Hemoencephalography (Toomim)

1. Introduction

Version followed: near-infrared HEG (nIR HEG) as Hershel Toomim's group describe it in Toomim et al. (2004, Journal of Neurotherapy 8(3)), and passive infrared HEG (pIR HEG) as Jeffrey Carmen describes it in Carmen (2004, Journal of Neurotherapy 8(3)) and in his NRBS webinar page. Both are described at the level of method only. This guide gives no device settings, sensor sites, threshold rules or session prescriptions; those belong to the device manufacturer's training and the developers' courses.

Hemoencephalography (HEG) is a form of neurofeedback. Instead of EEG it uses a forehead sensor that tracks a blood-flow-related signal from the front of the brain, and shows it to the client as a moving bar, a tone or a movie that plays or pauses. The client learns, by trial and feedback, to raise the signal. [source: Toomim et al. 2004; Carmen 2004; Wikipedia, Hemoencephalography]

nIR HEG (Toomim): Toomim coined the term "hemoencephalography" and built a near-infrared spectrophotometry system in the late 1990s (per Wikipedia's history, which cites Siever 2008 [uncertain: secondary]). The sensor shines red and near-infrared light through the forehead and reads a ratio thought to track local oxygenated blood. Toomim's group present the method as an intentional, top-down "brain exercise" (Toomim et al. 2004, p. 6). In their account, repeatedly raising regional oxygenation in a chosen area increases its energy demand, and this may support plasticity and blood-vessel growth (pp. 5–6, 16). This mechanism is the developers' hypothesis and is contested (see below).
pIR HEG (Carmen): Carmen is a New York-licensed psychologist who describes himself as the inventor of pIR HEG (NRBS webinar page). He developed it out of his earlier peripheral thermal biofeedback work (Carmen 2004, p. 23). A passive sensor reads infrared (heat) emission from the forehead, which Carmen treats as an index of frontal metabolic activity and blood flow. His main published use is migraine. Wikipedia's account says Carmen adapted HEG in 2002 by adding thermal biofeedback. [uncertain]: the 2004 paper does not describe a hand-warming component in its migraine protocol.

How change is said to happen (developers' claims, attributed): The client learns a state of intense, sustained but untroubled concentration that raises the frontal signal. Toomim's group frame repeated practice as exercise that strengthens the trained region (Toomim et al. 2004). Carmen frames it as strengthening frontal regulation, which reduces migraine intensity first and frequency later (Carmen 2004, p. 45). He describes the effects as both preventive and abortive (NRBS webinar page).

Who may deliver it: HEG sits within biofeedback and neurofeedback, which licensed health professionals, psychotherapists included, deliver within their scope of practice after specific training. Carmen himself is a psychologist. [source: NRBS webinar page; BCIA, BF Entry Level]

Regulatory status: In the US, a "biofeedback device" is a Class II device under 21 CFR 882.5050. It is defined as an instrument that gives a visual or auditory signal tied to a physiological parameter so the patient can learn to control it. Some prescription, battery-powered devices for relaxation training are exempt from premarket notification (Cornell LII, 21 CFR 882.5050). [uncertain]: the clearance status or cleared indications of any specific HEG product, and its status in the UK or EU (CE/UKCA). Ask the vendor for the device's regulatory documentation and labelled intended use.

Evidence status, from independent sources:

Migraine: The developer literature consists of case series without control groups. Carmen (2004) reported improvement in most of 100 migraine patients and himself calls the report "a collection of cases, not a controlled study" (p. 26). He calls pIR HEG "an experimental intervention" (p. 49). Walker & Lyle (2016, NeuroRegulation 3(2)) reported lower HIT-6 and MIDAS scores in 31 adults, but every participant received treatment and there was no comparison group. An independent review of headache biofeedback (Andrasik 2010, Cleveland Clinic Journal of Medicine) reports Grade A evidence (US Headache Consortium) for thermal biofeedback with relaxation and for EMG biofeedback. It does not mention HEG, and it says EEG-based approaches need well-controlled studies. A systematic review of neurofeedback for pain (Roy et al. 2020) found mostly moderate-quality, small studies, almost all EEG-based, and asked for higher-quality research.
ADHD, autism, attention, other conditions: The reports are small and uncontrolled, or parent-reported, and many come from groups linked to the developers (Wikipedia summary). Toomim et al. (2004) had no randomisation, blinding or sham control, and they themselves raise regression to the mean as an alternative explanation (p. 18). A systematic review of the related field of fNIRS neurofeedback (Kohl et al. 2020) found it feasible but concluded "valid conclusions about specificity or potential clinical utility are premature". It notes that large randomised controlled trials are still lacking.
Signal validity (pIR): An exploratory study by researchers outside Carmen's group (Freides & Aberbach 2004) found "no evidence of sensitivity to left hemisphere specialization for verbal processing" in pIR forehead emissions. The authors note that the device has no established research protocol.
NICE: no NICE guidance addressing HEG was found [uncertain]. Do not assume that NICE has either endorsed it or advised against it.

