A Neurofeedback Service Delivery Model

by Siegfried Othmer | October 5th, 2005

Last week the discussion was about a service delivery model of neurofeedback that allows access by those who most need it, namely the poor. Most neurofeedback clinicians probably have no contact with the poor at all, so that message may not resonate, least of all as a way to sustain a practice. But the model also applies more generally, in a manner that hopefully touches us all.

We increasingly see “self-regulation practice” as becoming a life-long preoccupation, even for those who consider themselves quite functional. If neurofeedback is to be a part of that, then it cannot be on the standard fee-for-service basis. In that regard, our own situation was rather unusual. We originally paid something like $15,000 in 1985 dollars for neurofeedback services for our son Brian, but the need there was obvious, as was the substantial benefit derived. There was no option but to proceed. Sue and I have each done many neurofeedback sessions over the years since, and that would never have occurred if we had had to pay for every session. In our larger family, there is also the example of Sue’s father, who did neurofeedback daily for a number of years prior to his death in the early nineties due to progressive supranuclear palsy. And currently Sue’s mother is doing daily neurofeedback in her own home at the age of 94, taking a NeuroCybernetics system through its paces largely by memory. For most people, this could not happen if services were charged on a retail basis.

Increasingly in our clinical work we are dealing with conditions for which there is no twenty-session or forty-session answer. Here too we must arrange for the longer-term continuation of the work on a more affordable basis. Whatever techniques we employ, the work of training tends to acquire some routine, and the necessity of having a clinician standing by at any moment diminishes over time. That needs to be reflected realistically in the services offered and in the pricing.

Increasingly also, our work involves families whose lives wrap around a variety of therapies for their impaired child. Much of the burden of execution of these therapies falls to the families themselves. Neurofeedback then becomes just one more thing for the parents to fold into the child’s schedule and to supervise. Only the occasional re-connect with the clinician is necessary to maintain progress.

The objective in psychotherapy is to allow the client to acquire competences and insights that permit graduation out of therapy. By the same objective, in neurofeedback we should confer self-regulation awareness and self-regulation skills on the client to the largest degree possible, and insert ourselves into the situation only to the degree that is necessary. This has been the tradition in peripheral biofeedback all along. Recruiting the individual into the enterprise of self-regulation was actually the heart of what was done for anxiety disorders and other conditions. Heart Rate Variability training can be accomplished by focusing on the data or equivalently by focusing on one’s emotional state. A big part of traditional biofeedback is simply enhancing awareness on the part of the client.

The whole biofeedback field has reflected these two perspectives throughout its development: being data-driven on the one hand and mediated by awareness on the other. In neurofeedback we have tended to be more data-driven, but the vast majority of conditions encountered by mental health professionals can be managed through “awareness-guided” neurofeedback. This allows the client to assume an increasing level of responsibility for his own work. As for the data-driven part, the availability of fat pipes into the home remove any barrier to remote data acquisition. The experience of Telemedx over the years in remote analysis of clinical EEGs has shown that this is quite possible even over the modest bandwidth of standard telephone lines. We face no such barrier any more, and our data transmission burden is also not much greater.

An Economic Model

We have previously identified two major thrusts in our economic life that are relevant here. The first is the increasing power of the consumer, and the second is the trend by the economic elites toward making nearly every aspect of our lives a paid-for experience. We have seen the power of the consumer particularly in three domains: telephony, air travel, and alternative medicine. Some 64M subscribers to Skype, a Voice-over-Internet-Protocol telephone service, were sufficient to break the back of telephone industry monopoly pricing, even though the industry has just put in place some $100B in infrastructure. The airlines seem to be always $5-10 per ticket short of making money. Why is that problem not easily solvable in such a highly concentrated industry? It is because pricing is actually being controlled by the smaller, more marginal players. The more than $40B annually poured into alternative health care on a self-pay basis is largely consumer-driven. More mail was received in Congress on the food supplement bill than on any other issue, including the entire Viet Nam War. The aggregate sum actually doesn’t amount to very much. We spend more on lawn care in this country, and we spend more than that on our exercise gyms. But it will soon be enough to break the pricing models of the medical monopolists.

