Infra-low-frequency training

1. Introduction

Version followed: the Othmer Method of infra-low frequency (ILF) neurofeedback as the EEG Institute / EEG Info (Siegfried and Susan F. Othmer, Los Angeles area) publishes it in its own papers, web pages and certification documents, as read in October 2026. The developers' Protocol Guide for Neurofeedback Clinicians (Susan Othmer; several editions, the certification forms refer to a 7th edition) is not verified here; its contents appear only as the topic headings its certification worksheet lists [uncertain].

Status: contested. ILF neurofeedback is a proprietary, developer-led method. Its mechanism, its wide range of claimed uses and most of its outcome data come from the developers and their practitioner network. An independent systematic review (Bazzana et al., 2022) found a small, mixed and weakly controlled evidence base and concluded that "any conclusion about ILF-Neurofeedback and its effectiveness would be premature" [source: Bazzana et al. 2022]. This guide sets out how the method is delivered as its developers describe it and what a psychotherapist does around it. It gives no device settings, target frequencies, electrode sites or session prescriptions. Those are set by a trained clinician using the developers' materials.

What it is. EEG neurofeedback in which the clinician feeds back very slow fluctuations of the EEG signal. These lie below the frequency range that conventional EEG work usually analyses. The developers say it descends from frequency-band training (see 047 Sensorimotor-rhythm training and 048 Theta-beta training), slow cortical potential training (049) and peripheral biofeedback. They date ILF training to about 2006 [source: Othmer, A Rationale and Model for ILF Neurofeedback Training; EEG Info, Infra-Low Neurofeedback page].

Core idea of change, as the developers state it. The brain is shown a continuous, slowly changing signal that is a correlate of its own activity, with no threshold or task to "succeed" at. In the developers' account, the brain uses this as an extra control loop to improve its own regulation. Siegfried Othmer proposes that the training reorganises functional connectivity among resting-state networks (the default mode, salience and central executive networks). He calls a fixed left-right relationship between optimal training frequencies a "fundamental organizational principle". The developers describe the goal as broad regulatory competence rather than relief of single symptoms. All of these are the developers' claims. Bazzana et al. (2022) note that the self-regulation model is not validated [source: Othmer, Rationale; Othmer & Othmer, Development History of the Othmer Method 1987–2016; Bazzana et al. 2022].

Who delivers it. Practitioners trained through EEG Info courses, often with BCIA neurofeedback certification as well. The developers' own Othmer Method certification is not a licence, and their FAQ says it "is not itself a license and is not restricted to licensed professionals" [source: EEG Info certification FAQ]. A psychotherapist can either train to deliver it (see Training route below) or work alongside an ILF provider. Regulatory status: the FDA, MHRA or CE status of ILF systems (the VA trial names the Cygnet software) [uncertain: not verified].

Cross-references within the Neurofeedback family: 045 Alpha training (Kamiya); 046 Alpha-theta training and the Peniston protocol (the Othmer Method includes an alpha-theta component); 047 SMR training (Sterman); 048 Theta-beta training (Lubar), which covers ADHD guideline positions including NICE; 049 Slow cortical potential training (Birbaumer); 050 QEEG-guided, z-score and LORETA neurofeedback. The Othmers moved away from QEEG-based site selection towards optimisation by client response [source: Development History].

2. Framework

The developers do not publish a fixed phased protocol. The framework below assembles what their documents and one independent trial protocol describe [source: Development History; Rationale; EEG Info ILF page; Carlson, VA protocol NCT04195685]. Where the stages are ordered by this guide rather than by the sources, they are marked [synthesis].

Stage A: Referral, screening and medical clearance [synthesis, drawing on the VA protocol's exclusions and Hammond & Kirk 2008]

Goal: decide whether ILF training is appropriate, safe and within the provider's scope, and involve the client's physician or prescriber where needed (see 4.10).
Move on when: medical and psychiatric review is done where indicated, a suicide-risk screen is complete, and the client has given informed consent.

