Neurofeedback in the mental health disciplines

by Siegfried Othmer | January 11th, 2006

Someone just drew our attention to the position taken by the American Academy of Pediatrics on certain alternative approaches to ADHD. (
We quote from the website:
“The following methods have not been proven to work in scientific studies:

  • Optometric vision training (asserts that faulty eye movement and sensitivities cause the behavior problems)
  • Megavitamins and mineral supplements
  • Anti-motion-sickness medication (to treat the inner ear)
  • Treatment for candida yeast infection
  • EEG biofeedback (training to increase brain-wave activity)
  • Applied kinesiology (realigning bones in the skull)”

Now most of us with long-term experience with ADHD are aware that all of the listed techniques are quite clearly effective in some children. Developmental vision training can be so helpful to a child that ADHD symptoms subside. Many mental health conditions, including ADHD, are known to respond profoundly in specific instances to megavitamin, mineral, and Omega 3 fatty-acid supplementation, or to detox in the case of the heavy metals. For years various practitioners have challenged the vestibular system with subtle, gentle, sustained movement in order to effect improved cortical regulation; it would not be entirely surprising if the administration of anti-motion-sickness pills to that same subset of kids might be helpful in achieving the same ends. Children with florid candida overgrowth may well exhibit depressive or under-arousal-type ADHD symptoms that subside once the condition is managed. And applied kinesiology may simply be mischaracterized (even by its proponents) as being about the realignment of bones in the skull. Kinesiology methods of adjustment may be just another pathway to reordering the brain’s regulatory function.

Conversely, any of the ADHD children coming to us for neurofeedback may be afflicted with one or more of the physiological deficits implicit in the above remedies. There are many more that could be listed. There is Irlen Syndrome, first of all. There is auditory processing disorder. There are food intolerances. There is blood glucose dysregulation, and there is thyroid dysfunction. We do not require of ourselves as practitioners that the professional competence to deal with all these other issues should necessarily be available on-site where neurofeedback is being done for ADHD.

The flawed observations flow from a flawed model of ADHD. When ADHD is seen as a homogeneous condition, then there should also be a homogeneous remedy. And such a standard remedy should clearly stand up to the classical group designs by which efficacy is established. But even if we are not quite prepared to jettison that essential organizing principle for the disorder we call ADHD, it should be sufficient to acknowledge complex etiology. So why then should there not be varied remedies as well, one or more per etiological pathway?

The particular aspect of ADHD that comes closest to justifying our hold on a unitary perspective on the condition is its description in mental health or behavioral terms. To borrow a phrase from John Nash, this has a certain tautological tinge about it. A behavioral phenotype is described that derives its relevance from significant incidence in the culture, and once that behavioral syndrome is described as a distinct entity, the constituent behaviors are henceforth seen as confirming the existence of the diagnosis. Providing for comorbidities and for “dual diagnoses” allows the rickety edifice of static diagnosis to lurch forward into the present even in the face of much contrary evidence.

The existence of this mental health model of ADHD can explain the persistence of a state of affairs in which obvious features of ADHD can escape detection by our medical and mental health communities. What gives the non-professional the advantage here is a necessary orientation toward an integrating perspective, one that must account for more of the data. Regardless of the degree of preparation for the task of parenting a dysfunctional child, the parent must by default slip into the role of providing the integrating perspective on her child because that will not come to her any other way.

We have come to a pass where the organizing principles for our mental health universe are now dysfunctional in their effects. The world of disregulation that we see cries out for an integrating perspective. None is provided by any of the established disciplines. This is also the reason that one might now greet with some skepticism the suggestion that a mental health professional should necessarily oversee or midwife the neurofeedback process. This is not intended as a criticism. The practitioner who understands autism from the standpoint of attachment theory is simply unlikely at the same time to understand leaky gut syndrome or worry about immune system status. Both mental health services and attention to the biochemistry may be needed for the autistic child. But neither needs to be co-resident with the neurofeedback practitioner for overall effective therapy.

We work with many people who are in the care of psychotherapists, and they come to see us for the neurofeedback. The relationship with their practitioner is strengthened thereby, not weakened, because the psychotherapeutic relationship can now function better in its natural realm, without the handicap of an obstreperous and out-of-control physiology. We also have licensed psychotherapists on our staff, but I see that as an advantage, not as a necessity, and certainly not as a condition of competent neurofeedback practice. Indeed, if the failure to attend to the mental health aspect of the conditions we work with constitutes a deficit worthy of outright condemnation, then no one would be a better candidate for our opprobrium than the typical MD, be he general practitioner or specialist! What percentage of children is ever referred out for mental health services after they get their Ritalin?