The answer to the reimbursement challenge is to avoid it entirely in our planning for future developments. There is no way that the reimbursement gatekeepers would allow the evolution of the above comprehensive kind of service delivery model. Avoiding this trap will allow us to evolve something much more wholesome for the client and for the clinician as well. The latter will simply shift toward being supported by a much larger base of clients with whom he or she is in more remote and less frequent–but hopefully more enduring–contact. This process is already well underway in our own office, as the intensive initial training is increasingly complemented with continuing remote use until the goals of training are reached.

Significantly, this model is being spear-headed by some of our most impaired clients, where the need for long-term training is least in question. Although this turns out to be quite challenging to manage remotely, it is possible to do. So with respect to any less seriously impaired client, matters should be even easier to manage. If the whole family is involved in the training process along with the “identified patient,” then there is further hope that the whole family will “adopt” neurofeedback going forward.

Which Way Neurofeedback?

With this as background, can we look forward and anticipate whether neurofeedback will fall into the classical pattern of monopoly medicine, with pricing controlled by the elites and access limited by economics, or whether it will fall into the pattern of near-universal access with a much lower pricing niveau? Consider that all common prescription drugs can currently be purchased on the web. Consider that our nursing shortage in the US is being met with physicians from the Philippines who can make higher income here as nurses than they can as physicians back home. Soon they will discover that they can make money in the Philippines by attracting the American customer to them for elective surgeries and cancer treatment. For many years already, Polish Americans have been traveling to Poland for cheap health care. Monopoly medicine is having a hard time even shoring up its core competencies.

Monopolistic pricing regimes are increasingly difficult to sustain in the modern economy. Given that neurofeedback can be done by such a large variety of means, it will be exceedingly difficult to control. It is for this same reason that investors have been hard to come by in this field over the years. There was no way in which they could guarantee themselves a market advantage for their investment since exclusivity was not to be had.

Given the likelihood that asserting control over this field will fail, it would be nice to simply avoid the grief of the battle and to let the natural evolutionary forces work their way. Technological development should be allowed to flourish without the Damocles sword of regulation overhead because the technology is intrinsically low-risk. The professions should be able to adopt neurofeedback as they see fit. Or not. In the entire history of mental health, there has not been a single instance of a major professional development that we did come to regret as being too limited in perspective. Privileged position was never deserved. The arrogation of power by the presumptive elites was always arbitrary.

Neurofeedback comes closest to the essential breakthrough that is needed for a more humane mental health environment. Yet there is no existing professional group that would be a natural and worthy custodian of this field. There is no existing discipline that can naturally “contain” or “encompass” neurofeedback. The new insights we are gaining are boundary-breaking, and they should not be encumbered by professions who are institutionally all about setting boundaries, and about shoring up their own position in the health care food chain. Every existing authority is by its very nature mainly retrospective in orientation, being based on concepts that are already established. Such existing authorities should not be looked to for the nurturing of ideas that could constitute a threat to the established order.

The two alternative futures:

Remarkably, it was the person now revered as the father of American psychiatry, Benjamin Rush, who argued for medical freedom as a matter of right: “The Constitution of this Republic should make special provision for Medical Freedom as well as Religious Freedom….to restrict the art of healing to one class of men and deny equal privileges to others will constitute the bastille (prison) of medical science. All such laws are un-American and despotic.” (Rush had been a signer of the Declaration of Independence. He was also the personal physician of President George Washington, and was responsible for nearly bleeding him to death. No one is perfect.)

Rush was not able to get his idea of medical freedom into the Constitution, or indeed into the Bill of Rights to follow. So where has this gotten us? In 1996 the physicians attending the meeting of the Federation of State Medical Boards (FSMB) jointly opined that “all practitioners of chelation therapy, homeopathic medicine, naturopathic medicine, and the food supplements industry, as well as the alternative medicine device industry are scandalously fraudulent in all of their practices and must be completely shut down as quacks, and prosecuted with law determined to put practitioners and companies in jail for years.”

