I’m not one for military strategy, but hearing this a few years ago was a lightbulb moment for me.

See, this rule applies to any form of progress in life, and it has important consequences for how we think about effort versus results over time. Let me explain:

This rule applies to physical skills, even basic ones like learning to walk. It takes a huge amount of force (effort) to ‘take the position’ of learning to walk. The math from one infant study works out to 14,000 steps and 100 falls per day. That’s more steps than most of us take daily, and 10,000 falls in 100 days. Immense effort to build, practically zero effort to maintain – when was the last time you tried to walk?

This rule applies to investing. It takes tremendous discipline and frugality to save your first thousand, or hundred-thousand dollars. But because of compounding (i.e., your money working for you once you’ve invested it), one hundred-thousand dollars invested is functionally a quarter of the way to a million in terms of timeline (see below for a visualization of this). Again, high effort to develop the habits that build the nest egg, but relatively little effort to maintain the habits or grow the nest egg.

Lastly, this applies to health and fitness. It takes a ton of effort to put muscle on your frame. After something like 3 hours per week for 52 weeks a year (156 hours total), you might have earned 5-15 lbs of muscle. But, in one study, it took a ninth as much effort to maintain those gains, the equivalent of 20 minutes per week or 17 hours 20 minutes per year. Again, initial progress takes an absurdly disproportionate amount of work compared with maintenance, which takes close to nothing.

Here’s how to visualize it:

Now, although this is an interesting and useful idea on its own – with some practical takeaways I’ll discuss at the end – the juicy bit is that this applies to mental health and psychological skillfulness too.

If you’ve done an intake call with me and asked, “How long until I see results?” or “How long do results last?”, you’ll undoubtedly have heard me say “Neurofeedback is like learning a skill.” Therapy, too, is like a skill. As with any other skill, results will take some time to show up, but after a sufficient amount of effort or investment, they won’t really go away.

Research on neurofeedback supports this idea. One meta-analysis of neurofeedback for ADHD showed attentional gains improved over the following months after stopping sessions. One study on epilepsy showed people still had significantly fewer seizures at 10-year follow-up without any additional sessions. Given the right feedback and training, it seems a brain can remember how to pay attention or not have a seizure in the same way it never forgets how to ride a bike.

There are similar findings in therapy research. A meta-analysis of studies on depression showed patients who did Cognitive Behavioural Therapy and then stopped were significantly less likely to relapse than patients who took medication and then stopped. You may start with weekly sessions and feel like nothing is changing, but by sticking with it, you gain skills that could last a lifetime.

Like the toddler who used to fall 100 times a day, you can get to the point where you can’t remember the last time you fell. For mental health, neurofeedback and therapy can help get you there.

Some takeaways:

Think about starting anything new as an investment. Friction and failure are, counterintuitively, the sign that it’s working. In this way, “Nothing is happening,” means “Something is happening.”

It will feel hard. Then it won’t. We often imagine that the difficulty of starting never ends. We picture the pain of every visit to the gym feeling as hard as day one does. But showing up becomes a habit, and habits have a momentum of their own. There comes an inflection point where effort stops feeling hard and starts feeling natural, and where you’ve started seeing enough results to be motivating, making effort even easier.

Once you’ve taken a position, defense is cheap. Eventually, it takes a once-unthinkably small amount of effort to maintain your results. Effort builds a foundation you can coast on. Self-improvement becomes self-improved.

You may not be a military strategist, but you are the strategist of your own life. Plan accordingly.

If you talk to therapy-minded folks about what matters most, ‘breaking the cycle’ of poor parenting is often a cherished goal – as it should be. Dreaming of being a better parent and causing less suffering for our kids than our parents caused for us is a beautiful and noble thing. After all, many of us can identify the scars that our parents’ failures have left on our lives.

What’s hard, however, is acknowledging that it’s more-or-less inevitable we’ll cause similar scars for our own kids. Not maliciously, but by virtue of being human.

Underneath the desire to ‘break the cycle’ are frequently veiled perfectionism and magical thinking. Somewhere in the minds of many people is the belief that “If I work hard enough in therapy and become a perfect parent, I won’t ever make my kids suffer or negatively impact their lives.”

Do not get it twisted. Abuse and neglect are condemnable, and being a great parent is a dream worth striving for. But the guarantee that you will be a perfect parent is a rigid fantasy. It sets us up for psychological collapse when we inevitably lose patience with a son or daughter who is, by any reasonable standard, genuinely being an asshole. It’s equally delusional to believe your kid will somehow be the exception – that they won’t hit other kids, call you fat, or throw their spaghetti on the floor to test your reaction.

For many, the covert self-expectation underneath ‘breaking the cycle’ is being a 24/7 Zen-Monk-Parent. Infinitely patient, infinitely compassionate, and constantly present and attuned to their kids. This unrealistic standard is itself the thing that will cause us suffering when we – as flawed humans – fall short of our ideals.

Even the Buddha – a symbol of psychological and emotional enlightenment – abandoned his infant son to pursue spiritual liberation. You shouted at your kid to be quiet after thirty consecutive minutes of screaming on a twelve-day road trip. 99% of adults would. How do you even scream for that long? Did God send you here just to piss me off?

There is a wide gap between being a good enough parent and actively neglecting or abusing your child. In fact, a good enough parent models being a realistic – flawed – adult by owning up to mistakes and apologizing for them. Such ownership challenges the belief that parents – or anyone – can be infallible and sets kids up for the real world.

Perhaps another reason to cling to this magical thinking is an unwillingness to accept the suffering our parents caused us. In accepting that we can’t be perfect, we are forced to accept that our parents couldn’t have been either, and thus forced to take responsibility for our own suffering rather than conveniently blaming them.

It’s harder to accept ourselves and others as flawed in this way than it is to daydream about how wonderful everything will be once we finally ‘break the cycle.’ Perhaps that difficulty is a hint of the true work. The work of acceptance: of our flawed selves, of the suffering we will inevitably cause those closest to us, and of the suffering those closest to us have caused us.

