By Siegfried Othmer, PhD
A good many years ago a writer for Fortune Magazine inquired with business managers about how they kept tabs on employee theft. The answer surprised him: “We ask the employees.” It turns out that those who steal from their employers assume that everyone does so, and they strategize that it would simply appear unbelievable if they didn’t own up to at least some of it. So the managers get a ‘good-enough’ answer to the question. The purloining employees essentially called themselves out.
The above recollection came to mind as I was contemplating the accusation by Drs. Raz and Thibault that neurofeedback practitioners were just pining for the tooth fairy. The results we are claiming are not the consequences of a real procedure we call neurofeedback but instead are nothing more than the varied manifestations of the well-known placebo.
It is quite clear to us that that cannot be the case, because the good results of our method are available to us only under very specific conditions that we have to identify for each individual. If the particulars of the technique matter, then clearly the technique matters. If things aren’t done right, we get bad results. We cannot just be dealing with the fulfillment of the client’s hopes and dreams here. We are jostled daily by the clinical realities that take us to the very limits of our professional competence in coming to terms with complex cases. The paths to recovery are as varied as the clients themselves, and so the work calls for great skill in execution.
That ends the discussion as far as we are concerned. But the argument is still alive among the critics. In particular, Drs. Raz and Thibault are still tantruming about neurofeedback in the journals. And their entire argument hinges on the placebo hypothesis. It is all they have! It is they who are occupying a world of pure intellectual constructs—of fantasy, really— because indeed they have nothing else to go on. After all, they have no relevant experience.
So it turns out that matters are quite the opposite of what they claim. Those who accuse us of pining for the tooth fairy are actually the ones pining for it: The placebo model plays the same role for them as the tooth fairy plays in real life! It can be summoned to explain away mystery, just like the tooth fairy. It can stifle further inquiry, just like the tooth fairy. It constitutes a complete explanation for whatever needs to be explained, just like the tooth fairy. In short, both the tooth fairy and the placebo play the role of what B.F. Skinner called an ‘explanatory fiction.’ “It is the function of an explanatory fiction to allay curiosity and to bring inquiry to an end.”
Plainly, then, the placebo is effectively their tooth fairy. It is they who are doing the pining, not we. It is they who utterly depend upon the tooth fairy for their little tantrum on the stage. And that means they are also inhabiting their own fairy castle. Whereas we encounter new clinical challenges every day in our practice because every client is unique, and every session with a client has its uniqueness, these folks have nothing but the tooth fairy and their fairy castle whenever they think about neurofeedback. The scene never changes. It’s always Last Year in Marienbad. It’s always Groundhog Day. How embarrassing it will be for them when they find out! It is almost impossible for them to see that they are the victims of a delusion, not we.
Consider that scientists are fond of accusing advocates of intelligent design of having a “God of the gaps.” God’s creative act is the answer for those mysteries of the development of complexity in nature for which no ready scientific model presently exists. The placebo is the scientist’s ‘God of the gaps,’ the explanation for recoveries in healthcare for which no scientific understanding presently exists—to wit, the mysterious influences of the mind on health outcomes.
Just as God is deemed omnipotent, so is the placebo. Just as the “God of the gaps” can fill any gap, so can the placebo. Just as believers accept the mystery of how God acts, scientists accept the mystery of the placebo without question. As soon as a scientific explanation is postulated for some aspect of the placebo response, then the term placebo is no longer applied to it, and the turf that remains to the placebo model shrinks accordingly. So what remains to the placebo is always featureless, just like the tooth fairy.
In an age of neuroscience, however, there is no longer any excuse for scientists to take refuge in the placebo. All the explanatory tools are available to us to answer the question of how neurofeedback works. We see the EEG change with training; we see the Slow Cortical Potential region change; we see evoked potentials (ERPs) change; we see the contingent negative variation (CNV) change; we see functional connectivities change. And we see the clinical landscape change. All that has already been demonstrated. A consistent picture emerges.
So there is no excuse whatsoever for scientists to invoke the nebulous placebo, their tooth fairy, to explain neurofeedback. What happens in the brain when we do neurofeedback is identical to what happens when we learn to perform any skill. Neurofeedback did not pose a fresh mystery beyond what was already there before. It was at most a surprise to learn at the outset that the brain can recognize its own EEG, but the novelty of that discovery has worn off by now. Everything else carries over from ordinary skill learning. The more we understand the particulars of how the brain learns and adapts, the more we will know about the particulars of how neurofeedback works.
Warren Buffett had a good description for what happened in the financial crisis, when the ultimate repository of risk in the mortgage market was AIG, and they had not covered their risk. “When the tide goes out, we find out who has been swimming naked.” It was, of course, AIG. The pseudo-scientists that still cling to the placebo in this modern age are indeed swimming naked. They are totally bereft of intellectual support beyond their own tooth fairy, the placebo, as a cover for their ignorance.
We come full circle, then, back to the story of employee theft. The sticky-fingered folks just assumed that other people were like them. And the scientists who are arm-waving about the placebo likewise assume that we inhabit an intellectual fairy castle just like they do—wallowing in excessive certainty beyond the reach of evidence, attending to evidence selectively, navigating with intellectual gamesmanship, posturing, and over-claiming—when in fact that is their game, not ours.
“He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” —William Osler