Contested aspects (label them as such to clients): what the pIR signal actually measures; the "brain exercise" and blood-vessel-growth claims; broad claims for ADHD, autism, depression and anxiety; and claims of high migraine success rates drawn from uncontrolled, developer-run series.

2. Framework

[source: Carmen 2004; Toomim et al. 2004; NRBS webinar page; Wikipedia, Hemoencephalography; sequencing marked [synthesis] where it is mine]

Phase	Goals	What happens	Move on when
1. Referral, medical clearance, intake	Confirm the diagnosis and rule out causes that need medical care	Carmen accepted only primary migraine meeting IHS criteria and excluded migraine secondary to head injury or active disease. His referrals came mainly from neurologists and primary care physicians (p. 27). Toomim's participants were physician-referred and gave informed consent (parents for minors) (p. 8).	A physician has confirmed the diagnosis, red flags are excluded, the prescriber knows about HEG, and consent is documented [synthesis for the last two]
2. Baseline assessment	Have measures you can compare against later	Toomim: a continuous performance test (TOVA) before and after training, and SPECT in a small subset, ordered medically (pp. 12–15). Carmen: a pain rating and a record of headache events and patterns. In a subset he also took infrared images before and after sessions (pp. 31–33, 45). Walker & Lyle: HIT-6 and MIDAS.	Baseline recorded; target problem and goals agreed
3. Orientation and first sessions	Teach the task and find a workable mental strategy	The sensor goes on the forehead. The client learns to raise the signal against bar or tone feedback (nIR) or movie feedback (pIR). Carmen says most clients grasp the target state within a minute or two (p. 33).	The client can raise the signal at will within sessions
4. Training course	Make within-session control reliable and track symptom change	Short sessions. In pIR, sessions are cut short when the client tires, the headache worsens or attention fades (Carmen p. 28). In nIR, practice comes in timed segments with rest breaks (Toomim p. 11). Carmen started weekly and spaced sessions out as the client stabilised (p. 28). He treats early improvement as a sign that goals are likely to be reached (NRBS page).	Symptom change is on track (e.g. migraines become hard to identify as migraine, Carmen pp. 33–34), or a review shows no response
5. Generalisation	Use the state outside the clinic	Carmen: clients learn to notice the feeling just before frontal engagement drops and to keep it engaged during everyday tasks (NRBS page). Home training is available for some clients (Carmen p. 43; Wikipedia).	The client uses the state in daily life without feedback [synthesis]
6. Spacing, ending, follow-up	Consolidate the gains and plan for relapse	Carmen spaced sessions further apart and ended by mutual agreement. Follow-up ran from one-to-two-month checks up to several years (pp. 40–41, 46–48).	Mutual agreement; a relapse plan is in place [synthesis]

Format: Sessions are individual, in the office, with a clinician present. Some home-training options exist (Wikipedia; Carmen p. 43). Course length varies widely between reports. The developers' papers give their own session numbers; follow the protocol and training you were taught, not a figure from this guide. [uncertain: no developer manual verified]

3. Guiding principles

[source per line; [synthesis] where mine]