Stage B: Assessment and baseline

Goal: build a symptom profile organised by the developers' clinical model. The Protocol Guide's assessment headings are physiological arousal, instabilities, disinhibition, localised dysfunctions, and learned fears and habits. Its symptom-profile headings range across anxiety, depression, attention, sleep, pain, eating, attachment, developmental disorders, brain injury and seizures [source: EEG Info Form 5A worksheet headings]. The Institute has given capable clients a continuous performance test (CPT) before and after training since 1990, first the TOVA and later the QIKtest. It also uses symptom-tracking software [source: Development History].
Move on when: there is a baseline that can be re-measured.

Stage C: Core ILF training with ongoing optimisation

Format: individual, seated sessions with sensors on the scalp and continuous visual and auditory feedback, often a game-like animation. The developers report session lengths of roughly 20 to 60 minutes [source: Development History; VA protocol].
Goal: find, within and across sessions, the individual training target that yields the best-regulated state, judged mainly by the client's reports of felt change [source: Rationale; EEG Info ILF page].
Sequencing (developers' description, named only): training follows what the developers call a developmental order. It starts with right-hemisphere regulatory functions, adds inter-hemispheric training for "instabilities", and then other placements. Each step depends on progress in the previous one, and training pauses when progress stops [source: Development History].
Course length: not fixed. The developers use a nominal session benchmark only to compare outcomes, and they say benefit is not exhausted by it. This guide gives no session prescription.

Stage D: Added components (where the clinician judges them indicated)

Alpha-theta training (see 046) and synchrony training are taught as separate EEG Info courses and appear as two-channel components in the Protocol Guide headings [source: Form 5A headings; certification requirements]. Synchrony is not described in detail in the sources cited [uncertain].

Stage E: Reassessment, generalisation and ending

Repeat the CPT and symptom measures. The developers talk of clients who "graduate" from training but give no discharge criteria [source: Development History] [uncertain]. Ending criteria in 4.19 are [synthesis].

3. Guiding principles

Individualisation over fixed protocols. Each client's target is found empirically. Practical meaning: expect the provider to adjust training session by session and not to follow a standard recipe [source: Rationale; Bazzana et al. 2022].
Client report is the instrument. The real-time signal means something only to the brain producing it, so "for the real-time response one is dependent on client report" [source: EEG Info ILF page]. Practical meaning: the client's ability to notice and describe state changes drives decisions, and the therapist can help build it.
Witnessing, not trying. In the developers' words, "the trainee merely witnesses the signal without a mandate to try to change it" [source: Rationale]. Practical meaning: coach clients away from effortful control.
No reward threshold. Feedback is continuous. Operant thresholds are dropped except for inhibit functions [source: Development History]. Practical meaning: there is no score to win, so do not frame sessions as performance.
Regulation, not symptom targeting. The developers aim at broad self-regulation and stability [source: Development History; Rationale]. Practical meaning: track functioning across several domains, not only the presenting complaint.
Stability first. Seizures, migraine, panic and bipolar episodes are treated as markers of brain instability that call for specific inter-hemispheric training [source: Development History; Rationale]. Practical meaning: clients with these histories need medical involvement and close monitoring (see 4.10) [synthesis].
Each client is their own control. Training is run as an ongoing A/B comparison of states [source: Development History]. Practical meaning: keep careful before/after records for each session.
Not innocuous. The developers say "This training procedure is not innocuous" and report worsening impulsivity in some children in their ADHD study [source: Development History]. Practical meaning: monitor for adverse change and report it.
Measure outcomes. CPTs and symptom tracking are used before and after training [source: Development History]. Practical meaning: insist on re-measurement before claiming benefit.
Practise within licence and competence. Neurofeedback for clinical conditions should be given by people licensed to treat those conditions [source: Hammond & Kirk 2008]. Practical meaning: developer certification does not extend a clinician's scope.

4. Intervention inventory

Part A (4.1–4.9) describes how ILF training is delivered as its developers and one independent trial protocol publish it. It stays at a descriptive level: settings, sites, montages and target frequencies are left to the trained provider and the developers' Protocol Guide. Part B (4.10–4.19) covers the psychotherapist's own work, whether you deliver ILF yourself after training or work alongside a provider.

