Neurofeedback and the Professions

by Siegfried Othmer | December 22nd, 2005

The current newsletter is a continuation of a thought process initiated with the previous one. What is the pathway by means of which neurofeedback can enter the professions without unleashing a variety of turf wars among the varied mental health disciplines, and while respecting the rights of the public? I proceed into this discussion in the firm belief that neurofeedback cannot succeed except through professional tutelage, sponsorship, and management. It cannot, for example, succeed simply as a grassroots movement among end users or, to push the metaphor, as a prairie fire through a public suddenly sensitized to its need for neurofeedback and apprised of the benefits thereof.

The second proposition is that whoever controls the instrumentation controls the field; so in order to prevent a scrimmage around the issue of who controls neurofeedback, both the technique and the instrumentation must be made part of the commons of mankind. No football, no scrimmage. That in turn means that the professions must distinguish themselves by virtue of added value, incremental competence, and integrative perspective, not because they control access to the technology. There will be objections to this on the basis of the claim that only the licensed professions can be counted upon to act in the public interest, and to protect that interest. It will be my disagreeable burden to point out that the professions do not have a history of doing any such thing, and give no sign of doing so now.

1) Neurofeedback must have professional sponsorship

A recent discussion on one of the lists mentions the high effect size that could be achieved with autogenic training in connection with pain management. Remember autogenic training? It actually came first, well before EEG biofeedback and before peripheral biofeedback. It had the benefit of sufficient efficacy to have put the self-regulation regime on a strong footing in health care. This did not happen, and in retrospect this was likely due to the fact that there was insufficient motive force to propagate the technique through the professions. It was if anything too accessible. One did not have to be a specialist to learn the autogenic phrases, and to deploy them appropriately. Nothing would set the “autogenic training specialist” apart. There was no identifiable professional path to success.

The method is still in use in various practices around the world. I understand that there are still international conferences around the method. Attendees are now coming by and large with white hair. In biofeedback circles, it is taught perfunctorily, and then one moves on to the real goods, instrumentation-based biofeedback.

A second example is the field of audio-visual stimulation (AVS). Not long ago we were all exposed to ads in airline magazines for various light and sound technologies that promised much, and improved IQ besides. Eventually these devices fell by the wayside, yet we suspect that in individual cases all those claims could probably be verified. The power represented by that technology was not matched by competence in its use. People would use the L/S techniques somewhat randomly, and most would end up missing out on its potential. The good that was accomplished was submerged among the ordinary, and things did not propagate beyond a core of aficionados. Professional leadership was missing.

A third example is Thought Field Therapy, or the Emotional Freedom Technique (TFT or EFT). Here is a simple technique that can be used to disrupt patterns of physiological responding related to phobias, anxiety, fears, etc. One might have thought that once the technique was surfaced it would spread universally through the mental health community as yet one more tool in the arsenal of psychophysiology. In fact, it has progressed somewhat fitfully, given the absence of any real barriers to entry, and a dearth of contra-indications or negative side effects. The technique is, at worst, innocuous.

A fourth example is the Feingold Association. Now it should be stated at the outset that even the Feingold Diet is no longer what Dr. Feingold initially had in mind. The Feingold Association is now a group of volunteers concerned with the impact of food additives in general on behavior. Since they offer nothing more than information, the operation has to sustain itself through donations. Despite the importance of its cause, the organization has been marginalized. There is no product to sell. There is no profession whose good fortunes are tied to the success of the Feingold initiative.

Techniques like the above tend not to flourish in the absence of strong professional sponsorship, even though there is no barrier to access by the public. When it comes to autogenic training, TFT/EFT, EMDR, relaxation training, and even hypnosis, the basic competence to replicate these techniques walks out the door with the client who has been exposed to them. Yet we do not see a diffusion of competence in the user community at large. When it comes to techniques like Heart Rate Variability training and AVS, there is at least an instrument around which things orient, and there are organizations behind these devices pushing them into the marketplace. Still, they remain marginalized. There was an initial flurry of interest around Heartmath and the Wild Divine, and then interest subsides.