Medical diagnosis comes first. HEG is offered only for a condition a physician has diagnosed. For headache, that means primary migraine, with secondary causes excluded (Carmen p. 27).
Adjunct, not replacement. Carmen did not stop medication as part of his protocol (p. 36). His clients also received diet advice, stress management and psychotherapy (p. 27). In practice, keep medical care in place and coordinate with it.
Medication decisions belong to the prescriber. Some of Carmen's patients stopped medication as they improved (p. 36). Your role is to send any such wish to the prescriber, never to advise it. [synthesis]
Low distress, high concentration. Carmen describes the target state as very low anxiety, anger or frustration combined with very intense sustained concentration (p. 33). Coach the client toward calm effort, not strain.
The client's wish to see the feedback drives learning. Carmen says the desire to watch the movie matters more than what the movie is (p. 33). Let the client choose feedback they genuinely want to see.
Use the effort, not a cognitive task. Toomim's group asked clients to concentrate on the goal and on the feeling of the effort, and to avoid unrelated mental tasks (pp. 11–12). Do not offer mental arithmetic or similar tasks as strategies.
Respect fatigue. Early sessions can bring frontal fatigue, irritability and a worse headache for the rest of the day, which usually resolves after sleep (Carmen pp. 26, 28). Toomim's participants reported occasional mild transient headache and fatigue (p. 12). Shorten sessions rather than push through.
Measure, don't assume. Compare outcomes with baseline: an attention test (Toomim) or pain and headache records (Carmen, Walker & Lyle). Carmen notes pain ratings are unreliable over time; only "0" is a reliable anchor (p. 33). Use structured records. [source + synthesis]
Honest framing of the evidence. The developers themselves describe their reports as uncontrolled and the method as experimental (Carmen pp. 26, 49; Toomim p. 18). Consent conversations must say so. [synthesis]
Stay within your competence. Train before delivering HEG, keep to your licence and to the device's labelled use, and seek mentoring. [synthesis; BCIA model, Wikipedia]

4. Intervention inventory

This section has two parts. Part A describes the method's components as the developers publish them, at the level of method only. Part B covers the psychotherapist's own work around the method. Device setup, sensor sites, thresholds, segment timing and session numbers are taught in the developers' or manufacturer's training and are deliberately left out here.

Part A. HEG components as published

A1. Referral and medical clearance

Purpose / when: Before any HEG. It confirms that the target condition has been diagnosed and that causes needing medical treatment have been excluded.
Steps: (1) Ask for a physician's diagnosis. Carmen's referrals came mainly from neurologists and primary care physicians, often because medication had not worked well, or because of medication risks (for example in pregnancy) or worry about dependence (Carmen p. 27). (2) For headache, accept only primary migraine meeting the IHS criteria, and exclude migraine secondary to head injury or active disease (p. 27). (3) Record current medicines and the prescriber's name. Carmen notes that triptans can be a serious risk for people with coronary risk factors, and that for them behavioural treatment can become a medical necessity (p. 27). (4) Obtain informed consent, including a parent's consent for minors (Toomim p. 8).
Example language (illustrative): "Before we start, I need your doctor to confirm this is migraine and not something else causing the headaches. I'll also let them know we're adding this alongside their care."
Watch for: new, changed or atypical headaches, or neurological symptoms: send these back to the physician before training [synthesis]. Medication-overuse ('rebound') headache, which Carmen notes migraine medicines can cause (p. 48): this needs a medical review, not more training [synthesis].

A2. Baseline assessment

Purpose / when: At intake, and repeated at review points and at the end.
Steps: (1) Attention-focused work (Toomim): a continuous performance test (TOVA) before and after the course. Toomim's group also used a within-session gain index that compares each segment with the starting value (pp. 12–13). SPECT was used in a small subset; it is a medical investigation ordered by physicians, never by the therapist. (2) Migraine (Carmen): a pain rating plus a record of when headaches occur and how intense they are, including low-intensity events and recurring time patterns (pp. 33, 45). (3) Standardised headache-impact and disability questionnaires (HIT-6, MIDAS) were used by Walker & Lyle (2016). They are licensed instruments: obtain and score them as their publishers specify; they are not reproduced here.
Example language (illustrative): "For the next couple of weeks, note each headache: when it started, how bad it got and how long it lasted. That gives us something solid to compare with later."
Watch for: Carmen calls self-report inadequate for tracking low-intensity events (p. 45). A daily diary is better than recall [synthesis].