Part A. Delivery as the developers describe it

4.1 Intake and symptom-profile assessment

Purpose / when: at the start, to map dysregulation across domains and to set a baseline.
Steps (as published, descriptive): take a history organised by the developers' clinical model: arousal, instabilities, disinhibition, localised dysfunctions, and learned fears and habits [source: Form 5A headings]. Record symptom profiles across areas such as sleep, anxiety, mood, attention, pain, eating, sensory and cognitive function, and physical and behavioural complaints. Give a CPT (the Institute uses the QIKtest) where the client can do it [source: Development History]. Set up symptom ratings that will be repeated. In the VA trial, participants rated their symptoms before every session [source: VA protocol]. Unlike QEEG-guided approaches (050), the developers do not need deficits to be identified at the outset [source: Development History].
Example language (illustrative): "Before we start I'd like a picture of how your sleep, mood, focus, body and stress responses are working. We'll rate these again regularly, so we can see whether anything actually changes."
Watch for: histories of seizures, migraine, panic, bipolar disorder or brain injury. The developers group these as instabilities, and they call for medical involvement (4.10).

4.2 Preparing the client and the session

Purpose / when: every session, so that sensors make good contact and the client can attend to their state.
Steps (descriptive): the client sits comfortably. Sensors are attached to the scalp with conductive paste after the skin contact has been checked [source: VA protocol]. The training uses two active sites, a bipolar arrangement, because the developers hold that the relationship between sites matters more than the amplitude at one site [source: Development History; Rationale]. No settings are given here. Ask for the pre-session symptom rating [source: VA protocol].
Example language (illustrative): "How have you been since last time: sleep, energy, mood, anything unusual the day after the session?"
Watch for: reactions in the day or two after the last session. Providers use these to adjust the next session [source: Rationale].

4.3 The ILF feedback session

Purpose / when: the core training.
Steps (descriptive): the client watches a continuous display, often a game or animation, and hears audio that follows the slowly varying training signal. There is no threshold to beat. Discrete auditory rewards in the developers' design come at a capped rate, so they form a steady rhythm. The client notices interruptions in that rhythm, not individual rewards. Inhibit functions remain [source: Development History; Rationale]. The developers say the client need not even be aware that training is happening, and that the signal can be presented covertly [source: Development History]. In the VA trial a trained specialist coached and documented each session, and feedback was visual, auditory and tactile [source: VA protocol]. In the developers' account the clinician generally gives no explicit instruction about how to change the signal [source: EEG Info ILF page].
Example language (illustrative): "You don't need to make anything happen. Just watch and let it run. Tell me whenever you notice a shift: warmer, heavier, more alert, calmer, edgier, anything at all."
Watch for: the client straining to "control" the display. Redirect them to witnessing (principle 3).

4.4 In-session optimisation by client report

Purpose / when: throughout each session and across sessions, to find the client's individual training target.
Steps (descriptive): the provider changes the target in small steps while the client, who does not know the setting, reports felt changes. These include alertness, emotional tone, body sensations, calm and agitation. The best target is the one that produces the best-regulated state. When in-session changes are hard to see, the provider relies on changes after the session [source: Rationale; Development History; Bazzana et al. 2022]. The developers describe "frequency rules" that link optimal targets across placements [source: Development History]. Their detail is in the Protocol Guide and is not reproduced here.
Example language (illustrative): "Compared with a minute ago, are you more settled, the same, or more wound-up? Where do you notice it in your body?"
Watch for: clients who cannot notice or name states (alexithymia, dissociation, young children). Here the therapist's work in 4.13 matters.

4.5 Sequencing and adding training placements

Purpose / when: after the starting training has stabilised and progress has been seen.
Steps (descriptive, approach named only): the developers sequence training in what they call developmental order. They start with right-hemisphere regulatory functions and the parietal hub of the default mode network, use inter-hemispheric training for instabilities (seizure disorder, panic, migraine, bipolar disorder), and then add other placements. A new step depends on progress in the one before, and training pauses if progress stops [source: Development History; Form 5A headings]. Sites and sequences are in the developers' Protocol Guide and are not given here.
Example language (illustrative): "We'll stay with what's working until it's steady before we add anything new."
Watch for: new or worsened symptoms after a placement is added. Report them to the provider (4.8).

