequency band across two areas of the brain. Synchrony training is most effective with normal resting rhythms of the brain. These rhythms are relatively invariant from person to person.

Usually we are working with alpha (10 Hz), or gamma (40 Hz), or ILF (.05 Hz) frequencies, and our usual starting placement is Fz+Pz. Synchrony feedback supports a quiet and peaceful state. People are usually seated upright with eyes open during some part of the session. Visual feedback options include intricate fractals, abstract patterns or natural scenes. Auditory feedback includes layers of sound with relaxing music. Binaural beats are optional.

2 channel Synchrony adds a third option to our neurofeedback process. We can think first of infra-low frequency differential training as promoting physiological self-regulation. Alpha-Theta then provides a process for accessing and resolving unprocessed traumas and otherwise inaccessible experiences. Synchrony promotes a state of calm focus which has many of the same benefits as mindfulness exercises. The question is how we might best combine these three options.