A3. Orientation, psychoeducation and consent to the method

Purpose / when: Before the first training session.
Steps: (1) Explain what the sensor reads: blood oxygenation (nIR) or infrared heat emission (pIR) from the forehead, used as an indirect index of frontal activity. (2) Explain what the method is not: it does not stimulate the brain, and nothing passes into the head except, for nIR, light from the sensor. (3) State the evidence status honestly: uncontrolled case series, described by the developers as experimental (Carmen p. 49). (4) Name the expected short-term effects (fatigue, a transient headache) and the plan for managing them. (5) Agree goals and a review point. [source: Toomim 2004; Carmen 2004; framing = synthesis]
Example language (illustrative): "The sensor reads a signal linked to blood flow at the front of your brain. You'll learn to push it up by concentrating hard while staying calm. The research so far is early and uncontrolled, so we'll measure carefully whether it helps you."
Watch for: expectations built on websites promising cure rates. Correct them gently and attribute the claims to their source.

A4. nIR HEG training session (Toomim version)

Purpose / when: The core training session in Toomim's method.
Steps (as described in Toomim et al. 2004, pp. 10–13): (1) A headband sensor is fitted on the forehead. Good contact matters: poor headband contact and sensor drift spoiled some of the study's data (p. 17). (2) The client sees a vertical bar graph and/or hears a musical tone that rises with the signal, and chooses sound, visuals or both. (3) The instruction is to maximise the signal. (4) Training runs in timed segments separated by short rest breaks. (5) For strategy, the client concentrates intensely on the goal; the authors used an analogy of reading progressively smaller print, then shifting attention to the feeling the effort produces. (6) Clients are asked not to use specific cognitive tasks, so that unrelated brain areas are not recruited. (7) The clinician praises successful segments. (8) Within-session progress is tracked against the starting value.
Example language (illustrative): "Imagine trying to read smaller and smaller print. Hold that effort, then notice what the effort itself feels like, and keep that feeling going. You don't need to think about anything in particular."
Watch for: Clients report feeling the change only through the feedback, not as a bodily sensation (p. 13), so tell them not to expect a particular feeling. Wikipedia reports that proponents read lower signal variability as a marker of progress [uncertain: not confirmed in the primary paper].

A5. pIR HEG training session (Carmen version)

Purpose / when: The core training session in Carmen's method, mainly for migraine.
Steps (Carmen 2004 pp. 28, 33; NRBS webinar page): (1) A comfortable sensor is placed on the forehead. (2) The client picks a movie, from the clinic's collection or their own. (3) The movie plays while the frontal signal stays above a threshold the clinician sets. When the signal drops, the movie pauses. (4) To restart it, the client focuses on a bar on the screen and raises the signal. This happens several times per session. (5) The target state is very low discomfort (anxiety, anger, frustration) combined with intense sustained concentration, which Carmen describes as focusing intensely but in a relaxed way. (6) Sessions are short and are ended early if the client tires, the headache gets worse or attention fades. Carmen preferred mornings when schedules allowed.
Example language (illustrative): "When the movie stops, look at the bar and bring it back up. Focus hard but stay easy in yourself; getting irritated with it usually makes it drop."
Watch for: Carmen says most people find the state within a minute or two (p. 33). Frustration and anger work against it. In the first one or two sessions, prefrontal fatigue, irritability and a worse migraine later that day can occur, usually resolving after sleep (pp. 26, 28).

A6. Session dosing and fatigue management

Purpose / when: Every session, and especially at the start of the course.
Steps: (1) Check at the start how the client is: sleep, current headache, fatigue. (2) Stop or shorten the session if you see fatigue, a rising headache or fading attention (Carmen p. 28). (3) Use the rest breaks the protocol builds in (Toomim p. 11). (4) After an early session, ask the client to report any delayed headache or irritability [synthesis].
Example language (illustrative): "You look like you're fading, so let's stop here. Short and good beats long and strained."
Watch for: a pattern of after-effects across sessions. Pass it to the clinician who set the protocol and, if headaches are changing, to the physician [synthesis].