4.6 Alpha-theta component

Purpose / when: an add-on taught within the Othmer Method, historically used in addiction work and in deep-state or trauma-related work [source: Development History; certification requirements].
Steps (descriptive): the developers adapted Peniston's alpha-theta protocol. In the addiction programme they describe, frequency-band training came first and alpha-theta followed [source: Development History]. For the method, its imagery work and its trauma cautions see 046.
Example language (illustrative): see 046.
Watch for: emerging traumatic material and abreaction. The therapist's support and pacing are central (see 046 and 5.4).

4.7 Synchrony training

Purpose / when: a two-channel component taught in its own EEG Info course [source: certification requirements; Form 5A headings].
Steps: not described in the sources cited. The developers' history mentions only alpha-band synchrony training, as one element in a comparison study [source: Development History] [uncertain].
Watch for: as for 4.8.
Example language (illustrative): "This part of the training is less well described in published sources, so I'll ask your provider what it involves before we add it." [synthesis]

4.8 Monitoring adverse effects and symptom change

Purpose / when: every session and between sessions.
Steps (descriptive): check symptoms before each session and record anything new after it. In the VA trial, expected effects were brief anxiety, muscle tightness, stomach discomfort or mental cloudiness that usually passed within minutes. A temporary worsening of symptoms after a session, or on the next day, was possible while the effective setting was being found. Adverse events were graded mild, moderate or severe, with relatedness, and tracked to resolution. Serious or unexpected events went to the IRB [source: VA protocol]. The developers report worsening impulsivity in some children in their ADHD study and lower rates of adverse change in adults [source: Development History]. Hammond and Kirk (2008) document that inappropriate neurofeedback training can cause negative effects [source: Hammond & Kirk 2008].
Example language (illustrative): "If anything feels worse or strange afterwards, even the next day (headache, irritability, sleep changes, feeling foggy), please tell us. It helps us adjust."
Watch for: seizures, severe headache or migraine, manic or hypomanic signs, increased suicidal thinking, and sustained worsening. These call for an urgent medical or psychiatric response, not just adjustment of training [synthesis].

4.9 Outcome reassessment

Purpose / when: at intervals and at the end of a course.
Steps (descriptive): repeat the CPT and symptom tracking and compare them with baseline [source: Development History]. In the VA trial, outcomes were measured at several points with validated scales for headache, insomnia, attention, mood and PTSD, and there was a follow-up [source: VA protocol].
Example language (illustrative): "Let's repeat the same measures and see what has actually shifted since we started."
Watch for: relying on the client's impression alone. Compare against the baseline numbers.

Part B. The psychotherapist's interventions

4.10 Screening and medical clearance

Purpose / when: before training starts and whenever new symptoms appear.
Steps: (1) Take a medical and neurological history: seizures or epilepsy, migraine, head injury, bipolar disorder, pregnancy, current medicines, implanted devices and scalp or skin conditions [synthesis; the developers name seizure disorder, migraine, panic and bipolar disorder as instabilities, Development History]. (2) If there is a seizure disorder, bipolar disorder, brain injury, a pregnancy or an unexplained neurological symptom, ask the client's physician, neurologist or psychiatrist to confirm that training is appropriate, and agree how warning signs will be communicated [synthesis]. (3) Do a structured suicide-risk screen. The VA trial used C-SSRS items: a positive screen stopped enrolment and triggered crisis procedures [source: VA protocol]. (4) The VA trial excluded people with impaired decision-making capacity, severe brain injury or pregnancy [source: VA protocol]. Treat these as reasons for specialist review, not as a complete list [synthesis]. (5) Never present ILF training as a replacement for medical assessment of headache, seizures, cognitive decline or other physical symptoms [synthesis].
Example language (illustrative): "Because this works with brain activity, I'd like your neurologist to know about it and agree it's suitable, especially given your seizure history."
Watch for: clients who want to use neurofeedback instead of medical care.