It will be observed that this did not happen. There have been occasional rear guard actions, but most have been against “apostates” within the licensed professions, not rogue practitioners outside of them. Robert Sinaiko is a case in point; Eric Braverman is another. In the Bill of Particulars raised against Braverman, for example, by the New Jersey Medical Board that suspended his license, we note two complaints in particular:
2. That young children with violence, aggressiveness, and rage disorders may not need a brain map; and
4. That head trauma patients do not need a brain map.

The argument was much stronger, of course. The implication here is that merely offering brain maps as being useful in these conditions was already going beyond the canons of medicine. More recently, the same charge was brought in California against Daniel Amen with regard to SPECT scans. All three MD’s, it will be observed, are still practicing medicine, and their “rogue” practices are increasingly becoming accepted. Regulation indeed established a bastille for medical science, empowering the mentally catatonic elements within each field. This regulatory mentality is increasingly out of step with modern trends toward inter-disciplinary science within a context of a faster pace of technological innovation.

In our own field we have already survived one siege of attempts to lock up the technology, namely by means of patents. That’s probably worth another newsletter, but for the moment it is sufficient to point out that this scourge was a real setback to the field at the time, involving a huge distraction of technical talent and major misallocation of resources, but it ultimately left hardly a trace. As a result, our technologies are all gloriously in the public domain. The attempt to lock up a technique that on its face requires less sophistication than driving a car will likewise be doomed. But given the history of acrimony in this field, it is only too likely that the lesson will have to be learned painfully. Shades of civil war in Iraq.

The patent battle had something in common with our current pre-occupation with regulatory issues. It was the first attempt to use the instrumentalities of government to clobber the competition. More recent invocation of the Grand Inquisitor, the FDA, and of State Licensing Boards has much the same objective, that of recruiting the resources of government to snuff out the non-elect. (Within their limited sphere, licensing boards operate with the authority of law.) There is a built-in contradiction here. Neurofeedback cannot reach its full flower except as part of a process of empowerment of the client. This is fundamentally antithetical to a traditional authoritarian model.

The traditional medical model is incapable of shedding its authoritarian orientation, rooted as it is in asymmetric power relationships. The fundamental difference that alternative health care has made in this country is in proceeding out of relationship rather than out of a position of authority. Now the clinician too is empowered through neurofeedback by virtue of an enlarged skill set. But at its best neurofeedback should be seen in its own terms, not in terms of a pre-existing framework. Neurofeedback takes us closer to how nature actually behaves. Interposing our prior models just interferes with the message and the process.

The above discussion has been largely in terms of a market framework. In a legal framework, the customer is also coming to be in charge. With help so accessible as it has become with neurofeedback for historically intractable conditions, access to care becomes a right as a matter of social equity. Since this need simply cannot be met within a traditional pricing environment, the innovative neurofeedback practitioner must be granted a derivative right to meet the obvious need with an equally obvious remedy.

Our glimpse of the future

In summary, we take it as a given that in a field in which a wide variety of options will be available the customer will be the controlling decision-maker, not the service provider. That power shift is most likely inescapable. If not even Delta Airlines can control its fate, then neither can the local mental health practitioner, even if he smites all his competitors. The likely unfolding of the neurofeedback future is that there will be a variety of techniques available to the client, each having its own requirements for levels of professional support.

At one end we have the usual temp and GSR devices and alpha trainers that anyone can purchase over the counter (OTC). This class also includes Audio-Visual Stimulation devices, and will come to include HEG and pROSHI. Then we have the remote-use EEG neurofeedback systems, which will involve only occasional clinician intervention. Also in this class are devices like the Alpha-Stim CES system and the Enermed for use with migraine and M/S. HEG and pROSHI would fall in this class for clinical applications. And finally we have the full-bore clinical systems. Success in each domain will create demand in the other domains. The growth rates will therefore be coupled. No advantage for clinical service is to be had by hindering the growth of remote use, and no advantage for remote use will be had for hindering the access to OTC devices. After all, the entire world is vastly under-served with respect to identified mental health needs at all levels. We have the choice of moving toward this delightful future jointly, or we can fight about it separately.

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