A7. Progress monitoring and review

Purpose / when: Each session, plus formal review points.
Steps: (1) Within sessions, track how easily the client raises and holds the signal. (2) Between sessions, track the headache record or attention measure against baseline. (3) In migraine, Carmen saw intensity fall before frequency (p. 45). His working definition of significant improvement was that headaches became hard to identify as migraine (pp. 33–34). (4) Carmen treats improvement within an early block of sessions as a sign that goals are likely to be met (NRBS page). If there is no change at review, discuss stopping [synthesis].
Example language (illustrative): "Your headaches are less intense but just as frequent. That's the pattern Dr Carmen describes in early improvement, so it's worth continuing to the next review."
Watch for: improvement that may come from parallel changes (medication, diet, stress management) or from natural fluctuation. Carmen (p. 27) and Toomim (p. 18) both note these confounds.

A8. Home training

Purpose / when: Some clients, once they have learned the skill in the office. Carmen mentions it as an option (p. 43), and Wikipedia notes that home options exist.
Steps: No published procedure was found in the sources cited [uncertain]. Use the device vendor's and the developer's home-use instructions and the device's labelled use. [synthesis:] Train in the office first. Keep the clinician in charge of setup, give a written plan and a practice log, and review the log at each visit.
Example language (illustrative): "Use it the way we set it up here, log each practice, and stop and call me if you get a headache afterwards."
Watch for: practising beyond the plan, or changing settings unsupervised. Carmen reports home training was not viable for at least one patient (p. 43) [synthesis + source].

A9. Generalisation to daily life

Purpose / when: From mid-course onward.
Steps: (1) Help the client notice the feeling just before frontal engagement drops, and practise keeping it engaged during everyday tasks such as homework (Carmen, NRBS page). (2) [synthesis:] Pick two or three daily situations (reading, desk work, early warning signs of a migraine) and rehearse bringing on the trained state there without feedback. Then ask the client to report how it went.
Example language (illustrative): "You know the moment just before the movie pauses? Catch that moment while you're working and bring the focus back."
Watch for: state use that turns into strain or worry. The trained state is calm effort.

A10. Combining with other treatments

Purpose / when: As the client's needs require.
Steps: Carmen's clients also received diet advice, stress management and behavioural or psychotherapy methods at the same time (p. 27). Wikipedia reports that Carmen added peripheral thermal biofeedback, and that Stokes & Lappin (2010) combined EEG neurofeedback, HEG and hand-warming biofeedback [uncertain: secondary; the Carmen 2004 paper does not describe hand-warming]. Thermal biofeedback with relaxation has independent Grade A support for migraine prevention (Andrasik 2010) and is a well-established companion approach.
Watch for: combined packages make it impossible to say which component helped (Carmen p. 27). Tell the client this.
Example language (illustrative): "We're adding HEG to the diet and stress work you're already doing, so if things improve we won't be able to say which part helped most." [synthesis]

A11. Spacing, ending and follow-up

Purpose / when: Once gains are stable.
Steps: (1) Space sessions further apart as stability grows (Carmen p. 28). (2) End by mutual agreement (pp. 46–47). (3) Schedule follow-up checks; Carmen used checks one to two months later and longer-term follow-up (pp. 40–41, 48). (4) [synthesis:] Agree a relapse plan: which warning signs mean a booster session, and which mean a medical review.
Example language (illustrative): "Let's see how you do over a longer gap. If the headaches creep back, we'll book a booster, and if they change in character you'll see your doctor first."
Watch for: dropping out before the review point. Carmen's dropouts gave financial, psychological and medication-related reasons (pp. 47–48).

Part B. The psychotherapist's own interventions

B1. Recognising when a medical review is needed

Purpose / when: At intake and throughout the course.
Steps [synthesis]: Refer back to the physician, urgently where appropriate, for: a new or sudden severe headache; a change in headache pattern; neurological symptoms; headache after a head injury; daily headache with frequent use of pain medicine (possible rebound, Carmen p. 48); or pregnancy-related questions about medication. For attention complaints, confirm that a proper diagnostic assessment has been done before training.
Example language (illustrative): "That headache sounds different from your usual ones. I'd like you to see your doctor before our next session."
Watch for: clients choosing HEG to avoid seeing a doctor.