Take a breath and forgive yourself. Apologize for losing your patience, repair the relationship, and remind yourself that you’re trying your best. Breaking the cycle is an aspirational goal, not a pass-fail grade. The literal Buddha would be considered a deadbeat by modern standards. You’re allowed to lose your patience without being a bad person.

Want some help doing the work? Neurofeedback can help you become more regulated, and psychotherapy can help you repair relationships when they inevitably fall into disharmony.

In a talk I recently gave for my master’s, I spoke about heart rate variability biofeedback, the most evidence-supported way to calm down your nervous system with your breathing. Jump to around 17 minutes in the YouTube video for a full list of benefits, but in brief, research tells us it helps with: anxiety, depression, PTSD, addiction, physical conditions like chronic pain and asthma, mood, executive function, et cetera.

Just like neurofeedback, heart rate variability biofeedback is one of the few biological wellness tools that genuinely seems to help with everything. This makes sense because it improves your nervous system’s ability to relax, and a stressed nervous system is implicated in just about every health problem imaginable. 

So, why have you not heard of this before? Frankly, most current heart rate variability biofeedback tools are super user-unfriendly. They’re clunky, require technical know-how, and involve complicated troubleshooting. Because of this, you typically need a technician (read: nerd) to teach you to use them correctly, at least initially.

This is about to change in a very big way. 

I was recently sent this podcast with Dr. Jay Wiles on Modern Wisdom — who, unbeknownst to him, is my clinical grandfather, my mentor’s mentor. Dr. Wiles has designed a product that seems to solve all of the above problems, the Ohm Lamp:

The small stone at the top of this lamp is loaded with heart rate sensors. When you hold it, it detects your heart rate and heart rate variability. It then detects the pace of breathing — unique to your body — which maximizes your heart rate variability. Breathe in line with light/sound from the lamp and vibrations in the stone and voilà, your body begins to relax.

No junky cables and sensors, no need to understand the tech, no need to go to a clinic. This tool delivers all the same benefits, but in a simple, sleek, and user-friendly way which might just put the nerds out of a job.

I’ve ordered one, so expect to use it at Hamilton Neurofeedback when pre-orders are shipped in August. The best part: you can do it while you’re doing a NeurOptimal or Vielight session, one of the few situations where I’d encourage multitasking.

Notably, I also picked up the previous gold-standard tech for this. If you’re interested in improving your body’s ability to relax, ask me about it. We can get started during your next Vielight session.

If you’re interested in picking up an Ohm Lamp for yourself, they’re available for pre-order for a limited time (I have no affiliation here, just excited to pass on the word about a great product).

Edit, from the following March 2026 newsletter: This product seemed to resonate, as several clients reached out to tell me they had ordered one. For those interested in how it works, I stumbled across a demo video that I thought I’d include here:

This Lamp Regulates Your Nervous System 😳 (ohm.health)

Notably, I receive no financial gain from promoting this. I really just genuinely believe HRV biofeedback can improve your quality of life. For many people I’ve done this work with on older tech, it can be the first time they’ve felt their nervous system relax in months. They’re available for pre-order, and I will have one available at Hamilton Neurofeedback in August when they ship!

First, carry the intention to get the most out of your sessions. Attention, motivation, and energy levels likely make a difference. I’ve had clients get meaningful results scrolling on their phones or half-asleep while doing sessions, but more and more I recommend being present and attentive.

Next, take care of your body and brain between sessions to help with learning from neurofeedback:

1) Sleep well. During sleep, your brain replays your experiences to consolidate what you’ve learned (Wei et al., 2016), so when you skimp on sleep, learning is impaired (Newbury et al., 2021).

2) Move and exercise more. All types of exercise (walking included) improve neuroplasticity (De Sousa Fernandes et al., 2020), and neuroplasticity improves learning (Cassilhas et al., 2016).

3) Eat healthy, balanced meals. Many of our brain’s neurotransmitters are made from building blocks in our diets (Gasmi et al., 2022), our gut microbiome (the mixture of bacteria in our stomach) influences our thinking ability and memory (Tooley, 2020), and micronutrient deficiencies like vitamin D (Annweiler et al., 2013), or low omega-3 (Andruchow et al., 2017), negatively impact learning and memory.

Lastly, micro-stressors on your brain and body like dehydration, low blood sugar, or substance use likely make it harder for your brain to function and learn at its best.

Simply put, treat yourself like a pro athlete and treat neurofeedback like game time. Be fully present during your training sessions. Take naps, go for walks, eat well, and keep stress low between sessions. As a side benefit, all these things will make you feel better on their own.

References

Andruchow, N. D., Konishi, K., Shatenstein, B., & Bohbot, V. D. (2017). A lower ratio of omega-6 to omega-3 fatty acids predicts better hippocampus-dependent spatial memory and cognitive status in older adults. Neuropsychology, 31(7), 724–734. https://doi.org/10.1037/neu0000373

Annweiler, C., Montero-Odasso, M., Llewellyn, D. J., Richard-Devantoy, S., Duque, G., & Beauchet, O. (2013). Meta-Analysis of Memory and Executive Dysfunctions in Relation to Vitamin D. Journal of Alzheimer’s Disease, 37(1), 147–171. https://doi.org/10.3233/JAD-130452

Cassilhas, R. C., Tufik, S., & De Mello, M. T. (2016). Physical exercise, neuroplasticity, spatial learning and memory. Cellular and Molecular Life Sciences, 73(5), 975–983. https://doi.org/10.1007/s00018-015-2102-0

De Sousa Fernandes, M. S., Ordônio, T. F., Santos, G. C. J., Santos, L. E. R., Calazans, C. T., Gomes, D. A., & Santos, T. M. (2020). Effects of Physical Exercise on Neuroplasticity and Brain Function: A Systematic Review in Human and Animal Studies. Neural Plasticity, 2020, 1–21. https://doi.org/10.1155/2020/8856621

