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Placebo Puffery

By Siegfried Othmer, PhD

placeboIf the placebo is such a big deal, why is it not being diligently studied? Why is the ‘cause’ of the placebo ‘effect’ not being looked for? If this is such a huge factor that it governs all drug studies, surely it deserves some attention in its own right.

One would certainly think so. But the fact that this is not happening also points to the answer. The placebo is not actually a thing. It is merely a catch-all term for all those factors contributing to recovery that can’t be clearly related to the drug being investigated. These are not really of interest to the pharmacology researcher. They are an inconvenience for him, a confound to the study. So they are collectively given a label.

All of the factors involved in the placebo are, however, related to brain function at some level. They testify to the existence of powerful mechanisms of self-recovery and of self-regulation. With neurofeedback, our objective is the enhancement of self-regulatory capacity. We achieve systematically what often happens randomly in drug experiments and then gets assigned to the placebo bin.

Now in surveying this threat to the drug monopoly, the drug researcher comes along and says that one needs to account for the placebo effect before neurofeedback can be accepted. Really? We are talking about self-regulation either way. To neurofeedback practitioners the placebo is not a confounding factor. Rather, it is a compounding factor. Whatever it is that is being labeled placebo helps the process toward success. We want all that we can get!

So the real argument being made is that neurofeedback, in its entirely, is reducible to the placebo, that there is nothing but the placebo. We have always known that that is not the case. After all, the work got started with animal studies, where the placebo is not operative. And the work has been done with people in persistent vegetative states. It has been used to bring people out of coma. It has been done with infants. It has been done with young autistic children who are not even aware that they are undergoing brain training. And it has been done with ADHD kids by the tens of thousands—-even hundreds of thousands.

The ADHD kids by and large are not doing the training because they recognize their problem. It is mostly because their parents or teachers see a problem. So why should there even be a placebo effect? The training is making problems go away that they don’t even know they have! Also, as they sit there and do the work, they may be gaining in IQ and their handwriting may improve. Their brains are becoming more competent, by and large, just through watching their own EEG. You cannot give credit to the placebo for that.

We find ourselves in a conceptual muddle, which calls for better understanding, not better and even more elaborate experiments. In neurofeedback, agency lies with the brain, not with the instrument. Likewise with the placebo: agency lies with the brain. Whatever can be legitimately assigned to the placebo, the brain did it. So if one is going to try to pick things apart, one has to be specific about one’s assumptions about the placebo. But here is where things get vague.

Scientific research involves the testing of predictions that come out of a model. The only real prediction that emerges out of the placebo model is that somehow things go the way the person wants: Placebo as ‘wish fulfillment.’ But with neurofeedback we get many benefits that have nothing to do with what the person came in for. Sometimes the training even goes against the person’s own wishes, as in training someone out of being a smoker. Some people give up smoking without ever having intended to do so, and without that issue ever having been discussed. There is no question that the training was responsible for the change, and this cannot be explained in terms of the placebo model.

Also in our method the good results are achievable only under very specific conditions of the training. If we train under other conditions, we may even see responses that are definitely not wanted! So the placebo argument is out the window for many reasons. Plainly, it cannot explain neurofeedback in its entirety.

But what happens if you change the proposition around: Neurofeedback explains the placebo effect. Now everything begins to make sense. The same brain mechanisms are involved, but with the tool of neurofeedback, these can actually be formally investigated. We find that the EEG changes; neural network connectivity changes; evoked potentials change; the contingent negative variation changes; the fMRI changes. In fact, it has been shown that all of these measures can change even in a single session! And of course the behavior and functionality change over time as well, which is the whole point of the exercise.

Understand neurofeedback and you will understand the power of the placebo. There is nothing of importance left to explain. So neurofeedback and the placebo are not adversaries. They are not even in competition. Both are manifestations of our natural brain plasticity, of our capacity for self-recovery, that we hope to benefit from. We do the best we can to steer the brain to better function with our training procedure, and the brain does the best it can on its own. We do the best neurofeedback training we know how, and in that process the so-called placebo is our ally. Only we have no need for the label. And we certainly have no need to distinguish one from the other in formal research. That is just a fool’s errand.