B2. Medication conversations

Purpose / when: Whenever a client raises reducing or stopping medication. Some of Carmen's patients stopped medication as they improved (p. 36), and the developer literature reports reduced ADHD medication in a case report (Wikipedia summary of Mize 2004) [uncertain: secondary].
Steps [synthesis]: (1) Explore what the client wants and why, without advising. (2) Say plainly that changes go through the prescriber. (3) Offer to share the headache or attention records with the prescriber, with the client's consent. (4) Help the client prepare questions for the appointment.
Example language (illustrative): "It makes sense to want fewer tablets if things are improving. That's a decision for you and your doctor. Shall we take your diary to that appointment?"
Watch for: stopping medication without the prescriber's knowledge, and rebound headaches.

B3. Informed consent and shared decision-making

Purpose / when: Before the first session and at each review.
Steps [synthesis]: Cover what HEG is, its experimental status, the alternatives with stronger evidence (for migraine prevention: medical treatment, thermal or EMG biofeedback with relaxation, and behavioural approaches, Andrasik 2010), the cost and time involved, the expected short-term effects, and the client's right to stop at any time. Document all of this.
Example language (illustrative): "There are approaches for migraine with stronger evidence. HEG is early-stage. You can try it, combine it, or choose the others, and we'll review it together."
Watch for: consent given out of desperation after failed treatments, or because a family member is keen; check it is the client's own choice. [synthesis]

B4. Monitoring and passing on side effects

Purpose / when: Every session.
Steps: Ask about post-session headache, fatigue and irritability (Carmen pp. 26, 28; Toomim p. 12), and about any skin irritation from the sensor or headband [synthesis]. Record what you hear. Pass persistent effects to the protocol clinician, and changes in the headache picture to the physician [synthesis].
Watch for: worsening migraine after sessions that does not settle overnight.
Example language (illustrative): "Any headache, tiredness or irritability later on the day of a session? I'll pass that on so the protocol can be adjusted." [synthesis]

B5. Integrating psychotherapy

Purpose / when: Before, during and after the HEG course.
Steps [synthesis; Carmen co-delivered stress management and psychotherapy, p. 27]: Work in parallel on trigger and stress patterns, sleep regularity, pacing, catastrophising about pain, low mood or anxiety that often accompanies chronic headache, and attention-related coping at school or work. Use the trained state as a coping skill in that work (A9).
Example language (illustrative): "Let's use the focus you've trained when you notice the early stress build-up we've mapped."
Watch for: psychological work being put on hold while the client waits for the device to work. [synthesis]

B6. Crisis and safety planning

Purpose / when: With chronic pain or attention problems that come with depression, hopelessness or suicidal thoughts.
Steps [synthesis]: Screen for risk at intake and when mood changes. Follow standard risk assessment and safety planning, involve the medical team, and never let a training course delay crisis care.
Example language (illustrative): "Living with headaches this often can wear anyone down. Have you had thoughts that life isn't worth living?" [synthesis]
Watch for: hopelessness after a training course that has not helped; rising risk when pain flares. [synthesis]

B7. Equipment and electrical safety (general)

Steps [synthesis]: Use only devices whose regulatory status and labelled intended use you have checked (US: biofeedback devices are Class II under 21 CFR 882.5050). Follow the manufacturer's instructions on cleaning, charging and mains or USB connection. Inspect cables and headbands. Keep an incident log. A pIR sensor only reads emitted heat. An nIR sensor emits light at the forehead, so keep it on the skin as the manufacturer instructs and do not point it at the eyes [synthesis; not stated in the sources cited].
Purpose / when: before first use of any HEG device and at regular checks. [synthesis]
Example language (illustrative): "This sensor only reads a signal; tell me if the headband feels too tight or the skin gets sore." [synthesis]
Watch for: damaged cables, devices without regulatory documentation, skin irritation under the headband. [synthesis]