4.11 Informed consent and shared decision-making

Purpose / when: before the first session, and again if the plan changes.
Steps: (1) Explain what the training involves: sensors, continuous feedback, the reports you will ask for, and that the provider adjusts settings. (2) State the evidence status plainly. The method is developer-led and contested, independent reviewers judge conclusions premature, and the controlled studies are few and small [source: Bazzana et al. 2022]. (3) Name the known adverse effects: transient discomfort, temporary worsening while settings are found, and worsening in some children [source: VA protocol; Development History]. (4) Discuss alternatives with stronger evidence for the client's condition. For ADHD guideline positions see 048 [synthesis]. (5) Agree measures and a review point at which you will decide together whether to continue [synthesis]. (6) Use plain-language written consent with a teach-back check, as the VA trial did [source: VA protocol]. (7) For children, get parental consent and the child's own assent, involve parents in reporting change, and take extra care given the developers' report of worsening impulsivity in some children [source: Development History] [synthesis].
Example language (illustrative): "Some people report real benefit, but the research is still early and much of it comes from the people who developed the method. So let's agree how we'll measure change, and review honestly after a set point."
Watch for: expectations raised by testimonials or broad claims.

4.12 Psychoeducation without overclaiming

Purpose / when: early on, and whenever the client asks how it works.
Steps: describe the developers' model as their model ("the developers propose…"). Say that the mechanism is not established [source: Bazzana et al. 2022]. Frame training as practice in self-regulation that sits alongside therapy, not as a cure [synthesis].
Example language (illustrative): "The developers think the brain learns from watching its own slow rhythms. That's still a theory. What we can check is whether your sleep, mood and stress actually change."
Watch for: the client attributing every change, good or bad, to the device.

4.13 Building state awareness for client report

Purpose / when: for clients who struggle to notice or describe changes, which the in-session optimisation depends on (4.4).
Steps: [synthesis] (1) Teach a simple vocabulary for state: alert or drowsy, calm or agitated, heavy or light, warm or cool, emotionally close or distant. (2) Practise brief body scans in therapy sessions. (3) Use a short daily log of sleep, mood, energy and physical symptoms that the client brings to training. (4) With the client's consent, share the log with the provider.
Example language (illustrative): "On a scale from 'flat and foggy' to 'wired', where are you right now?"
Watch for: dissociation, or reports made to please the provider. Encourage honest "no change" reports.

4.14 Medication coordination

Purpose / when: for any client taking psychiatric or neurological medicines.
Steps: (1) Tell the prescriber about the training, with the client's consent. (2) If the client reports feeling over-medicated, side effects or a wish to reduce medication, route it to the prescriber. Never advise any change yourself [synthesis]. The developers list a Protocol Guide topic on medication efficacy, and they identify the inability to adjust medication in coordination with training as a limitation of their ADHD study. This implies that coordination with the prescriber matters [source: Form 5A headings; Development History].
Example language (illustrative): "That's an important question for Dr X. Shall we write down what you've noticed so you can take it to your next appointment?"
Watch for: clients stopping medicines on their own because they "feel better".

4.15 Integrating psychotherapy with training

Purpose / when: throughout a course.
Steps: keep the psychological work going: formulation, emotion regulation, trauma processing at a safe pace, and behavioural change. Use training periods to practise regulation skills. Arina et al. (2022) gave a psychoeducation session before training and emotional support throughout. They argue that psychotherapeutic components should be included explicitly in neurofeedback protocols [source: Arina et al. 2022].
Example language (illustrative): "When you feel that settled state after training, let's notice what helps you get back to it on your own."
Watch for: psychological work being postponed "until the brain is trained".

