The Reality and the Promise

by Siegfried Othmer | September 21st, 2006

The entire research agenda for stem cells is at this moment still based on a promise and an expectation for a big payoff downstream, on some uncertain timescale. There is nothing wrong with that. No one is putting conceptual barriers in the way with the argument that there is insufficient experimental support to go forward. Even the recent major research scandal in South Korea did not nick the halo of stem cell research. This work quite simply has the benefit of belief on the part of the scientific community.

Consider now the comparable state of affairs in neurofeedback. Here we are variously told that the data are insufficient to support our claims. But implicitly we are also being told that neurofeedback is insufficiently promising to be worth pursuing in research. That is the real message. But to be interested in neurofeedback research going forward, you would not actually have to have any data at all. You would simply need an intriguing hypothesis, just as in the case of stem cells. All you would need is the hypothesis that brain function could actually be influenced by means of operant conditioning techniques, for which the implications are so huge that it mandates investigation.

But that is not what is happening. And it is not happening despite the fact that data in support of the above hypothesis is piling up on all sides. This simply cannot be due to a concern about the placebo. The placebo hypothesis is a red herring in this issue. After all, the placebo model is not capable of negating, or ruling out, the posited hypothesis!

Let’s make this argument as simple as possible.
Imagine some children playing with their sleds on a hill fresh with snow.
After lugging their sleds to the top, some kids put their sled down and it starts downhill spontaneously. They have to jump on quickly or it goes on without them.
Other sleds need a push to get started.
The fact that some sleds slide down the hill spontaneously does not take away from the hypothesis that pushing the sled succeeds in sending the sled down the hill.
Of course it may not always succeed. Some sleds are put down and freeze into place, making them difficult to dislodge. (Maybe somebody just peed in the snow.)
But it is actually not very difficult to reach agreement on the proposition that pushing the sled down the hill makes a difference.
Even if nearly every sled starts down the hill spontaneously, the case could still be made quite readily that giving the sled a push makes a difference.
First of all, we would discover a proportionality.
The bigger guys give a bigger push and get the sleds going faster.
And even when the sled has already started to move on its own, it can still be pushed to move even faster.
And if anger flares up among the group of children, we find that it is even possible to hinder the progress of the sled down the hill, and no degree of spontaneity on the part of the sled will make any difference.
In other words, the push can be used to exercise bilateral control. Spontaneous movement is not like that. We will never see the sled start spontaneously to move back up the hill.
So there is a variety of means by which the child gains certainty that being pushed down the hill makes a difference. And such certainty would emerge quite irrespective of what percentage of sleds start moving down the hill spontaneously. In other words, the certainty emerges in an entirely self-referential fashion, based entirely on the child’s own experience with his own sled being pushed. The child achieves certainty in this regard through reproducibility of the event, which eventually leads to the prediction that when pushed sufficiently, the sled will move.

What happens is that a consistent worldview emerges in which the benefit of pushing the sled down the hill simply becomes a part of the child’s understanding of the world that is not at war with any other understanding of his world. The principle is self-consistency.

Matters are the same in neurofeedback. The scientific principles are reproducibility of the event, leading to predictability of outcome, leading to the investigation of parametric sensitivity, scaling phenomena, reversibility, and other hypothesis testing related to the procedure itself. Every scientific issue surrounding neurofeedback can be settled in a self-referential manner. And that of course has already happened, and we are all essentially acting in that knowledge already. So the placebo is a red herring.

The person who insists that neurofeedback has to be guided by QEEG-based information cannot at the same time feign a rational agnosticism with regard to the larger question of whether neurofeedback has any validity at all–that somehow our judgment needs to be provisional pending the completion of some suitably controlled study down the line. The idea that we are confident in the details while holding the larger issue in abeyance is just nuts.

For this group of people to tell each other precisely how neurofeedback is best done and then to say: “We really need controlled studies to be sure that we are not all deluding ourselves” is a logical inconsistency, as well as being perverse. Every particular piece of evidence also makes the case for the larger hypothesis. So the larger hypothesis always ends up better supported than the subsidiary ones. And every microscopic demonstration in favor of a subsidiary hypothesis also helps to cement the case for the larger, more inclusive one.

Our existence as a flourishing discipline is an abiding insult to the folks at the NIH who have been missing the boat. It’s not about the placebo effect at all. It is perfectly clear to our critics that what we are saying cannot be swept under that carpet. So, it is probably quite useless to expend effort to put yet more facts in front of people who are affronted by the facts that they already have. “It is difficult to get someone to understand something if his paycheck depends on his not understanding it.” There is nothing more hidebound than a scientist threatened in his core beliefs.

The NIH cannot say, when all is said and done, that just because the placebo hypothesis has not been adequately rejected there is at this point nothing for the NIH to do. They are not hired to sit in the bleachers and have research served up to them. The NIH does not have to buy into the facts in order to undertake research. They just have to buy into either the promise or the premise. The fact that they do not is a political and economic, not a scientific, reality. And such a reality cannot be altered by scientific argument. These people are not naïve, and they are not stupid. They do, however, know very well where their self-interest lies. The NIH will ultimately be embarrassed into responding, much like our Administration was embarrassed into action by Katrina. And the source of embarrassment will be what we have collectively brought into existence: the most successful mental health model extant anywhere. Congratulations, everyone.

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