It was back in 1968 that Garrett Hardin published his famous piece, “The Tragedy of the Commons,” in Science (162, pp 1243-1248, Dec. 13, 1968, American Association for the Advancement of Science). The example of over-grazing of lands held in common was given as an exemplar of a universal truth, namely that assets held in common by a large population inevitably end up over-exploited. This follows from the ineluctable workings of Adam Smith’s Invisible Hand, in which each individual acts in his own interest. He derives the whole benefit from his own exploitation of the commons, whereas the costs are distributed among all, so he bears only a fraction. As the population grows, the ratio of concentrated benefits to distributed costs only grows, and the incentive to exploit only escalates with it.

The sense in which Hardin uses the word tragedy is that of Alfred North Whitehead: “The essence of dramatic tragedy is not unhappiness. It resides in the solemnity of the remorseless working of things.” Of course such workings out of irresistible trends results in unhappiness, and we require unhappiness to give the futility of escape dramatic poignancy. Says Hardin, “Ruin is the destination toward which all men rush, each pursuing his own best interest in a society that believes in the freedom of the commons. Freedom in a commons brings ruin to all.” So, unhappiness portends–and not only unhappiness, but ruin as well. It would be best to take notice.

In the midst of all this impending tragedy, there is one commons that so far seems to violate all the rules, and that is the Commons of the Internet. As long as we don’t individually pay for usage of the Internet backbone, there is no incentive to limit one’s utilization. The result is evidenced in some 85% of web traffic being either spam, scam, or scum. The Invisible Hand is at work, and untold social harm is somewhere in the bargain. Yet we see little effect of overload on the Internet itself. Sometimes downloads are slowed on cable, but that’s about the worst of it. That small cost rears its head only at a time when the Internet has already substantially transformed the economy, and it hardly rises to the level of tragedy. Somehow more nodes are added to the network, and more trunk lines, to keep the whole thing humming reasonably well.

The Internet may be seen as an example of a Commons where the downsides of over-exploitation are reasonably manageable, and therefore appear to be subject to our rational forecasting and planning. In this it seems to be relatively alone, although the Economist now projects that telephony will go the same route of becoming essentially free. Both time and distance are no longer cost factors for the telephone companies, and hence these can be squeezed out of the pricing models. But telephony becoming a commons is only possible by virtue of the Internet itself, so this example is not independent of the first. Ironically, it is also possible only because of the billions in infrastructure put in place before the bubble burst, all in the anticipation of riches beyond the dreams of avarice. Greed does have its uses.

There are several other major trends at work in our society with regard to the Commons. The most obvious response is increasing privatization of things that used to be free or available at rates subsidized by the public through government. Beach access and national park facilities are obvious but relatively trivial cases in point. More significantly, we are seeing the privatization of health care. This is happening in direct response to the fear of health care as part of the Commons. Given the opportunity, people will overuse access to care.

The evidence for this is actually slim. The real problem of over-use is by the folks who order the tests and the procedures, i.e. the medical community itself. But that problem relates to the Commons as well, so we end up at the same place in the argument either way. The other problem is that we do not have good options for chronic health conditions, so by means of a palliative and largely futile assault on symptoms the “system” ends up exacerbating the problems it cannot solve. We can call this the iatrogenic health care problem. We have a system that creates and perpetuates its own dependencies, which it then laments.

One could argue that the fear of the Tragedy of the Commons has guided American health care policy ever since universal health care was first proposed in the U.S. (by President Truman, I believe). Better to suffer a gazillion indignities individually than to suffer the Tragedy of the Commons collectively.

The above observations lay the groundwork for the issue we confront as a discipline: Shall we entrain ourselves to the pathological health care system that has evolved in this country, or do we have an alternative future in what remains of the Commons, one to which the Internet may be a beacon for us? On one side are gate keepers and rule makers and licensed service providers and torrents of paperwork from the deniers of care. On the other side is the realistic hope of universal access to care, one in which the contact hour does not necessarily equal the professional hour, where service delivery can become largely time- and distance-independent, just as telephony is becoming. Or can we have both systems concurrently? Those who have already “taken the bit” in the existing system have to find a way to fold in neurofeedback. But those who are not on the inside track with respect to reimbursement have to find other ways to go forward.

A natural way to start is with the assumption of entitlement of care. We already make that assumption with regard to acute care; in principle anyone can show up in an emergency room and sooner or later get some attention. As a society we avoid holding out the same promise for chronic care. (We can’t very well allow people to bleed to death on our doorstep, but long-term suffering is another matter.) When help for chronic conditions is suddenly as accessible as it has become with neurofeedback, however, it brings along its own ethical mandate. There are now both the method and the means of service delivery for nearly everyone, and the failure to progress toward that goal will take the active interposition of threatened elites.