New technologies like this tend to flame out like meteors unless there is an abiding professional involvement that sustains public attention and interest. Some years ago the question was asked why oil spills couldn’t simply be burned off at the ocean surface. It was pointed out that one crucial missing ingredient was a wick that would mediate the process of vapor formation from the oil that would then sustain burning. The same thing is true of candle wax spilled on the kitchen table. It cannot simply be lit with a match. It needs a wick. The professions provide the wick to keep the flame going on any of these technologies. They keep the information flow going; they provide the assurance of authority to the skeptical mind; and they keep the technique from calcifying.

The other wick in the wax is instrumentation. If gadgetry is involved then there is a commercial interest that drives things forward as well. The fields of biofeedback and neurofeedback have illustrated this very well. If it were not for the manufacturers, the biofeedback field would be in somewhat the same position as the autogenics people.

2) Control of the instrumentation implies control of the field

If the mental health professions and the instrumentation are the two tall poles in the tent, does it follow that the professions need to control access to the instrumentation to maintain professional standards, and to have some hope of salvaging credibility for our work? Is professional custody of access to the instrumentation the ideal, and if so, is that an achievable goal?

Let me take a historical perspective first. It was most certainly our view at the outset of our instrumentation development twenty years ago that we were building for the clinician exclusively. With an instrument priced at some $15,000 initially, this was not going to pencil out for home use. After some years, we started to accommodate some home use with an instrument aggressively priced at less than half of $15,000. The mass market was not on our minds with such an offering. We were filling a clear need among some of our clients for continued long-term training.

Over time there has been a shift in the clientele to those for whom the need for ongoing training is apparent from the outset. We are seeing more chronic conditions, and more serious disabilities among the children. As a result we see the integration of remote use with in-clinic training as a necessity. We use term “remote use” rather than home use to indicate that the clinician is really still in charge of this operation. To further support that view, the instrumentation is leased rather than sold to the end user. By now the field as a whole has accommodated to this kind of operation.

There is more heartburn over the possibility of home users setting up little cottage industries and wiring up the neighborhood. Professional exertions to establish the field will just pump up these little enterprises. Professional efforts along these lines will have concentrated costs, while the benefits will be widely diffused, and won’t even entirely redound to the benefit of the professions. Matters are somewhat analogous to movie companies seeing their DVDs copied around the world.

There is both a market-based remedy and a regulation-based remedy for this looming concern. The market-based remedy is for the professional to be ahead of the curve by sponsoring the insertion into the home environment under his own terms. The regulation-based remedy would be to restrict some kinds of instrumentation or some particular kinds of capacities when instruments are deployed into home use. The remote-use NeuroCybernetics instrument was always limited in its functions, and the remote-use BrainMaster is as well. So both a market-based and a regulation-based regime can coexist.

Matters are more problematic if a stronger position is taken that neurofeedback instrumentation should always remain under the control and supervision of a professional, that “leakage” into the user community is worth considerable effort to forestall. The argument here has to be made on the basis of risk avoidance or the lack of competence on the part of the end user. The competence argument is the one most easily dispatched. Even if one were to argue that the software presently does not offer the end user sufficient handrails for autonomous operation, it is certainly in prospect that in the near future the software will be sufficiently competent. So if there is indeed a problem here, it is largely a transient one, and the more benign remedy is to adapt the software for more margins of safety.

It is ironic in that regard that the strongest case for professional supervision of neurofeedback comes from the quarter that insists upon QEEG-guided training even in cases of ordinary, broad-spectrum disregulation. It is, after all, QEEG-guided training that can be most readily “manualized” and operationalized in software. Whatever is observable in the steady-state is also observable in the moment, or at least over the course of a session. An adaptive technique “learns” from the EEG over the course of a session, and no human hand need intervene. Thus the training methodology held out to be the most rigorously and comprehensively guided is also the one most easily cut loose from clinical supervision. Sorry. I am repeating myself, but the point is once again relevant in the flow of the current discussion.

It is in the mainstream of the development pathway of neurofeedback for us to derive more competent measures and more comprehensive appraisals of the variable state of regulation of the system. To benefit us, these criteria all have to be implemented in real-time systems. The clinician will not even know what is happening. Progressively, the competent end user will be more and more on the same footing as the clinician with respect to the deployment of the technique itself, at least to the extent that the EEG itself prescribes the neurofeedback protocol. As a result, the competence argument will in future largely disappear. The competence of the clinician will still be important, but mostly around the issues that surround neurofeedback.

