Silencing the Voices: Neurofeedback for Schizophrenia

In the complex field of schizophrenia treatment, auditory hallucinations (AH) remain one of the most difficult symptoms to manage. Affecting between 60% and 80% of people with schizophrenia, these hallucinations—often described as intrusive and distressing voices—can be both debilitating and resistant to traditional antipsychotic medications. This resistance drives patients and clinicians to seek alternative strategies for relief.

New emerging research with novel insights highlights a promising non-invasive technique: real-time functional magnetic resonance imaging (fMRI) neurofeedback. A new study by Bauer et al. (2025) explores how this form of neurofeedback can modulate brain activity in schizophrenia patients experiencing frequent, medication-resistant hallucinations. By targeting the superior temporal gyrus (STG)—a key region involved in auditory processing—the researchers investigated whether individuals could learn to self-regulate their own brain activity to reduce these hallucinations.

Biofeedback generally enables individuals to gain control over certain physiological functions (like heart rate or muscle tension) via real-time feedback. Neurofeedback, more specifically, focuses on brain activity, using tools like EEG or fMRI to help individuals self-regulate neural processes. In this study, researchers combined neurofeedback with mindfulness meditation techniques, creating a holistic approach that bridges neuroscience and mental training.

The results not only offer hope to individuals struggling with persistent hallucinations, but also open exciting new avenues for psychiatric treatment. Let’s dive into how this innovative approach was tested—and what it could mean for the future of schizophrenia care.

Methods

This double-blind, placebo-controlled randomized study builds on earlier findings that real-time fMRI neurofeedback can reduce STG activation and lessen auditory hallucinations in schizophrenia patients. This research aimed to confirm those results while exploring broader neural mechanisms.

Participants and Study Design:

Twenty-three adults diagnosed with schizophrenia or schizoaffective disorder—each experiencing frequent, treatment-resistant auditory hallucinations—were recruited. Participants were randomly assigned to one of two groups:

• Real Neurofeedback Group (n=10): Received real-time neurofeedback based on activity in the superior temporal gyrus (STG), the primary auditory processing region implicated in hallucinations.

• Sham Neurofeedback Group (n=13): Received feedback from the motor cortex, a region unrelated to auditory processing, as a control condition.

To strengthen the design, participants in the sham group were later given a single session of real neurofeedback, allowing for within-subject comparisons (Real After Sham).

Neurofeedback Procedure:

All sessions took place inside an fMRI scanner. Participants listened to pre-recorded phrases—some in their own voice and some in a stranger’s voice. Real-time feedback was visualized through a thermometer-style display, with a green bar indicating successful down-regulation of STG activity (during “ignore” blocks), and red indicating increased activity.

What set this study apart was the integration of mindfulness meditation, specifically a technique called mental noting. Participants were trained to observe and label their sensory experiences without emotional or cognitive engagement. For instance, upon hearing a stranger’s voice, they would mentally note “hearing” and then let the experience pass without dwelling on it. This strategy played a crucial role in helping participants regulate auditory cortex activity during neurofeedback.

Session Structure:

Each neurofeedback session included six cycles, each lasting 2.5 minutes:

• Cycles 1 and 6: Transfer blocks with no feedback, assessing brain activity before and after the intervention.

• Cycles 2–5: Active neurofeedback training blocks using mental noting to down-regulate STG activity.

Participants also provided subjective feedback on how well they were able to focus on or ignore the voices, rated on a scale from 1 (fully attentive) to 6 (completely ignored).

Results

This study produced compelling findings on how neurofeedback combined with mindfulness can modulate brain activity and reduce schizophrenia symptoms.

Reduction in Auditory Hallucinations:

Both the Real and Sham neurofeedback groups showed a reduction in the severity of auditory hallucinations after the intervention, as measured by the Psychotic Symptom Rating Scales – Auditory Hallucinations (PSYRATS-AH). However, no statistically significant difference emerged between the two groups. This suggests that while neurofeedback had a role, the mindfulness component may have independently contributed to symptom relief.

Changes in Brain Activity and Connectivity:

The neuroimaging data revealed more nuanced distinctions:

• Superior Temporal Gyrus Activation: The Real Neurofeedback group showed significantly greater reductions in activity within the secondary auditory cortex (part of the STG) compared to the Sham group. This reduction was also observed when the Sham group later received real neurofeedback, suggesting a robust effect.