I just ran across a list of conditions for which biofeedback was held to be effective, a list which Barry Sterman used in the promotion of his erstwhile clinical practice. The list includes migraine, tension headache, essential hypertension, sleep-onset insomnia, anxiety, bruxism, hyperventilation syndrome, Raynaud’s Syndrome, some gastro-intestinal problems, pain of a muscular or circulatory nature, and neuromuscular or musculoskeletal disorders. These are by and large not conditions where a prospective patient would in first instance seek out a mental health professional.

Only with the arrival of neurofeedback did this landscape change significantly. And even then, as I have pointed out previously, researchers took care to distinguish between those conditions (those “neuro-biological” ones) for which neurofeedback was appropriate, as distinct from those for which psychological methods were necessary. This distinction is further buttressed by setting research standards that test neurofeedback bereft of any input from health professionals. They are even to be blinded, for heaven’s sake, while things are actually happening! And finally, the distinction is cemented by the fervent promotion of the idea that a single protocol can be identified from the EEG by means of which self-regulation may be achieved for that person. No mental health considerations need enter. No bifurcations or choice points are provided for. “One procedure per patient” emulates “one drug per disease.”

This same distinction has carried over into the coding for biofeedback services. Back in 1997 Bob Whitehouse inquired with the American Medical Association on behalf of the AAPB with regard to the two biofeedback codes, 90901 and 90875. Eventually he received his response:

“From a CPT coding perspective, the intent of having the two different biofeedback-related codes is to denote the difference between the use of biofeedback training versus the use of psychophysiologic therapy. The intent of code 90901 [Biofeedback training by any modality] is to denote training to help the individual gain some element of voluntary control over autonomic body functions. This is accomplished via use of a variety of different biofeedback monitoring equipment that might possibly vary from one session to another depending on the complex presenting symptomatology. Verbal and visual instruction may also be given to the patient as to how to interact with biofeedback information. The patient is also provided with directions for appropriate reduction of tension in the targeted area of treatment.’

“Code 90875 Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient) (e.g., thought-oriented, behavior-modifying or supportive psychotherapy); approximately 20-30 minutes is indicative of not only the use of biofeedback training as is indicated above, but also incorporates the use of behavior modification, supportive psychotherapy, and/or the development of insight or affective understanding.’

“Therefore, the main factor determining the use of the two sets of codes is whether or not psychophysiological training is performed. Both services utilize biofeedback techniques.”

Clearly it is envisioned here that a kind of biofeedback practice be provided for that is distinct from one that is wholly embedded in a mental health service delivery context. Regarding who may take advantage of these codes, the statement goes on to say:

“ …the codes are generally intended for use by physicians. There are, however, some procedures that may be used by non-physicians as well. Determination of the use of the psychophysiologic codes is by determination of the 3rd party payor…. The 90875 and 90101 services may be used by any provider who is qualified to perform this type of service. No distinction is made concerning the provider’s licensure or professional credentials. Licensure and credentialing vary on a state-by-state and institutional basis.”

So there we have it. Biofeedback appears to be recognized in the CPT formalism as a “procedure” that can be conducted outside of a mental health context. Mere technical competence is required, and the third-party payors are left with the opportunity to sort out whom they will reimburse for this procedure. Already we have seen insurance companies insist on “down-coding” to 90901. The race will likely be to the bottom once again.

The field as a whole has not helped the cause of a more encompassing, integrating, and humane perspective on neurofeedback. It is doubtful that the third-party payers will help that cause either. So once again the real threat to the more idealized world of neurofeedback comes from the top, both from inside our own organizations and from without. No existing discipline qualifies by virtue of its prior history or current conduct to be custodian of the emerging field of neurofeedback. It needs to carve out a unique niche for itself. That emerging reality will come to color every existing health discipline in a particular way. But such organic growth cannot happen if the field is captured by, and made subservient to, one or another existing perspective. Neurofeedback must resist early domestication.

Some of the most dramatic moments we are privileged to witness in our work are when clients begin to realize the connectedness of the issues that concern them. Some realize it as early as the initial intake evaluation. Others come to believe it through their experience of the training. Many times they will tell us, “I always knew these things were connected, but I was always told that that could not be the case.” Neurofeedback is intrinsically integrating in its essential character. Disregulation usually has a broad footprint, and the remedy should have a broad footprint as well. It is this unitary character that prevents neurofeedback from finding hospitable quarter in any existing discipline. And that is why, for the moment, it must stand somewhat apart, and we must simply be open to the insights that it yields rather than imposing on it the particular order that we may prefer. It will be soon enough that neurofeedback will establish yet a new orthodoxy, one even more unshakeable than the last by virtue of being that much closer to the way nature actually behaves.

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