Gasmi, A., Nasreen, A., Menzel, A., Gasmi Benahmed, A., Pivina, L., Noor, S., Peana, M., Chirumbolo, S., & Bjørklund, G. (2022). Neurotransmitters Regulation and Food Intake: The Role of Dietary Sources in Neurotransmission. Molecules, 28(1), 210. https://doi.org/10.3390/molecules28010210

Newbury, C. R., Crowley, R., Rastle, K., & Tamminen, J. (2021). Sleep deprivation and memory: Meta-analytic reviews of studies on sleep deprivation before and after learning. Psychological Bulletin, 147(11), 1215–1240. https://doi.org/10.1037/bul0000348

Tooley, K. L. (2020). Effects of the Human Gut Microbiota on Cognitive Performance, Brain Structure and Function: A Narrative Review. Nutrients, 12(10), 3009. https://doi.org/10.3390/nu12103009

Wei, Y., Krishnan, G. P., & Bazhenov, M. (2016). Synaptic Mechanisms of Memory Consolidation during Sleep Slow Oscillations. The Journal of Neuroscience, 36(15), 4231–4247. https://doi.org/10.1523/JNEUROSCI.3648-15.2016

Welcome to the November 2025 Hamilton Neurofeedback Newsletter. See below for Neurofeedback for Sport Performance, Client Wins, and Covert Contracts.

1) New Research on Neurofeedback for Sport Performance

Author’s note: I’m writing this before Game Seven of the World Series, praying that the Blue Jays have a skilled neurofeedback trainer.

A meta-analysis was recently published on neurofeedback for sport performance which showed encouraging results. A meta-analysis is a research study which reviews and summarizes the results of other studies. Meta-analyses give a good picture of the field as a whole and are usually considered higher quality evidence than individual studies.

Understanding how neurofeedback helps people perform in high-stakes fields has an interesting amount of carryover to understanding how neurofeedback helps people improve mental health symptoms. 

Toward that aim, here are a few takeaways from the meta-analysis in plain English:

1) Physical performance improved across a range of sports (e.g. golf, darts, archery, dance, soccer, et cetera), “physical performance,” being defined as objective observable muscular outputs such as reaction time, precision, and body balance. Across all studies, physical performance jumped (pun intended) by an average of ~28 percent. This is equivalent to lining up 100 people from worst to best at a sport and moving from number 50 to number 78 without directly training sport performance.

2) There was variability in how much a given individual responded to neurofeedback, with novices improving more than experts. This is equivalent to patients improving more when they have more symptoms. A bigger deficit means a bigger runway for improvement. 

3) In addition to improvements in motor learning and application, results likely came from improvements in attention/presence, relaxation, and a sense of ‘effortlessness.’ These translate very clearly into how neurofeedback improves mental health.

Taken overall, these results are exciting not just in the context of sport performance, but as a complementary data-point that neurofeedback works for improving how people feel, work, and perform across the board. 

2) Client Wins from October

Here are three quick wins from the last month:

1) After her first Rental Vielight session, one client reported feeling noticeably calm and present. Her exact words were, “I was thinking about all the stuff I had to get done today, now I’m not even worried about it.”

2) A client was nervous before her first neurofeedback session the other day. After her session was over, her whole demeanour changed. She was calm, upbeat, and socially engaged. She said, “I feel like I just meditated,” and gave me a big smile before saying goodbye.

3) A neurofeedback rental client packed in 20+ sessions for her son in just 27 days, using a Minecraft video instead of the standard music. After a month of sessions, he started doing his chores more, being open to changes in routine, and began to get a sense of whether he was late for things (all very impressive for a boy under 10).

It’s always such a joy when a client experiences a win like this.

3) Covert Contracts

Think of a time someone put an expectation on you without telling you about it. Maybe they invited you to a party and assumed you’d come. You decline, and suddenly you’re “an awful friend.” It’s like they wrote a contract in their head and forged your signature on it, “Didn’t you read the contract? You’re supposed to say yes!”

These covert contracts aren’t just something other people do to us. We write them for ourselves, for others, and even for the world — and it’s usually the contract, not the trigger, that causes us suffering.

For example:

1) Disappointed that you’re not happy on your day off? That’s a broken contract with yourself, “I’ve been looking forward to this — I should feel good.”

2) Let down because someone didn’t help you? Probably a broken contract, “I drop everything for you; you should drop everything for me.”

3) Road rage? Broken contract with the universe, “There was no traffic yesterday; there should be no traffic today too!”

Covert contracts are unconscious. They hide in our psychology, and we don’t realize when they’re triggered. When we do notice them — without self-judgment — they often seem ridiculous. Try saying out loud, “Everyone should know exactly what I need without me saying it, and if they don’t, they don’t care about me.” It’s hard to get behind something that sounds so absurd, even if we believe it on some level.

They escalate from reasonable preferences — “I’d prefer people be kind to me.” — into inflexible demands — “People must always be kind to me,” and hardened demands like this set us up for predictable disappointment.

So, first, practice pausing when you’re upset.

Then, make your covert contracts conscious. Ask yourself what rules or assumptions you feel have been broken. Look for must, should, or have to statements (or must not, should not, or cannot statements). When you identify it, say it out loud and ask yourself if it’s logical, true, or helpful.

Finally, restate your demands as preferences. Reminding yourself that you’re not contractually obliged to be happy on your day off — that it’s simply a preference — softens the sting when reality doesn’t cooperate.

Do these things once or twice and the temperature will drop. Do them often and you’ll develop a reflex to counter the covert contracts which cause you suffering.

Imagine walking more lightly through your day – not because the world, others, or your emotions suddenly obey you, but because you stopped carrying invisible, impossible contracts. 

The universe is terrible at reading the fine print anyways.