In addition to the neurofeedback strategy that is simply responsive to what is observed in the EEG, there is the “prescriptive” strategy of reward-based training where the clinician must decide what reward strategy to employ where, and there is no way to automate that. The clinician is essential to this approach, and must be involved at least until the client’s responsiveness to each of these challenges has been characterized. So there is a natural divide here that foresees EEG-derived training to be done autonomously, and a more directive, targeted strategy to be implemented under clinician guidance. Both options can be straight-forwardly handled in the software.

We are left with the argument of risk. Does a professional need to be standing by to manage the risk of neurofeedback? And do the “ethical bounds” placed on clinical practice protect the client? So we turn to the third item on the agenda.

3) The risk of neurofeedback; and risk management by the professions

It is estimated that the cost to our society of the litigation-based approach to risk management–malpractice insurance; the cost of defensive medicine; the care and feeding of personal injury attorneys–costs the society some $200B out of the $1.6 trillion that we commit to healthcare in this country annually. (No wonder that not a single other country has followed our lead in this regard.)

However, wherever one looks into the actual cases making their way into the system, one sees situations of personal tragedy and loss. That does not always translate into medical malpractice, but that is not the issue here. The practice of medicine involves a high degree of tangible risk. We in neurofeedback are not even close to being in the same ballpark. There is no equivalent for us of people dying in great numbers from inappropriate medication dosing, or of liver toxicity, or of medication mix-ups, or of medication interactions. When we talk about risk, we are most likely talking about training non-optimally.

This may not matter much when we are up against a litigation apparatus that carries the ideal of entirely risk-free operation into the courtroom. According to some, only about ten percent of malpractice cases have substantial merit (although about ninety percent of those that would have merit are not brought…). We are not so much living in the presence of actual risk as we are living in a state of litigation risk. And that is enough to get our attention. We are aided by the fact that just as we live with “soft risk” in neurofeedback, we also live with “soft expectations.” Neurofeedback is not like obstetrics in that regard, or anesthesia, where people carry firm expectations of a discrete, successful outcome into the procedure. As long as our language continues to match the reality of soft expectations, litigation risk can be managed.

We can further partition the risk throughout the neurofeedback process. Just as in the case of medication the risk goes with the person who prescribes rather than with the person who administers, in neurofeedback the greater risk would seem to attach to those who issue prescriptions about how neurofeedback should be done in a particular case. Now those who would restrict neurofeedback most firmly to the licensed professions have curiously allowed a situation to arise in which the most risk-afflicted activity within the field is being conducted by people who are, in mental health terms, largely uncredentialed. In an almost frantic search for standards, these people have repaired to the most uncertain of standards, promulgated by people not at all qualified in mental health terms, i.e. by licensure. This represents a huge internal contradiction, on the one hand, and a major flaw in the risk management strategy, on the other.

This takes us then to the final issue, namely that the professions are needed to protect the interest of the client. In my perspective as an outsider from the licensed disciplines, this is not how the world looks to me. In the latest issue of the APA Monitor, for example, outgoing President Ronald Levant talked about visiting Guantanamo: “APA is very interested in the role that psychologists are playing in national security investigations…and will continue to advise the DoD to assure that such work by psychologists is safe, legal, ethical, and effective.” Yet another source present at the same meeting–a medical ethicist–has suggested that one of the reasons the Pentagon is particularly interested in using psychologists in these roles is that they do not have to subscribe to the Hippocratic oath. This was a major topic of discussion that day at Guantanamo. How is it that Levant did not see fit to raise this issue with his colleagues?

The story can be helped along with an anecdote. Vicki Pollock, our Director of Research at the Brian Othmer Foundation, had occasion to visit a hospital recently for a procedure. She was so offended by the manner of the assigned doctor that she later sent a letter of complaint. That letter has never been responded to, but additionally she mentioned that she had sent such a letter to another hospital staffer on the occasion of a later hospital visit. “Oh, I’m so glad you did that. All the staff know that this guy is a problem, but there is nothing we can do.” The story is familiar. The professions will defend themselves against the public far more readily than they will naturally embrace the public interest against one of their own. Errors have to be both egregious and numerous to bring about a regulatory response.