4.16 Generalisation into daily life

Purpose / when: mid-course onwards.
Steps: [synthesis] link the states the client notices in training to everyday cues. Rehearse self-regulation skills such as paced breathing and grounding in real situations. Review the log for transfer: sleep, reactivity, focus. The developers claim gains generalise and persist, and they report long follow-ups in their own cases [source: Development History]. Independent confirmation is lacking [source: Bazzana et al. 2022].
Example language (illustrative): "Where in the week did you notice yourself recovering faster after stress?"
Watch for: gains that vanish between sessions. Note this and raise it at the review.

4.17 Safety and crisis planning

Purpose / when: for clients with suicide risk, self-harm, mania risk, seizures or severe PTSD.
Steps: keep a written safety plan up to date, and agree with the provider who will act on which warning signs. The VA trial routed a positive screen to mental-health triage, a crisis line, or emergency services if danger was imminent [source: VA protocol]. Agree that new neurological symptoms go to a physician the same day [synthesis].
Example language (illustrative): "If after a session you notice your mood dropping sharply or thoughts of harming yourself, here is exactly who to contact."
Watch for: risk rising during a period of symptom flare.

4.18 Choosing a provider and the training route

Purpose / when: when referring a client, or if you want to deliver ILF training yourself.
Steps:
- Your own licence first. Treat only conditions you are licensed and competent to treat [source: Hammond & Kirk 2008].
- BCIA Board Certification in Neurofeedback (BCN), as a third party summarises it: a bachelor's degree or higher in a BCIA-approved health-care field; a BCIA-accredited didactic programme; a neuroanatomy or related course; mentoring contact hours; personal self-regulation sessions; supervised client sessions; case conference presentations; and a proctored written exam. Recertification is every four years, and there is a technician route under supervision [source: BioSource Software summary]. Check the current numbers on BCIA's own site [uncertain: not verified].
- Othmer Method Certification, from EEG Info's own pages as read October 2026: a health-care bachelor's degree or three years of neurofeedback experience; the live Introductory Course within the last two years; further EEG Info courses (Practicum or Mastering Neurofeedback, Next Level, Synchrony, Alpha-Theta); mentoring with a certified provider; personal ILF and alpha-theta training sessions; a minimum amount of clinical experience; and a written case presentation with pre-post measures that follows the current Protocol Guide. Renewal is every two years [source: EEG Info certification requirements]. The FAQ page lists a shorter course set (Introductory Course plus Practicums 1 and 2), so the two pages differ [uncertain]. Certification is not a licence and is not required to practise [source: EEG Info certification FAQ].
- When referring: ask about licensure, certifications, medical liaison, how outcomes are measured, how adverse effects are handled, and what the costs are [synthesis].
Watch for: unlicensed providers treating clinical conditions, or broad cure claims.
Example language (illustrative): "Before you book, it's worth asking what licence they hold, how they measure progress and what happens if something feels worse." [synthesis]

4.19 Ending and follow-up

Purpose / when: when goals are met, progress plateaus, or the agreed review shows no benefit.
Steps: [synthesis; the developers publish no discharge criteria] (1) Compare against baseline (4.9). (2) Stop or pause if there is no measurable benefit by the agreed review point, or if adverse effects persist. (3) Plan relapse-prevention skills and a follow-up check. (4) Continue psychotherapy as needed.
Example language (illustrative): "The numbers show sleep has improved and stayed steady. Let's taper our focus to keeping that going and check in again in a couple of months."
Watch for: open-ended courses with no review, or pressure to keep buying sessions.

5. Handling problems

The developers' sources say little about problem handling. Most of the guidance below is [synthesis] unless a source is tagged.