Andrew Solomon put the case well in an article in The New York Times Magazine (May 6, 2001, pp 112-117) with the title “A Cure for Poverty.” He asked the question: “What if you could help end people’s economic problems by treating their depression?” More years of productive life are lost to depression than to the combined influence of war, cancer, and AIDS. Worldwide, depression ranks first in public health impact after the childhood diseases that are traceable to poor hygiene and the poor state of public health. Realistically, in the developing world neurofeedback should be right up there with clean water and mosquito netting for malaria as agents of change. Universal neurofeedback could be delivered for costs comparable to those of clean water and mosquito netting.

Suppose that we had taken the perspective that psychic trauma–a generational contagion of disorders of attachment–is the real issue among the American poor, rather than simply depression. No matter. Neurofeedback would still be the remedy of choice. Suppose we had taken as a point of departure that poor nutrition among the poor is really the key issue, leading to diminished cognitive function as an agent in the maintenance of patterns of poverty. No matter. Neurofeedback would still be the remedy of choice for the deficits that already exist on that account. Suppose we had started with the posture that addiction is the real scourge of the underclass. No matter. Neurofeedback would still be our preferred answer. Suppose it were said that obesity is really the cause of general ill health among the poor, mental health included. No matter. Neurofeedback would still be the remedy of choice for eating disorders.

Finally, suppose it were true that one factor overrides all of the above factors combined in its health impact. Then surely we would not countenance slippage in this one factor as we addressed all of the others. That factor is socio-economic status itself. When all the obvious risk factors are accounted for (obesity, smoking, drug addiction, poor nutrition, etc.) nothing has a greater impact on the health of the poor than poverty itself. In fact, it exceeds the impact of the top six individual risk factors combined. So we dare not steep people further into poverty as the price of getting our help. There is no boot-strapping out of this problem. There is only the Commons. There must be a societal guarantee of access to care. There must be a different service delivery model that allows for universal access.

What shape might such a service delivery model take? The self-regulation approach must quite simply become largely a self-care remedy. Professional guidance must be provided at the outset and along the way, but the bulk of the work must be done without a high-priced professional in attendance. This is obviously not relevant to most of the people who currently come to our offices, but it can be quite relevant to most of the poor. This is particularly so insofar as we need to move away from a “pathology-based” model anyway. The poor do not wish to consider themselves in the framework of a mental health model. They must be approached in an optimum-performance or educational model. Such an approach cannot have a mental health price tag attached to it.

The device that comes closest to filling the bill here is something like the personal ROSHI. It does not come across as a medical device. It is not diagnosis-specific. It is does not have to have a mental health professional in attendance after an initial trial. One does not have to travel across town to get access to it. It can handle the whole family’s needs. When needs extend beyond that, one can transition to full-bore neurofeedback, but largely on a remote-use basis.

It is the Commons without Tragedy, the Internet, which will make this all possible by allowing for the occasional involvement of the therapist on an as-needed basis. We have just this week completed our “remote-use” symptom-tracking program where remote users of neurofeedback can input their symptom ratings. The clinician can then inspect the cumulative data and note trends. The time demands fall largely on the client who has to enter the data. The clinician can review progress efficiently, and on his or her own schedule.

The other necessary advance in this service delivery model is the full transition to QEEG-based training. This may sound jarring to those who have been listening to our message over the years, but the only hope of making the training relatively autonomous lies with shifting the burden to a more self-referential way of working, namely on the basis of information that is available in real time in-session. The answer lies in a more comprehensive QEEG-based model. The difference between then and now is that this information will not pass through the intellectual digestive system of a knowledgeable authority on QEEG. The intelligent observer of the data will be encoded in software.

It is truly ironic that the field has divided in the way that it has, with the heavy hitters–psychologists all–lining up on the side of QEEG-based training, whereas the symptom-based approach, which is the one that actually requires the mentality and sensitivity of a clinician to implement, is disparaged. It is, of course, through the QEEG-based approach that the mental health professional will most likely render himself largely irrelevant to the ongoing neurofeedback process. Most of the information needed for training is available in real time, and does not require anyone to inspect it, to spill any words about it, or apply any English to the findings.

The software shall provide. We shall be training the brain using algorithms of increasing competence, as NeuroCarePro is already beginning to do. The brain shall recognize itself in the proceedings. It will not only be engaged, but ultimately it will be enchanted. Mental health will ensue.

So, will the mental health practitioner be edged out of the scene? Of course not. Consider again the example of the Internet. It may be essentially free, but each of us is most likely paying a lot per month for “communication,” and a lot more than we used to when it was just Ma Bell. Similarly, increases in utilization of mental health services brought about by our clinical success will lead to growth in all aspects. If we want to be the first resort for mental health conditions, then we have to offer the lowest-cost solution. As in the case of the Internet the cost breakthrough has to come first. Then utilization follows. And from utilization comes prosperity for all. No one is stealing anyone’s bacon.

By hitching a ride on the Internet revolution, neurofeedback can benefit from the growth of the Commons without the tragedy.

This entry was posted on Thursday, September 29th, 2005 at 11:07 pm and is filed under Application of Neurofeedback, Professional Issues, Software Related. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.