A Profession of Neurofeedback?

by Siegfried Othmer | March 31st, 2005

Last year Tom Allen wrote a newsletter for us on the issue of a licensed profession around the emerging field of applied psychophysiology. We have decided to take up this issue at the meeting of the Allied Professionals
Section of the AAPB, and Tom Allen will be there to help lead the discussion.

I am personally agnostic on this issue, and just want to see happen what will be best for the progress of the field. In reviewing historical material for the preparation of our Alpha/Theta web-course I came to realize what deep roots this issue has. Even 100 years ago Hans Berger confronted the same issue. In deciding on his professional course he judged that the emerging field of neurology did not sufficiently take the mind and behavior into account, whereas the emerging field of psychiatry did not concern itself sufficiently with the data of experimental science with respect to the nervous system. Freud had made a similar judgment with regard to neurology, namely that it was simply not ready to tackle the issues that most interested him, but then he, Jung, and Adler left the brain completely out of the discussion. The legacy of this decision has carried forward to this day, causing fellow-traveler Daniel Amen to lament that ~psychiatry is the only branch of medicine that does not look at the organ it treats.~ Neurology, on the other hand, has migrated even more toward dealing with the piece parts of the nervous system and their ills, and thus the journals take them even farther from the domain of behavior and of functional medicine.

The result for Hans Berger was that with respect to the EEG research he worked essentially alone, despite having a high university position in his day job.
And even after his findings were recognized, his objective of coupling the realm of behavior and psychophysiological measures did not bear fruit at that time. Had he been more imbedded with conventional research, had access to funding, and been surrounded by eager graduate students, he might well have found much better ways of discerning the EEG than with galvanometers, and it would not have taken him so many years to finally observe the signal he was looking for. Also his inspiration might have been transplanted to a new generation of researchers.

As it was, when Joe Kamiya set a similar objective some fifty years later, the world was not particularly more hospitable to such inquiries. Kamiya was almost as much off on a tangent as Hans Berger had been. And when Sterman published his results, there was simply no context within science that allowed that work to be appraised. The EEG had found only a minimal role within medicine, a role where profound new insights were not to be expected. Tying the world of behavior~even sleep behavior~and the waking EEG together was a novelty.

So would the establishment of a licensed profession around psychophysiology finally yield a level playing field, correcting an imbalance that has existed for more than 100 years? Is licensure needed to give cohesion and focus to a discipline in which nearly all participants have their primary loyalties elsewhere? Or is this proposal late to the party, as the world is already on the threshold of accepting the objective of ~integrated medicine,~ of functional medicine, of ~electromedicine~? Does the ~Self-Regulation Remedy~ require the status of sponsorship by a licensed profession to carry the flag, or is the Disregulation Model something that will simply marble through all of the health professions, and influence all of them? Is the knowledge we have gained something that can remain the unique province of a certain cadre of professionals, or must it become the universal knowledge base of all health professionals? And even if the latter is the case, is there at least a transient role for a dedicated, trained group of professionals with psychophysiology as their primary distinguishing expertise, before the nirvana of universal acceptance can be reached? On the downside, would the establishment of a profession give this field a ~procedure-focus~ or technical preoccupation that simply sells short the complexity of human behavior in yet another dimension? Would licensure promote the very compartmentalization that the Disregulation Model leads us to break down?

In all of these speculations, we should not delude ourselves into thinking that this issue is actually under our control. But we should at least have the issue in mind. A movement toward licensure would mobilize opposition by the existing licensed professions, and it would also further disadvantage unlicensed professionals. There would have to be a rather substantial thrust toward licensure, and the existing body of professionals does not give any sign of being capable of such organized behavior. Most likely such a movement would arise only out of reaction to an attempt by mainstream professionals of one stripe or another to appropriate this discipline as their own. Up to now we have had principally intra-mural regulatory issues~psychologists and MDs accused of acting unprofessionally by their own boards for offering neurofeedback. Recently, we have had a case in which a non-psychologist has been accused of practicing psychology without a license because he was doing neurofeedback. This may be the beginning of a trend.

On the positive side, licensure would establish a pathway into this field with a more assured outcome. Academic programs would organize to serve this community, and reimbursement issues would clarify. Conceptual unification would be more likely to occur among the disparate thrusts in the field. On the downside, the regulatory mechanisms that would build up around the new licensure would also work to enforce a clinical uniformity, and such uniformity could be detrimental to the most creative forces currently operative in the field. We would have the BCIA with real teeth. On the other hand, the movement toward licensure would likely take some time to bear fruit, and by that time the essential new departures that need to be nurtured will all have taken root.

The most likely outcome is that the existing professions will adopt the insights from psychophysiology. We have just had an example of this in psychiatry, which moved from a totally psychodynamic perspective to a thorough-going biological model without changing the sign on the door.
Accreting the bioelectrical modalities is not that big a leap, and psychiatrists would do so adroitly if the reimbursement environment were more favorable. Psychology has in store for it a similar kind of revolution, irrespective of any licensure in biofeedback. Neurofeedback is simply too effective to be ignored by psychologists for very long. The market will more and more shift our way, and at some point that will begin to bite.

There is an obvious coupling between the issues of licensure and reimbursement.
In the case of chiropractic, naturopathy, and acupuncture, licensure came before reimbursement ramped up significantly. In the case of biofeedback, the world is already full of professions who stand ready to lunch off any improvement in the reimbursement environment. It would seem that if reimbursement rates ramp up in the near term, any movement toward an independent licensure would meet headlong opposition. Licensure may only have a chance if reimbursement rates remain uninviting for some time to come. In other words, licensure can only happen if nobody else really cares very much.

Ironically, then, both those who wish to see the field move in the direction of licensure and those who want to maintain its status as an unlicensed discipline should be united in the objective of promoting growth outside of the reimbursement environment. With reimbursement inevitably comes a slide of the field into strong hands, which would be those of the existing licensed professions. Such a trend can be resisted only if a counterforce of licensure already exists. It would be too late at that point to get it started.

If the space, time, and opportunity in which licensure could get started is limited, one needs to ask why this hasn~t happened already. As one looks at the history of the field, one sees it curiously dominated by an atmosphere of stasis. Even by some of its most devoted leading practitioners, biofeedback and neurofeedback seem to be treated as something of grace note in the mental health field rather than as a core truth and as an organizing principle through which all of mental health should be viewed. The field is already dominated by folks whose primary professional identification is elsewhere. In sum, then, there doesn~t seem to be the environment suitable for the kindling of a new thrust toward licensure, one that would take the energy of a whole lot of people. And if the movement toward licensure does not take place soon, then it is unlikely to happen at all. I will report again after the meeting on Friday.

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