Hurray, the placebo is dead. Long live the placebo!

Siegfried Othmer, PhD
drothmer.com

P.S. Of course some research on the placebo has actually been done, and is still being done. But it has been a marginal preoccupation. The research confirms that in ‘placebo responders’ EEG parameters change just as they do in neurofeedback, and the change differs from those seen in medication responders and in placebo non-responders. This still does not mean that the placebo rises to the level of a scientific theory. It is not a unitary phenomenon. As the mechanisms of self-regulation are further elucidated, the term will surely disappear from respectable scientific discourse. It is a hangover from a time when scientists did not even acknowledge the existence of brain plasticity.

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7 Responses to “Placebo Puffery”

  1. John Mekrut says:

    I recall a client from my earliest days that came to train for “peak performance”, a general catch all phrase for him. After 10 or 15 sessions he announced that along with better sleep, focus and attention skills and improved social relationships, he surprisingly noticed that he was no longer consuming his normal 8-10 cans of Red Bull per day! I wasn’t training him for his, unrevealed to me, stimulant addiction, just a wonderful by product of his better regulated brain.

    Reply

    Clay Ryan Reply:

    Thank you for putting the placebo argument in its place ! (although the power of positive thinking, placebo and mind attenuation of a different method are real).

    John, an interesting byproduct. Thanks for adding your experienced viewpoint and providing a salient example.

    Reply

  2. june rickard says:

    a very interesting summary

    I hope that neurofeedback will help my grandson one day with his reading comprehension defiict
    thank you

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  3. June—The earlier he gets to train his brain the better.

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  4. The placebo is a case of what BF Skinner calls an explanatory fiction. “It is the function of an explanatory fiction to allay curiosity and to bring inquiry to an end.” The placebo hypothesis accomplishes that marvelously. However, it should be clear to the reader that the author knows this perfectly well, so that must also be the intention. Should one listen to someone who just wishes the discredit the topic? Anyone who invokes the placebo model as an explanation of neurofeedback absents himself from the frontier of inquiry and thus disqualifies himself from the ongoing conversation.

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  5. Anna Thewlis says:

    When studies show neurofeedback as efficacious as “sham neurofeedback” and therefore suggestive of a placebo effect for neurofeedback are you in agreement with the statement that neurofeedback is as useful as “sham neurofeedback”. If so, what is the additional benefit of neurofeedback over watching a video game?

    Reply

    Siegfried Othmer Reply:

    All of the formal studies that show the sham training control to be as effective as actual neurofeedback have been targeting attentional training for ADHD. In this application, sham training is not the neutral control that it was intended to be. Consider that in order to make a complete match between the sham training and the neurofeedback the children will be coached in the task, they will be trying to meet the goals, and they will get random rewards for doing so. This challenges attentional mechanisms in a manner very similar to actual neurofeedback. And if that is done over a period of twenty to forty sessions, then attentional function will likely improve even for the sham training group. What this shows is just how easy it is to train attention! Playing video games can do it. Mindfulness training can do it. And good sham training can do it.

    If, on the other hand, sham control is used in a study of recovery from stroke, then the difference shows up very starkly. This has been done.

    You see that the researchers have just fooled themselves in the sham-controlled studies on ADHD. Some of them come to the research task quite skeptical about neurofeedback, and when the results turn out to meet their expectations, they don’t stop to ask the hard questions.

    There is even published evidence that sham training alters the functional connectivity of brain networks, which proves that it is an active process.

    And finally, it must also be said that the sham-controlled research evaluated neurofeedback designs that were not very effective. The researchers were compelled to dumb down the designs in order to be able to create a match with the sham control! This is of course quite perverse. The protocols used are not representative of the state of the art. If we had ever used such protocols, I doubt if we could ever have been successful in launching a practice. So we don’t see this research as in any way relevant to our present reality.

    Reply

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