P.S. This post was heavily influenced by the Naval Ravikant quote, “Desire is a contract you make with yourself to be unhappy until you get what you want.” and Albert Ellis’ brand of psychotherapy Rational Emotive Behaviour Therapy (REBT), which I’m learning in my psychotherapy practicum. In about five months I’ll be guiding clients through this work one-on-one (instead of scratching my itch by writing about it).

In April 2026 I’ll complete my master’s degree in psychotherapy and Hamilton Neurofeedback will evolve into a combined neurofeedback/psychotherapy clinic. This has been my dream since well before the beginning of Hamilton Neurofeedback 3 years ago, and I’m thrilled for the start of this chapter. If you know me personally, you know there are few things I’m more passionate about than the combination of these treatments and how they complement each other.

If you’ve enjoyed working with me and think you might benefit from working on your mind just as much as working on your brain, I’d love to help you.

P.S. This means all in-person neurofeedback sessions with me will be eligible for psychotherapy benefits coverage in ~6 months!

1) Free Intracranial Red Light Therapy 

To give back and help more people, we’re permanently offering free (yes, completely free) intracranial red light therapy during your normal one-hour in-person sessions. This tool improves mood and anxiety and reduces symptoms of dementia, concussions, and PTSD. Even if you’re diagnosis-free, it will keep you and your brain feeling healthy and sharp.

Book now at either of our locations to give your brain a boost:
- Hamilton Clinic, downtown, book online here.
- Burlington Clinic, ~3 minutes from the 403 on Guelph Line and Prospect, call or email to book a session covered by insurance.

You’ve probably seen red light therapy panels or masks that rejuvenate your skin. Picture the same thing but for your brain. Introducing Vielight.

How Vielight works: Red and infrared light help the mitochondria in your brain (the ‘powerhouses of your cells’) produce more energy and function better. Simply put the headset on, turn the infrared LEDs on for 20 minutes, and voilà - your brain soaks up the light and functions better, basically side effect free.

Personally: I consistently notice that ~4 hours after a Vielight session I’m having a great day. I feel calm, I’m in a good mood, and it feels like I’ve had a perfect cup of coffee (minus the jitters).

What Vielight does:
- improves blood flow to the brain
- reduces brain inflammation
- helps support healthy cellular functioning
- supports healthy aging and protects against neurodegeneration
- improves mood, calmness and focus

Who can benefit from Vielight sessions: Although red light therapy is well researched, emerging research on its application to the brain suggests it helps with anxiety, mood, concussions, autism, long COVID, PTSD, neurodegenerative disease, and more. That said, you don’t need to be symptomatic to benefit. This is part of why we’re choosing to offer Vielight moving forward: it’s a versatile tool that works just as well in non-symptomatic populations as it does symptomatic ones.

Still need convincing: Vielight has been featured on NBC news channels, and their website is rich with testimonials from top researchers, former pro athletes, and military veterans. For more, see this YouTube video discussing the results from a study on Vielight in treating concussions.

Bottom line: come see how it works for you! Vielight sessions are a free and simple add-on to your regular neurofeedback session. Consider it a thank you for being a client of Hamilton Neurofeedback.

If you’re curious, book a session at either of our locations:
- Hamilton Clinic, downtown, book online here.
- Burlington Clinic, ~3 minutes from the 403 on Guelph Line and Prospect, call or email to book a session covered by insurance.

2) A Family (Rental) Affair

A recent NeurOptimal Neurofeedback rental family just set the all-time session record: 80 sessions in 5 weeks! Here’s what changed for them after ~20 sessions each:
- Mom: felt sharper, calmer, and more present
- Brother: slept better, less brain fog, better focus at work
- Son (with severe dyslexia): able to recall the day of the week for the first time ever, later reported feeling more clarity and less brain fog 
- Teenage daughter: started cleaning her previously always messy room without being asked

Here’s what the mother had to say about her experience with Hamilton Neurofeedback:

“I’m very glad I rented this machine and I would highly recommend it. The experience of renting was easy and allowed my family the freedom of using the device at our leisure, and allowed me to treat several of us at once. [...] I definitely recommend neurofeedback therapy.”

— Amanda M., Rental Client

Although effects like this often show up quickly, it sometimes takes weeks, months, or years to notice the more subtle changes neurofeedback creates (for more on this idea, see last month’s newsletter blog: Identity Lags Reality). It will be exciting to follow up with this family over time to see what else unfolds for them.

What would it look like if your family beat the record? How would your lives change for the better? Book a free consultation to start brainstorming (there’s even a prize if you beat the record).

3) Quick Tool For Challenging Your Thoughts

Here’s a tool I show patients to help them ‘unhook’ from troubling thoughts which has them laughing in the face of their fears in ~three minutes. Here are the steps:

1) Identify a thought that you rationally know isn’t true, but that you emotionally can’t shake

2) Put it into a simple sentence (e.g. “my friends won’t like me if I’m sad”)

3) Say that sentence out loud and ask yourself how much you believe it on a scale of 1-10 (usually a six or above)

4) For one minute straight, say the thought out loud as fast as you can. Imagine a personal trainer pushing you to say it faster and faster

5) When one minute is up, switch to saying the thought as slowly as you can for another minute. However slowly you just imagined speaking, speak twice as slowly, then even slower. Laughing yet? Good, that’s the point

6) Last step: switch to saying the thought in the silliest voice you can for another minute. Arnold Schwarzenegger? Great! Whale noises? Yes! Make it into a silly song? Bravo! Encore! This should begin to feel totally ridiculous. Again, that’s the point — we’re turning something that seems very emotionally serious into something to laugh about

7) Finally: take a few breaths and say the sentence out loud like you did at the beginning. Ask yourself how much you believe it now on a scale from 1-10 (usually a four or below) and note the change from a few minutes ago. 

Every single time I’ve done this myself or with my patients, they end up feeling at least some relief from the seriousness they felt moments earlier. 