It is only recently that the Medical Board in California was required to make public its disciplinary actions. The pressure, of course, came from the outside, and matters would remain confidential if the Medical Board had its choice. The examples one could cite are legion that a guild will act to protect itself, on the one hand, but invoke the public interest in its defense, on the other. But it is not just the healthcare field; it is not just the guilds; there seems to be a general vulnerability to abuse when there are asymmetric power relationships.

Asymmetric Power Relationships

One of the cleanest experiments on the impact of status differentiation on human interactions was the experiment conducted by Professor Zimbardo at Stanford, who divided his psychology class into groups of prisoners and guards. Nothing differentiated the groups here but a bookkeeping entry in a research log, a totally arbitrary assignment, yet grave and lasting mental health consequences are still being documented from that experiment for some of those who ended up in the category of prisoner, and possibly for some of the others as well. In California prisons today, we have a virtually unbreakable code of silence in operation among the guards.

I attended a number of “Combat Stress” Conferences being held for reservists at Camp Pendleton, and on several of these occasions, the stress was only too real. One exercise was a simulated takeover by a Palestinian contingent. Even though the abuse was largely verbal, the psychiatrist who had invited me had no doubt that the victims were being traumatized. Everyone in the room was a soldier, and was therefore a candidate for being drawn into these proceedings. The play-acting takeover artists gave themselves permission to make it quite real. As a further element of realism, they had picked out the Jews in the audience. Said the psychiatrist: “We can do anything we want with the soldiers.”

We now understand that the division of the Rwandans into the Hutu and the Tutsis was largely an arbitrary one by the Belgian overlords. What started out as nothing more than another bunch of bookkeeping entries ended up in genocide of one group against the other. An arbitrary power asymmetry had become very real.

Thom Hartmann has pointed out that high birthrates in emerging countries is not so much a function of prosperity as it is a matter of the woman’s power of decision over her own child-bearing. High birth rates are another manifestation of power asymmetry. Incidence of physical and sexual abuse of women ranges between 20-75% in a number of countries. Four out of five abusive acts are by the partners. That is to say, they occur in a climate of perceived power imbalance.

U.N. peacekeeping forces are established in a number of countries, and now we find that a mystique of hyper-masculinity and the existence of yet another code of silence has allowed a climate of rampant sexual exploitation to flourish among them.

A California hospital was recently exposed for having a dysfunctional liver transplant program. Explanations abound, and the issues were indeed complex. But the fact remains that the program fell short of all goals set by monitoring agencies, and many patients waited in vain for livers. The hospital continued to give the appearance of a functioning program when that did not exist. Many died waiting for livers that would never arrive. A UC Irvine oversight position remains vacant after a previous hire abandoned the job almost immediately, having realized that the position was mere window-dressing.

Some 900 foster children have gone missing in Los Angeles just this year. A task force established to find them was just recently dismantled. The Los Angeles Times just did an expose on the scandalous status that prevails among conservators for the elderly.

One could cite also the sexual abuse scandal within the Catholic Church. A priest is now suing the Church for having been terminated when he spoke out against the cover-up of the abuse years ago. Once the Church had decided on official silence, it was increasingly in a bind. Matters are similar with regard to the manifest risk of vaccines. The official position is quite indefensible, but how does one acknowledge error now without unleashing a nightmare of recrimination?

Several features can be abstracted from these power imbalances. The impact is greater the greater the asymmetry in status, and the impact is greater when the absolute power of the weaker party is minimal, as in the case of children, the severely ill, and the elderly.

On the basis of the historical and continuing experience with asymmetric power relationships, I would argue that the hazard to the underling overwhelms the remedy, namely standards of ethical behavior. The existence of power asymmetry mandates ethical standards as a response, but the existence of such standards does not make power asymmetry the preferred state of affairs. It does not improve matters to put people into a more asymmetric status on the argument that their behavior will be constrained by codes of ethics.

