Neuroenhancement for sale: assessing the website claims of neurofeedback providers in the United States

Controlling Virtual Reality With Brain Signals: State of the Art of Using VR-Based Feedback in Neurofeedback Applications

The rapid progress of commercial virtual reality (VR) technology, open access to VR development software as well as open-source instructions for creating brain-VR interfaces have increased the number of VR-based neurofeedback (NF) training studies. Controlling a VR environment with brain signals has potential advantages for NF applications. More entertaining, multimodal and adaptive virtual feedback modalities might positively affect subjective user experience and could consequently enhance NF training performance and outcome. Nevertheless, there are certain pitfalls and contraindications that make VR-based NF not suitable for everyone. In the present review, we summarize applications of VR-based NF and discuss positive effects of VR-based NF training as well as contraindications such as cybersickness in VR or age- and sex-related differences. The existing literature implies that VR-based feedback is a promising tool for the improvement of NF training performance. Users generally rate VR-based feedback more positively than traditional 2D feedback, albeit to draw meaningful conclusions and to rule out adverse effects of VR, more research on this topic is necessary. The pace in the development of brain-VR synchronization furthermore necessitates ethical considerations on these technologies.

Neurofeedback on twitter: Evaluation of the scientific credibility and communication about the technique

Neurofeedback is a popular technique to induce neuroplasticity with a controversial reputation. The public discourse on neurofeedback, as a therapeutic and neuroenhancement technique, encompasses scientific communication, therapeutic expectations and outcomes, as well as complementary and alternative practices. We investigated twitter publications from 2010 to 2022 on the keyword "neurofeedback". A total of over 138 k tweets were obtained, which originated from over 42 k different users. The communication flow in the neurofeedback community is mainly unidirectional and non-interactive. Analysis of hashtags revealed application fields, therapy provider and neuroenhancement to be the most popular contents in neurofeedback communication. A group of 1221 productive users was identified, in which clinicians, entrepreneurs, broadcasters, and scientists contribute. We identified reactions to critical publications in the twitter traffic and an increase in the number of tweets by academic users which suggest an increase in the interest on the scientific credibility of neurofeedback. More intense scientific communication on neurofeedback in twitter may contribute to promote a more realistic view on challenges and advances regarding good scientific practice of neurofeedback.

Neurofeedback as placebo: a case of unintentional deception?

The use of placebo in clinical practice has been the topic of extensive debate in the bioethics literature, with much scholarship focusing on concerns regarding deception. While considerations of placebo without deception have largely centred on open-label placebo, this paper considers a different kind of ethical quandary regarding placebo without an intent to deceive-one where the provider believes a treatment is effective due to a direct physiological mechanism, even though that belief may not be supported by rigorous scientific evidence. This is often the case with complementary and alternative medicine (CAM) techniques and also with some mainstream therapies that have not proven to be better than sham. Using one such CAM technique as a case study-electroencephalography (EEG) neurofeedback for attention-deficit/hyperactivity disorder (ADHD)-this paper explores the ethics of providing therapies that may have some beneficial effect, although one that is likely due to placebo effect. First, we provide background on EEG neurofeedback for ADHD and its evidence base, showing how it has proven to be equivalent to-but not better than-sham neurofeedback. Subsequently, we explore whether offering therapies that are claimed to work via specific physical pathways, but may actually work due to the placebo effect, constitute deception. We suggest that this practice may constitute unintentional deception regarding mechanism of action. Ultimately, we argue that providers have increased information provision obligations when offering treatments that diverge from standard of care and we make recommendations for mitigating unintentional deception.

Opportunity Cost or Opportunity Lost: An Empirical Assessment of Ethical Concerns and Attitudes of EEG Neurofeedback Users

Background

Electroencephalography (EEG) neurofeedback is a type of biofeedback that purportedly teaches users how to control their brainwaves. Although neurofeedback is currently offered by thousands of providers worldwide, its provision is contested, as its effectiveness beyond a placebo effect is unproven. While scholars have voiced numerous ethical concerns about neurofeedback-regarding opportunity cost, physical and psychological harms, financial cost, and informed consent-to date these concerns have remained theoretical. This pilot study aimed to provide insights on whether these issues were supported by empirical data from the experiences of neurofeedback users.

Methods

Semi-structured telephone interviews were conducted with individuals who had used EEG neurofeedback for themselves and/or for a child.

Results

The majority of respondents (N = 36) were female (75%), white (92%), and of higher socioeconomic status relative to the U.S. population. Among adult users (n = 33), most (78.8%) resorted to neurofeedback after having tried other therapies and were satisfied with treatment (81.8%). The majority paid for neurofeedback out-of-pocket (72.7%) and considered it to be good value for money (84.8%). More than half (57.6%) considered neurofeedback to be a scientifically well-established therapy. However, of those, 78.9%were using neurofeedback for indications not adequately supported by scientific evidence.

Conclusion

Concerns regarding opportunity cost, physical and psychological harms, and financial cost are not substantiated by our findings. Our results partially support concerns regarding insufficient understanding of limitations. This study underlines the disconnect between some of the theoretical concerns raised by scholars regarding the use of non-validated therapies and the lived experiences of users.

Ethical and Legal Considerations of Alternative Neurotherapies

Neurotherapies for diagnostics and treatment-such as electroencephalography (EEG) neurofeedback, single-photon emission computerized tomography (SPECT) imaging for neuropsychiatric evaluation, and off-label/experimental uses of brain stimulation-are continuously being offered to the public outside mainstream healthcare settings. Because these neurotherapies share many key features of complementary and alternative medicine (CAM) techniques-and meet the definition of CAM as set out in Kaptchuk and Eisenberg-here we refer to them as "alternative neurotherapies." By explicitly linking these alternative neurotherapy practices under a common conceptual framework, this paper draws attention to, and critically considers, the cross-cutting ethical and legal issues related to the provision of these services. The first section of this paper provides an updated empirical overview of uses of SPECT neuropsychiatric evaluations, EEG neurofeedback, and experimental/off-label forms of brain stimulation. Next, drawing on CAM bioethics scholarship, we highlight the pertinent ethical issues in the alternative neurotherapy context, including the truthful representation of evidence base, marketing to vulnerable populations, potential harms, provider competency, and conflicts of interest. Finally, we consider the principal legal issues at stake for the provision of alternative neurotherapies in the U.S., namely those related to licensing and scope-of-practice considerations. We conclude with recommendations for future research in this domain.