• Functional Connectivity: The Real Neurofeedback group showed reduced connectivity between the secondary auditory cortex and cognitive control regions, including the right dorsolateral prefrontal cortex (rDLPFC) and the anterior cingulate cortex (ACC). This disconnection between auditory processing and executive control regions correlated with reduced hallucination severity.

Interestingly, primary auditory cortex activity also declined in both groups, suggesting a broader effect of mindfulness on sensory processing.

Discussion

This study opens up fascinating possibilities for combining neurofeedback with mindfulness-based techniques to address persistent auditory hallucinations in schizophrenia. Although both groups experienced symptom relief, the neuroimaging data revealed deeper insights into the mechanisms at work.

Mindfulness as a Neurofeedback Amplifier:

The mental noting practice likely contributed to the overall reduction in hallucinations observed across both groups. Mindfulness meditation is known to influence sensory processing, enhance self-awareness, and reduce emotional reactivity—factors that can help patients manage distressing auditory experiences. However, the specific targeting of the STG via neurofeedback led to distinct neural changes that mindfulness alone may not produce.

Clinical Implications:

For clinicians, this study suggests that combining neurofeedback with mindfulness training could offer a powerful, non-invasive alternative for patients with treatment-resistant hallucinations. By directly targeting neural circuits involved in hallucination generation—like the STG and its connections to cognitive control areas—this approach could complement traditional treatments and provide relief where medications fall short.

Neurofeedback Practice Takeaways:

For neurofeedback professionals, the study underscores the importance of targeting specific brain regions related to the symptoms being addressed. In this case, focusing on the STG yielded meaningful changes in activation patterns and connectivity. Incorporating mindfulness techniques like mental noting may also enhance engagement and attentional focus during training.

Future Directions:

While the findings are promising, several limitations remain. The study lacked a group that received mindfulness training alone, making it hard to disentangle the individual contributions of neurofeedback and meditation. Additionally, the small sample size highlights the need for larger-scale trials to confirm these findings and explore long-term effects.

Brendan’s Perspective

This study touches on one of the most exciting intersections in neurofeedback practice today: blending brain training with mindfulness. As practitioners, we often see how neurofeedback helps clients self-regulate specific brain activities, but combining it with mindfulness may amplify these effects by enhancing self-awareness and attention.

One of the key takeaways is the potential for neurofeedback to modulate not just isolated brain regions, but entire networks of connectivity. The observed reduction in functional connectivity between the auditory cortex and prefrontal control regions suggests that neurofeedback might help restructure maladaptive neural circuits, offering a more holistic approach to symptom management.

In clinical practice, this means we should consider integrating mindfulness into neurofeedback protocols, especially for clients with attentional difficulties or emotional dysregulation. Techniques like mental noting can help clients stay present during sessions and carry skills into daily life.

The study also highlights the importance of individualized protocols. While the STG was a key target for auditory hallucinations, other symptoms might respond better to different regions or network configurations. It's even theoretically possible for auditory hallucinations to be the result of a dysfunction in another part of the brain. As always, tailoring neurofeedback to each client’s unique needs is essential for the best outcomes.

Conclusion

The combination of real-time fMRI neurofeedback and mindfulness meditation offers a novel, promising approach to treating auditory hallucinations in schizophrenia. By targeting the superior temporal gyrus and teaching patients to modulate their brain activity, this intervention could bring relief to those unresponsive to traditional treatments. While more research is needed to fully understand the mechanisms at play, this study represents an exciting advance in the fields of neurofeedback and psychiatric care.

As neuroscience continues to explore the dynamic interplay between brain activity and conscious experience, techniques like neurofeedback and mindfulness may become central to future mental health treatments.

References

Bauer, C.C.C., Zhang, J., Morfini, F., Hinds, O., Wighton, P., Lee, Y., Stone, L., Awad, A., Okano, K., Hwang, M., Hammoud, J., Nestor, P., Whitfield-Gabrieli, S., Shinn, A.K., & Niznikiewicz, M.A. (2025). Real-time fMRI neurofeedback modulates auditory cortex activity and connectivity in schizophrenia patients with auditory hallucinations: A controlled study. bioRxiv. https://doi.org/10.1101/2025.01.13.632809