This works by distancing our selves from the fears in our minds. We often buy into our fearful thoughts, believing them to be true without questioning them. This tactic de-fuses us from our thoughts, reminds us that they’re only thoughts, and lets us laugh instead of dwell. It lightens the mood just enough to feel the fear and do it anyways. Most importantly, this works without neurofeedback.

I heard a useful idea in a podcast clip that I wanted to share: our sense of identity lags our reality, typically by 1-2 years. 

In other words: our identity — how we feel about ourselves, the quirks of our personalities, and the automatic reactions built into the wiring of our brains — has a slow rate of turnover compared with changes in our life circumstances. It lags behind our reality.

Here are some examples:

1) Being promoted to a management role and doubting whether you’re qualified for the job. You still identify as the newbie at the office, but the reality is the big boss believed you were competent enough to take on something new. Enough hard-earned moments of success in the new role and your identity catches up: “Hey, I’m actually pretty good at this!”

2) Going on a diet, hitting the gym, and dressing better, but still doubting you’re attractive. You identify with your ugly duckling past self, but the reality is you’ve become a swan. Enough looks from people who are — suddenly and surprisingly — interested in you, and your identity catches up: “Wow, I’m hot!”

3) Having built financial security but still feeling financially anxious and insecure. You still identify as someone who struggles to get by, but the reality is you’ve developed the habits to keep you safe and sound in the long-term. Enough months of not struggling to make rent and your identity catches up: “Oh my god, I don’t have to worry!”

Part of why it takes a long time to think of oneself as a good manager, an attractive person, or financially stable is because it takes a lot of ‘reps’ to change these deeply held, identity-level beliefs — a lot of consistent, repeated, corrective instances of feedback from your environment. In a client’s words: “you don’t notice when you’re growing,” it takes having your proverbial Grandma saying “you’ve grown so much!” before we stop and look in the mirror deeply enough to notice who we’ve been becoming.

This idea is especially relevant to psychological self-development practices like neurofeedback and psychotherapy because they involve deliberate attempts to change one’s identity: how you feel about yourself, the quirks of your personality, and the automatic reactions built into the wiring of your brain.

This idea also explains a pattern I’ve seen in myself and my clients: changes continue to emerge in people’s lives years after they’ve completed neurofeedback training. I am coming to model changes from neurofeedback in the following ways:

1) Neurofeedback causes near-immediate positive changes to one’s brain functioning (e.g. decreased anxiety, better sleep, better focus).

2) These changes allow people to make healthier choices in their lives (e.g. exercising consistently, socializing more comfortably, investing in a rewarding hobby), which go on to create additional positive changes in brain functioning.

3) The slow internalization of these new realities into one’s identity in the years after they’ve completed training — the emergence of a new set of “I-am-the-kind-of-person-that” statements in one’s mind, which again go on to create additional positive changes in brain functioning and decision making.

It’s this third type that is so interesting partly because personality changes are subtle, rarely spoken about, and a slow, emergent process. You may spend six months or two years reacting to life with less anxiety, but still not recognize yourself as a calm person. You’re still expecting an anxious reaction to emerge in you because it takes time and ‘reps’ to stop expecting this. How would a person who only knows themselves as anxious even recognize that they are now an un-anxious person, rather than an anxious person not currently feeling anxiety?

Perhaps this is why the early stages of self-development often feel so tenuous and tentative. There is an unsureness, a shakiness to experimenting with and eventually relying on a new identity, especially if it might mean being blindsided by your old reactions coming up when you were hoping they wouldn’t.

But, after enough ‘reps’ — enough repeated examples of no longer reacting the old way — your identity begins to change. Each neurofeedback session sows seeds that lay dormant, waiting for the external world to activate them. Eventually, they grow into a foundation as solid and secure as a tree’s roots in the ground: a sense of identity.

Eventually, you find yourself saying “Wow, this is me now?!”

Identity lags reality.

Therapeutic breakthroughs are rarely straightforward. They start with awkward silences, small talk, or stories that feel off-topic (until they don’t).

As a student therapist, I’m learning that these sideways conversations often appear right before clients touch something uncomfortable and important. My job, then, is to meet clients with presence in these moments.

Presence means really listening, even when the client is ‘talking around’ the thing they most need to say. It means holding in mind both the clients’ goals and my goals as their therapist. It means paying attention to the third party in the room: the relationship between us.

When I’m able to be present in this way — non-judgemental, patient, and attuned to the ‘movement’ in the conversation — something shifts. Everyone settles, the pressure to get it right goes away, and the session begins to ‘click.’ Meeting scattered clients with this caring, warmth, and attentiveness helps them be present with themselves, which on its own can be therapeutic.

The cool part? The NeurOptimal® Neurofeedback system we use at Hamilton Neurofeedback does the same thing. It mirrors your brain back to you without judgment or instruction. It helps you notice, self-correct, and become more present within yourself.

This skill isn’t just for the therapy room. Presence is how you stay grounded when your kid’s having a meltdown. It’s how you maintain your sanity in Toronto traffic. It’s how you notice that you’re anxious before your day derails.

And, if presence feels out of reach — if your mind is racing, numb, or just worn down — neurofeedback can help you get back there. Because whether it comes through therapy, meditation, prayer, interpretive dance, or brain training: presence is power.

Bonus: an excerpt from last month’s Newsletter on Avoidance:

I recently started providing Psychotherapy as a part of my Master’s Degree. One of the things I’ve noticed is the role that avoidance plays in maintaining my clients’ suffering.

Intuitively, avoidance means avoiding doing something you don’t want to do. The upside? It’s a guaranteed way to stay comfortable. The downside? This comfort carries the cost of not bettering your life long-term. Avoidance can be benign, like choosing not to do the dishes, resulting in a messy kitchen. But avoidance can also be deeply consequential, like choosing not to chase your dreams, resulting in a regretful, unlived life.