5.1 "Does it work?": evidence status to give clients and referrers

Independent reviews. Bazzana et al. (2022) reviewed 18 heterogeneous studies covering depression, PTSD, ADHD, autism, pain, insomnia, headache, eating problems and other conditions. The studies were mostly small, with weak randomisation and little control of confounders. The authors judged conclusions premature [source: Bazzana et al. 2022]. They also noted that sham ILF is not a neutral condition [source: Bazzana et al. 2022]. Their review appeared in a journal section where Siegfried Othmer is reported as the handling editor, so a possible conflict of interest is worth weighing [source: Bazzana et al. 2022 page] [uncertain].
Controlled studies. One cross-over, sham-controlled study in tension-type headache reported benefit from ILF training but not from sham [source: Arina et al. 2022]. A 2026 NeuroImage mechanism study of a single session in healthy volunteers is described secondhand in a blog commentary as "a mechanism paper, not an outcomes paper" [source: Shaffer 2025, describing de Matos et al. 2026, not verified] [uncertain].
Guidelines. The Dutch psychiatric association's ADHD-in-children guideline (NVvP, 2020) does not recommend neurofeedback in general, citing limited and inconsistent evidence. It is not specific to ILF [source: NVvP Richtlijnendatabase]. NICE's position on neurofeedback for ADHD is covered in 048; NICE was not verified for this entry [uncertain]. No source cited shows a guideline recommending ILF training for any condition.
Developers' claims. The developers claim applicability to "the full spectrum of mental disorders" and report large practitioner networks and long follow-ups from their own data [source: Rationale; Development History]. Present these as claims attributed to the developers.
Response (illustrative): "It's an experimental, developer-led method. A few small studies are encouraging, but independent reviewers say it's too early to conclude it works. If we try it, we measure carefully and stop if nothing changes."

5.2 No change or a plateau

The developers pause progression when progress stops, and they report non-responder rates of roughly 5–24% depending on definition [source: Development History]. Response: check whether the client's reports are being collected reliably (4.13), discuss with the provider whether the training approach is being re-optimised, and hold to the agreed review point. If there is still no measurable change, stop and turn to treatments with stronger evidence (4.19) [synthesis].

5.3 Worsening or adverse effects after sessions

Transient effects and short-term worsening while settings are found are described as expected in the VA trial [source: VA protocol]. Response: record what happened and when, inform the provider before the next session, and escalate to medical or psychiatric care for seizures, severe headache, manic signs, increased suicidality or sustained deterioration [synthesis]. In children, ask the parents about impulsivity and behaviour, because the developers report worsening in some children [source: Development History].

5.4 Overwhelm and emerging trauma material

This applies especially when the alpha-theta component is used (see 046). Response: slow down, use grounding, keep a window-of-tolerance frame, and agree with the provider to pause add-ons until stabilisation work is done [synthesis].

5.5 Clients who cannot report states (children, alexithymia, dissociation, cognitive impairment)

The method depends on client report [source: EEG Info ILF page]. Response: build a state vocabulary (4.13), use observer reports from parents or partners, rely more on between-session logs, and take extra caution with capacity and consent [source: VA protocol excluded impaired capacity] [synthesis].

5.6 Non-adherence, missed sessions and cost

Response: discuss value openly against the agreed measures. Do not pressure the client to continue. Help them weigh cost against evidence status [synthesis]. The VA trial ended participation for excessive missed visits [source: VA protocol].

5.7 Over-attribution and dependence on the device

Response: keep the client's own skills and life changes in view. Review together what else changed in their life. Consider tapering training while continuing self-regulation practice [synthesis].

5.8 Medication changes and conflicting advice

Response: route every medication question to the prescriber (4.14). If a provider or a source suggests reducing medication because of training, write to the prescriber with the client's consent and do not endorse the change [synthesis].

5.9 Ruptures and role confusion between therapist and provider

Response: agree in writing who monitors what, who handles risk, and how information is shared. Hold joint reviews. If the provider makes claims or practises outside their competence, raise it professionally [source: Hammond & Kirk 2008 on qualifications] [synthesis].

5.10 DIY and home devices

Clients may ask about consumer devices or home training. No source cited describes home ILF training [uncertain]. Response: advise against unsupervised use for clinical conditions, given the developers' own statement that the training is "not innocuous" [source: Development History], and refer to a qualified provider [synthesis].

Sources

Online sources:

Not verified [uncertain]: Susan Othmer, Protocol Guide for Neurofeedback Clinicians (7th edition referred to by EEG Info); BCIA's official certification pages; NICE NG87 (see 048); EEG Info course pages; de Matos et al. (2026), NeuroImage, known only through Shaffer (2025).

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