If there is any doubt along those lines, then let me also mention that in the State of Massachusetts malpractice premiums for psychologists were majorly reduced after a new law went into effect prohibiting psychologists from touching their patients. The resulting decrease in malpractice suits showed up so prominently that rates had to be reduced to stay within regulatory bounds.

A code of ethics is like the levees in New Orleans. They were designed for conditions that can be reasonably anticipated, not for the worst that can be imagined. During a storm surge, overtopping can be expected, but the city will not drown. Similarly, isolated ethical breaches can be managed. In practice, however, codes of ethics are like levees that are never inspected for integrity. As long as they are not challenged, they give the appearance of being protective, when in fact they are already broken.

The only way to assure that codes of ethics are both reasonably self-enforcing as well as externally enforced is to accompany them with transparency. But this is hardly possible given the inherent intimacy and confidentiality of psychodynamic therapies. The other alternative is to empower professionals by virtue of competence rather than mere status. Insofar as status remains, as it will, the power asymmetry should nevertheless be minimized. In the meantime, use of the code of ethics as a defense of the professions should not be overdone, lest we drag out more disagreeable data from the wretched past of the mental health field in rebuttal.

The final argument to be made in favor of restricting neurofeedback entirely to the licensed professions is the tutored competence to be found there. Every professional has gone the route of being inducted into a particular professional tradition, with shared assumptions, a common vocabulary, and integration into a set piece of established norms for relating to allied professions.

The trouble with that argument is that in the ambient cartography of mental health, every profession has grown vertically and not laterally, like fir trees in a dense forest. There is no connectedness. Every profession seeks to bring a relatively homogeneous worldview to bear on a heterogeneous health enterprise. Every affected profession can rightfully say that it is in a position to bring unique insights to neurofeedback, none more so than the psychodynamic tradition. What speaks more loudly, however, is what each discipline excludes from the discussion. Collectively the missing pieces in each case add up to more than what is being brought to the table. That is to say, the negatives outweigh the positives, regardless of who is making the claim. The silences speak louder than the utterances.

An example tells the tale of mono-dimensional thinking. In Great Britain a mother must be brought up on charges of child neglect if more than one child in the family succumbs to SIDS. The presumption is that the mother’s parenting, or lack thereof, can be the only significant common element here, thus mandating her indictment. In a mental health perspective, this may make some sense–neglect at least has to be considered. But those who know of medical risk factors for SIDS would consider the hypothesis absurd. What about the presence of a chain-smoking grandmother in a small apartment? Prematurity? The list could go on.

The greatest need is to embed neurofeedback in an integrative perspective, and there is simply no existing professional community that is prepared to step up to this task. Under the circumstances, any current claim to proprietorship of neurofeedback must be found wanting. It is in the nature of the neurofeedback process at its best that the person undergoing the training should feel empowered thereby. This naturally militates against any power asymmetry that may exist at the outset. The diffusion of competence similarly militates against the mounting of an adversarial proceeding against the clinician. The liability for what transpires no longer resides entirely with the clinician. The client assumes an increasing burden of responsibility for what happens in the training. Neurofeedback itself, rather than licensure, is the natural antidote to the litigation leviathan. By contrast, rather than serving as a bulwark against litigation, licensure attracts it.

The final argument for vesting the ultimate responsibility for neurofeedback in the client specifically and among the public generally is the potential for mind control. With the discovery of the malleability of aspects of the self, of the alterability of memory, and of our capacity for the management of states, mere disclosure forms and the usual “informed consent” just don’t cut it anymore. Clients must have sufficient understanding of the process that their “provisional assent” throughout the training is actually a meaningful decision, not a relinquishing of their decision-making before a more august authority.

Summary and Conclusion

Progress in neurofeedback depends upon the central role played by the professions. Yet neurofeedback does not have a natural home in any one discipline. It must diffuse into many. It would be ideal if turf wars could be avoided over an issue of control that can never be won by any one discipline in any event. One way to avoid turf wars is to assure that custody of the instrumentation cannot be lodged in any one profession. This means that instrumentation issues must be decoupled from licensure in general. Specifically, neurofeedback instrumentation can be made part of the commons from which all professions can draw. Neurofeedback will eventuate in devolution of the locus of power to the client. The resulting reduction in power asymmetry is not only good for the client; it is also good for the professions.

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