It might come as no surprise that a lot of mental health challenges are caused and maintained through avoidance: social anxiety involves avoidance of judgement, OCD can involve the avoidance of dirt or germs, and PTSD involves the avoidance of triggers. The list goes on.

Naturally, I’ve also been reflecting on the role of neurofeedback in overcoming avoidance. The enhanced emotional stability, reduced impact of stress, and increased ability to lean into discomfort mean that neurofeedback can help clients choose to confront what they’d been avoiding. 

Perhaps this is why — for many clients — the positive changes they experience continue to develop well after they finish their last session. Neurofeedback helps you become the kind of person who is able to overcome avoidance.

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Enjoy, be well:

Narrative Review - Neurofeedback and Post-Traumatic Stress Disorder

Introduction

Post-Traumatic Stress Disorder (PTSD) is a significantly impairing psychiatric condition (Jellestad et al., 2021) with a high lifetime prevalence (13-20.4% in females, and 6.2-8.2% in males; Bryant, 2019) resulting in high economic burden ($232.2 billion lost in the United States in 2018; Davis et al., 2022).

Though current treatments for PTSD are moderately efficacious, trauma-focused psychotherapies show high dropout rates, mixed client engagement due to the avoidance-related symptoms of PTSD, and less-than-desired clinical response (Norman, 2022). Medication as well affords only modest symptom reductions and can present a host of side effects (Zhang et al., 2023).

An emerging treatment for PTSD is Neurofeedback (NFB). NFB has risen in public awareness after its mention in the popular book The Body Keeps the Score (van der Kolk, 2014) and through a growing body of clinical research in the previous 20 years (Ali et al., 2024). Mechanistically, NFB treats PTSD by reducing the chronic neurological, physiological and emotional dysregulation common in patients suffering from PTSD (Nicholson et al., 2020). NFB does this by teaching patients to control the electrical activity of their brains (S. Fisher, 2014). First accomplished in 1968 (Kamiya, 1968), NFB can be conceptualized as a cyclical four-step process (see Figure 1 below): 1) a patient’s brain produces electrical activity; 2) sensors detect this activity; 3) a computer processes and abstracts this raw data into a simplified representation (e.g. how ‘relaxed’ one’s brain is); and 4) the patient is rewarded for desirable brain activity in real time through clear visual or auditory feedback (e.g. a green checkmark appears on a screen or a bell rings when one’s brain is ‘relaxed’). Through repeated exposures to this closed-loop feedback system and the gradual raising of the minimum threshold for rewards, patients can shape long-term, resilient changes in the resting state activity of their brains, which corresponds with symptom relief for a variety of psychiatric diagnoses including PTSD (Marzbani et al., 2016). Accordingly, studies reveal a variety of stereotyped, heterogeneous abnormalities in the electrical activity of the brains of traumatized individuals, which are normalized through NFB (S. F. Fisher et al., 2016).

Thus, given the psychological, societal, and economic burden of PTSD, the relative inefficacy and complexities of current treatments, and the rising social awareness of NFB, it is imperative for the informed therapist to understand the nature of NFB as a treatment for PTSD. Toward this aim, this narrative review seeks to communicate the present state of the clinical research on NFB for PTSD, as well as to analyze the dynamic ways in which NFB influences the psychotherapeutic process, presenting both opportunities and challenges for trauma treatment.

Meta-Analyses & Systematic Reviews

Choi et al. (2023) performed a meta-analysis of 8 randomized controlled trials (RCT) and two non-RCTs which examined the effectiveness of NFB in treating adults with PTSD. Several findings stand out among their results: 1) NFB was effective at reducing overall PTSD severity and the severity of most symptoms (e.g. arousal, anxiety, numbing) for all sample groups except single-episode trauma; 2) 20 or more sessions was more effective than fewer than 20, and sessions longer than 20 minutes were more effective than sessions shorter than 20 minutes; and 3) Alpha-Theta NFB and traditional linear NFB stood out as more effective than other options. The overall effect size for PTSD symptom reduction was a Hedges g of 0.74, which, according to norming on PTSD symptom severity in United States veterans by Bovin et al. (2016), places the average NFB recipient into the sub-diagnostic range for PTSD (i.e. no longer meeting diagnostic criteria). However, this paper reported a high risk of bias in the design of the included studies.

Next, Panisch & Hai (2020) performed a systematic review of 10 studies, looking particularly at behavioural outcomes in adults with PTSD. Across all studies, participants diagnosed with PTSD showed clinically significant improvements across a range of symptoms, with at least one symptom area improving in each study. Notably, the studies did not exclude participants with comorbid diagnoses (which most patients with PTSD possess; Brady et al., 2000), lending to greater generalizability of their results. The authors highlight NFB’s utility in treating complex, developmental trauma in particular; a valuable finding given these patients are known to respond more poorly to traditional psychotherapy for PTSD (e.g. prolonged exposure) due to their chronically elevated arousal (Panisch & Hai, 2020).

Finally, Steingrimsson et al. (2020) performed a systematic review and meta-analysis of four RCTs. The results mirror the above findings that NFB is an effective, clinically significant treatment for PTSD. However, in addition to (Choi et al., 2023), this study also assessed the methodological rigour of the studies it analyzed and found a very low level of certainty due to unclear randomization, lack of predefined or preregistered analyses, low sample sizes, et cetera.

Taken together, these review papers found strong support for NFB in the treatment of PTSD. However, although it is likely that the direction of the effect is valid (i.e. NFB is effective in treating PTSD), due to methodological shortcomings the size of the effect could be exaggerated.

Integrating Neurofeedback and Psychotherapy

There are few more informed on NFB, psychotherapy and trauma than Sebern Fisher, a near-30-year veteran in the field. Fisher is likely the world’s most skilled practitioner, theoretician, and advocate when it comes to integrating NFB and psychotherapy in the treatment of trauma, and she has written extensively on the unique, dynamic opportunities and challenges inherent to the combination of these treatments. To communicate these for the benefit of the discerning psychotherapist who is interested in NFB, two of her case studies are explored below.