B8. Training and certification route

Steps: (1) Hold a licence for independent practice in a health profession, or work under supervision. Neurofeedback is used within each profession's scope. (2) BCIA's neurofeedback certification (BCN) is the main general credential. Per the Wikipedia summary, the clinical track requires: a degree in a clinical health field; a didactic course covering BCIA's Neurofeedback Blueprint of Knowledge; human anatomy and physiology; mentoring by a BCIA-approved mentor; a set number of client sessions and case-conference presentations; an exam; adherence to BCIA's ethics; and recertification through continuing education. [uncertain]: check current requirements at bcia.org. Note that BCN's scope is defined as EEG biofeedback and adjunctive procedures, and no HEG-specific BCIA credential was identified. (3) For HEG itself, train with the developers or device vendors. Carmen teaches pIR HEG through professional-society webinars (NRBS, sponsored by a vendor; NRBS states it does not endorse vendors). Get mentoring from an experienced HEG clinician for your first cases [synthesis].
Purpose / when: before delivering HEG yourself, or when checking a provider's credentials. [synthesis]
Example language (illustrative): "I'm certified in neurofeedback, and I trained in this method with the developer's course; I'm still supervised on my first cases." [synthesis]
Watch for: device-vendor training presented as a clinical qualification; practising beyond your licence. [synthesis]

5. Handling problems

[source where cited; otherwise [synthesis]]

The client cannot raise the signal. Check sensor contact and position first; Toomim et al. (p. 17) report headband contact problems. Then move the strategy toward calm, intense effort and away from strain or mental tasks (Carmen p. 33; Toomim pp. 11–12). Shorten the segment and praise small gains. If there is still no control after several sessions, review with the protocol clinician [synthesis].
Frustration or anger during feedback. Carmen names low frustration as part of the target state (p. 33). Pause, normalise it, use a brief settling exercise, then restart. If the movie pausing becomes aversive, let the client choose a movie they want more (the desire to watch is what drives learning, p. 33). [synthesis + source]
Overwhelm, fatigue or a headache after a session. Expect it in the first one or two sessions (Carmen pp. 26, 28). Shorten sessions, avoid scheduling them before demanding tasks, and check for sleep debt. If headaches keep worsening, stop and refer to the physician [synthesis].
No symptom change at the review point. Carmen treats early improvement as predictive (NRBS page). Discuss stopping or switching to better-supported options such as thermal or EMG biofeedback with relaxation (Andrasik 2010) or medical review. Do not extend indefinitely [synthesis].
Non-adherence (missed sessions, no diary). Simplify the diary, link it to an existing routine, and look at cost and travel, which were among Carmen's dropout reasons (pp. 47–48). Agree a realistic schedule [synthesis].
Ambivalence or a wish to stop medication. Use B2. Never encourage or discourage a medication change yourself; route it to the prescriber [synthesis].
Over-belief in claims ("it will cure me", "it grows blood vessels"). Attribute those claims to their sources, explain that they are contested, and return to the client's own measured data [synthesis].
Scepticism or fear about "brain" work. Explain that the sensor only reads, and that nIR uses light at the forehead. Offer a trial session with no commitment [synthesis].
Rupture (the client feels blamed when the signal stays low). Repair it: own your part in setting the task, reframe low readings as information rather than failure, and invite the client to say what is frustrating [synthesis].
Children and adolescents. Parental consent was obtained in Toomim's study (p. 8). Use short sessions and an engaging feedback choice, coordinate with school and the prescriber, and keep a separate check of the child's own assent [synthesis].
Home device misuse. Re-train in the office, lock or limit settings as the vendor allows, review practice logs, and stop home use if after-effects appear [synthesis; procedure not found in sources cited].
Confounded improvement. When diet, medication or stress changed at the same time, tell the client that the cause cannot be isolated (Carmen p. 27). Keep effective components going together rather than dropping one to test it, unless the prescriber or the team advises otherwise [synthesis].

Sources

Online sources:

Cited from secondary summaries [uncertain]:

Siever D (2008). History of biofeedback and neurofeedback: the Hershel Toomim story. Biofeedback 36(2), 74–81.
Mize W (2004). Hemoencephalography: a new therapy for attention deficit hyperactivity disorder (ADHD): case report. Journal of Neurotherapy 8(3), 77–97.
Stokes DA, Lappin MS (2010). Neurofeedback and biofeedback with 37 migraineurs: a clinical outcome study. Behavioral and Brain Functions 6, 9.
Tinius T (ed.) (2004). New Developments in Blood Flow Hemoencephalography. Hawthorne Press, as the secondary source gives it [uncertain].

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