First, Fisher discusses (2016) the case of Bea: a woman with severely impairing complex PTSD resultant from traumatic stressors during childhood. This highly medicated woman presented with a history of multiple suicide attempts, ongoing self-injurious behaviour, and chronic, extreme physiological and affective dysregulation. Despite 19 years of psychodynamic and dialectical behavioural therapy, her symptoms were unremitting. After ten sessions of NFB intended to restore her “[brain’s] own capacity for regulation in the [electrical] frequency domain,” (S. F. Fisher et al., 2016), Bea’s latent capacity for self-regulation of the emotions of fear, shame and rage began to emerge – a latent capacity left unlearned during her traumatic childhood. As treatment progressed Bea began to further stabilize – and eventually fully remit – from her PTSD symptoms. Fisher describes that through Bea’s affective stabilization, she experienced the emergence of a “more robust sense of self,” (S. F. Fisher et al., 2016).

The unique psychotherapeutic challenges posed by this emerging sense of self are described further in the case of Eleanor: a teenage girl with severe developmental trauma, Asperger’s, and an eating disorder (S. Fisher, 2014). Before therapy, Eleanor’s life was characterized by unremitting affective instability, uncontrollable bingeing and purging episodes, and an unformed sense of self and other – this last issue being particularly common in those who have experienced trauma (Horowitz, 2018). Through treatment with NFB, Fisher describes the “unfolding of this girl [...] and the emergence of a young adult,” as she “[gained] access to a deeper region of self perception.” (S. Fisher, 2014). Amongst the common – if notably expedited – psychotherapeutic tasks of trauma treatment (e.g. the integration of the trauma into one’s life experience, the deconstruction of maladaptive beliefs caused by the trauma, the detachment from associated shame, rage or fear) psychotherapeutic tasks emerged which are relatively unique to NFB. Eleanor grew, matured, and “[leapt] across developmental milestones,” which had been left stunted due to her dysregulated home environment and – resultant – brain activity (S. Fisher, 2014), creating the emergence of a sense of self in and of itself – the rapid and pronounced flourishing of an identity where before Eleanor considered herself essentially afloat on and fused with waves of negative affect. Through enhanced emotional regulation, she began experiencing a continuous sense of self who experienced affect. The coalescence of her identity was not an entirely smooth experience, however. As her chronic fear subsided, Eleanor began to cling to her fear-based identity, as, for many, “it is the only self they know.” (S. Fisher, 2014), posing complexities in therapeutic goals and dynamics.

Overall, Fisher’s work suggests the clinical picture of best practice in NFB for trauma-populations necessitates effective, NFB-informed psychotherapy, as the challenges patients experience: 1) are often more rapid, intense processing of trauma afforded by enhanced affective stability; and 2) require psychotherapeutic techniques or practices designed to effectively “[negotiate] with [the patient] a changing and unfamiliar identity.” (e.g. Acceptance and Commitment Therapy, Internal Family Systems Therapy, and Mindfulness-Based therapies. S. F. Fisher, 2010).

Summary and Implications

Overall, meta-analyses and systematic reviews support NFB in the treatment of PTSD (Choi et al., 2023; Panisch & Hai, 2020; Steingrimsson et al., 2020). NFB offers a unique means of resolving trauma-related disorders: teaching long-lasting bottom-up affect (read: brain) regulation skills, without the complexities of therapy or medication (Nicholson et al., 2020). However, even the most cutting-edge, well-controlled research appears to lack methodological rigour (Choi et al., 2023; Ros et al., 2020; Steingrimsson et al., 2020). Though this does not invalidate research findings (particularly noting the triangulation of positive results from on-the-ground clinicians’ case reports), additional, higher quality research is required.

A solution to this problem may be the Consensus on the Reporting and Experimental Design of Clinical and Cognitive-Behavioural Neurofeedback Studies (CRED-nf; Ros et al., 2020). The CRED-nf is the result of a large collaboration of NFB researchers and practitioners which is intended to serve as a gold-standard checklist for research design, execution, and reporting, similar to tools available in other research domains (Ros et al., 2020).

Critically, more methodologically rigorous research will allow for translation of research into practice, which is notably lacking in the field (Norris et al., 2024). Evidently, the meta-analyses and systematic reviews discussed above failed to report on the types of NFB devices used, rationale for protocol selection, decision criteria for changing protocols over time, et cetera. Further, like so many other fields, leading practitioners are years ahead of clinical research in terms of their protocols and results (S. Fisher, 2014). Thus, the problem goes both ways: there is a concurrent lack of translation from practice into research.

As a final word, meta-analyses represent the average of many studies, and studies represent the average of many individuals. Critically, no one individual is captured by the average of their group, lending importance to the value of individualized treatment, both in the form of NFB and the psychotherapy it necessitates (S. Fisher, 2014). It is likely the case that effective psychotherapy is more rather than less necessary when working with patients with PTSD, particularly of a complex, developmental nature. However, the promise remains: when combining NFB and psychotherapy, the whole can be greater than the sum of its parts – the ‘one-plus-one’ of NFB and psychotherapy likely equals not two, but three, or five. There is hope that through additional high-quality research, the clinical advancements of on-the-ground practitioners, and growing public awareness and acceptance, that NFB may be a promising solution for reducing the suffering in so many patients’ lives.

References

Ali, S. A., Mohamad Ghazali, M., Ab Aziz, N. A., & Nisar, H. (2024). Bibliometric analysis of neurofeedback research from 2000 to 2022. Neuroscience Research Notes, 7(1). https://doi.org/10.31117/neuroscirn.v7i1.265

Bovin, M. J., Marx, B. P., Weathers, F. W., Gallagher, M. W., Rodriguez, P., Schnurr, P. P., & Keane, T. M. (2016). Psychometric properties of the PTSD checklist for diagnostic and statistical manual of mental disorders-fifth edition (PCL-5) in veterans. Psychological Assessment, 28(11), 1379–1391. https://doi.org/10.1037/pas0000254

Brady, K. T., Killeen, T. K., Brewerton, T., & Lucerini, S. (2000). Comorbidity of Psychiatric Disorders and Posttraumatic Stress Disorder. J Clin Psychiatry, 61 (suppl 7), 22–32.

Bryant, R. A. (2019). Post-traumatic stress disorder: a state-of-the-art review of evidence and challenges. World Psychiatry, 18(3), 259–269. https://doi.org/10.1002/wps.20656

Choi, Y. J., Choi, E. J., & Ko, E. (2023). Neurofeedback Effect on Symptoms of Posttraumatic Stress Disorder: A Systematic Review and Meta-Analysis. Applied Psychophysiology Biofeedback, 48(3), 259–274. https://doi.org/10.1007/s10484-023-09593-3

Davis, L. L., Schein, J., Cloutier, M., Gagnon-Sanschagrin, P., Maitland, J., Urganus, A., Guerin, A., Lefebvre, P., & Houle, C. R. (2022). The Economic Burden of Posttraumatic Stress Disorder in the United States from a Societal Perspective. Journal of Clinical Psychiatry, 83(3). https://doi.org/10.4088/JCP.21m14116

Fisher, S. (2014). Neurofeedback in the treatment of developmental trauma: Calming the fear-driven brain. W. W. Norton.

Fisher, S. F. (2010). Arousal and Identity: Thoughts on Neurofeedback in Treatment of Developmental Trauma The Cost of Developmental Trauma. Biofeedback, 38(38, 1), 6–8. www.aapb.org

Fisher, S. F., Lanius, R. A., & Frewen, P. A. (2016). EEG neurofeedback as adjunct to psychotherapy for complex developmental trauma-related disorders: Case study and treatment rationale. Traumatology, 22(4), 255–260. https://doi.org/10.1037/trm0000073

Horowitz, M. (2018). Redefining Identity after Trauma or Loss. In Psychodynamic Psychiatry (Vol. 46, Issue 1).

Jellestad, L., Vital, N. A., Malamud, J., Taeymans, J., & Mueller-Pfeiffer, C. (2021). Functional impairment in Posttraumatic Stress Disorder: A systematic review and meta-analysis. In Journal of Psychiatric Research (Vol. 136, pp. 14–22). Elsevier Ltd. https://doi.org/10.1016/j.jpsychires.2021.01.039

Kamiya, J. (1968). Conscious control of brain waves. Psychology Today, 56–60.

Loriette, C., Ziane, C., & Ben Hamed, S. (2021). Neurofeedback for cognitive enhancement and intervention and brain plasticity. In Revue Neurologique (Vol. 177, Issue 9, pp. 1133–1144). Elsevier Masson s.r.l. https://doi.org/10.1016/j.neurol.2021.08.004

Marzbani, H., Marateb, H. R., & Mansourian, M. (2016). Methodological note: Neurofeedback: A comprehensive review on system design, methodology and clinical applications. Basic and Clinical Neuroscience, 7(2), 143–158. https://doi.org/10.15412/j.bcn.03070208

Nicholson, A. A., Ros, T., Jetly, R., & Lanius, R. A. (2020). Regulating posttraumatic stress disorder symptoms with neurofeedback: Regaining control of the mind. Journal of Military, Veteran and Family Health, 6, 3–15. https://doi.org/10.3138/jmvfh.2019-0032

Norman, S. B. (2022). Effectiveness of currently available psychotherapies for post-traumatic stress disorder and future directions. World Psychiatry, 21(2), 309–310. https://doi.org/10.1002/wps.20973

Norris, W. K., Allison, M. K., Fisher, S., & Curran, G. M. (2024). Implementation Science Application to EEG Neurofeedback Research: A Call to Action. NeuroRegulation, 11(2), 211–218. https://doi.org/10.15540/nr.11.2.211

Panisch, L. S., & Hai, A. H. (2020). The Effectiveness of Using Neurofeedback in the Treatment of Post-Traumatic Stress Disorder: A Systematic Review. In Trauma, Violence, and Abuse (Vol. 21, Issue 3, pp. 541–550). SAGE Publications Ltd. https://doi.org/10.1177/1524838018781103

Ros, T., Enriquez-Geppert, S., Zotev, V., Young, K. D., Wood, G., Whitfield-Gabrieli, S., Wan, F., Vuilleumier, P., Vialatte, F., Van De Ville, D., Todder, D., Surmeli, T., Sulzer, J. S., Strehl, U., Sterman, M. B., Steiner, N. J., Sorger, B., Soekadar, S. R., Sitaram, R., … Thibault, R. T. (2020). Consensus on the reporting and experimental design of clinical and cognitive-behavioural neurofeedback studies (CRED-nf checklist). Brain, 143(6), 1674–1685. https://doi.org/10.1093/brain/awaa009

Steingrimsson, S., Bilonic, G., Ekelund, A.-C., Larson, T., Stadig, I., Svensson, M., Vukovic, I. S., Wartenberg, C., Wrede, O., & Bernhardsson, S. (2020). Electroencephalography-based neurofeedback as treatment for post-traumatic stress disorder: A systematic review and meta-analysis. European Psychiatry, 63(1). https://doi.org/10.1192/j.eurpsy.2019.7

van der Kolk, B. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Viking.

Zhang, Z. X., Liu, R. Ben, Zhang, J., Xian-Yu, C. Y., Liu, J. L., Li, X. Z., Zhang, Y. Q., & Zhang, C. (2023). Clinical outcomes of recommended active pharmacotherapy agents from NICE guideline for post-traumatic stress disorder: Network meta-analysis. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 125. https://doi.org/10.1016/j.pnpbp.2023.110754