The State of the Union

by Siegfried Othmer | January 1st, 2005

With the State of the Union speech coming up shortly, it’s not a bad time for us to do the same with regard to our discipline of neurofeedback. When people are asked about the prospects for society at large, they tend to assess it somewhat more negatively than society deserves, but when they are asked about their own prospects, they tend to assess them too positively. If only a fraction of everybody’s dreams were realized, what a growth rate there would be! We may be subject to the same bias. The world around us may have dim prospects, but our field is doing fine, thank you.

There is first of all a change in the attitudes with which our claims are being met. Neurofeedback is no longer being dismissed out of hand. The publication pipeline is filling up, and mainstream media are publishing articles about neurofeedback. The latest article in new Scientific American quarterly, Mind, did not even feel it necessary to issue a disclaimer: Neurofeedback is the coming thing for ADHD.

But more significantly, there are internal signs of health. This is much more important even than current mainstream opinion. The latter will come around sooner or later, at a pace that we can only marginally influence. An important question is whether this field will be ready when the press finally turns its eyes upon us. The growth thus far has been gradual, but the press is capable of generating a tsunami of sorts. And like a tsunami, press attention has two phases. The first is the buildup phase, where the topic gets swept up with the crest of the wave, and the second phase is where the receding tide carries things back out to sea, as the press soberly reappraises what it has just featured.

My favorite metaphor in that regard goes back to bar fights in old Westerns, where the villain ends up limp and practically lifeless lying across the bar, and the hero picks him up by the collar and delivers yet one more blow. The press destroys what it first lifts up. So if the question is, are we ready for this kind of whiplash in the public sphere, the answer is no. But back to the internal signs of health: It lies in our diversity. There are just so many directions into which this field is growing that it is difficult to keep up. The pace of development is more characteristic of high technology, of the software and semiconductor worlds, than of the field of mental health. We have been incredibly favored by not being in the NIH funding chain (think ball and chain), which would have just bogged things down tremendously.

By being outside of the funding environment on the one hand, and largely outside of the traditional publication arena on the other, an independent communication network had to be created in which clinicians communicate findings to each other. It took us a while to quiet the hazing, but a number of viable channels for the interchange of clinical information have now been established, and they are functioning as intended. This has introduced an informal information diffusion mechanism that was previously absent in science except within research groups themselves. The incoming President of the AAAS has recently written of the need to provide space for imagination to be at play in the sciences. The sentiment is wonderful, but how is that to happen when the journals take themselves so seriously that they can only publish the truly non-controversial material, and when the funding agencies will not gamble on anything that might conceivably besmirch their reputations? There is no open adversarial process in science. There are only the treacherous ones behind the scenes. There is no atmosphere in which the new is cultivated, and there is no platform for different views to engage, where one could find use for a devil’s advocate. The lack of mainstream acceptance, however, has also been our gain, as we have had a chance to find our footing and make our mistakes outside of the limelight. It has been possible to create the conditions of progress that most suited our immediate needs, on the one hand, and to bring about a critical mass of professional acceptance (the significant professional minority) for the boundary-breaking aspects of our new discoveries, on the other.

So let us celebrate the healthy diversity that is coming into this field, something that will make our extinction much more difficult. That diversity is to be found in our instrumentation, in our techniques, and in the range of professionals taking up this work. If there is a downside to all this, it is in the impression given that all the disagreements essentially serve to annihilate each others’ claims.Eventually nothing is left standing unscathed. While it appears that we are busy killing each other off in this destruction derby, nobody from the “outside” even needs to lend a hand.

The facts are otherwise. Every major development in this field is growing. This includes EEG neurofeedback, HEG feedback, the stimulation technologies, and multi-modal feedback. It includes mechanisms-based or symptom-driven training, QEEG-based training, and NLD-based renormalization. Systems cover the range of requiring a great deal of clinical expertise to those that require little supervision and clinical judgment. On the high-specificity, high-performance end we have the protocol-driven training of the BrainMaster/NeuroCybernetics/BioExplorer contingent, the LENS for stimulation-based training, and the Deymed and NeuroPulse for QEEG-based training. At the other end, one has the NCP, the personal ROSHI, and the HEG options, all of which involve a minimum of clinical decision-making.

All that is required in order to turn the competition among systems and doctrines into a positive for the field as a whole is the recognition that clinical success is indeed available to all. There is an almost religious quality to the belief that there has to be one right or preferred way by which improved self-regulation is to be achieved. It is simply laughable that the one field in medicine that should be most oriented toward integration of function is the one that is most fragmented and compartmentalized in its conceptions.

So health for our field lies in the recognition that improved self-regulation is achievable in any of a variety of ways, and that the choice of clinical approach must be a multi-faceted one. That choice goes beyond the particular features of the instrumentation or the clinical approach to take into account the setting, the professional talents available, and the predilections of the practitioner. Different practitioners thrive with different methods. This transition into an atmosphere of mutual acceptance can happen to an extent at the intellectual level, but it will become a living reality as more clinicians adopt more than one modality in their practice. So this I see as the frontier for the coming year—the proliferation of multiple modalities in the individual practices.

For the clinicians that have already committed to a particular instrument, this evolution will come about incrementally. The BrainMaster user may want to add the visual stimulation accessory that operates under threshold control, or the tactile feedback option. The BioExplorer or BrainMaster user may want to add HEG. The personal ROSHI can be readily used to complement conventional neurofeedback. It is trivial to add Heart Rate Variability training to any practice. Neurofeedback practitioners should consider adding the peripheral modalities for monitoring if not also for training purposes. And the practitioners of conventional neurofeedback might consider adding the LENS or more sophisticated EEG analysis.

Is this all too daunting a prospect for the mental health professionals who thought they would never have to come seriously to terms with a computer in their professional lives?I suppose the answer is that each of these challenges is undertaken in turn at the clinician’s own pace. But whatever the pace, it will become accepted doctrine that there are many pathways to improved self-regulation. Correspondingly, most professionals will not content themselves with just a single approach once they have seriously committed themselves to this field.

So the fragmentation that is occurring in the field would be entirely healthy if only it were to take place against the backdrop of a unified perspective on self-regulation. That is the scientific challenge, and the “science of networks” may be the answer. We have to understand our respective interventions in terms of network models that tie everything together, in the realization that we possess a network of regulatory networks. Surely this was already intimated when people first did hand-warming to change the client’s emotional state. Now we need to make this part of an explicit model.

The network model allows us to understand that disregulation may be picked up by any number of variables, and the network can similarly be cued toward improved function through a variety of reinforcements. It remains to be settled which methods are the most efficient in a particular case. It is in the network model that disparate techniques such as EEG NF and Heart Rate Variability training can have comparable efficacy for asthma, although no direct nexus to presumptive mechanisms in asthma is apparent for either technique. The network model also allows us to bring other modalities within the framework. Network models can take the mystery out of acupuncture changing brainwaves. It is the network model that allows us to interpret the effects of traditional chiropractic manipulation in terms of a non-local mechanism. (Quite possibly what is being accomplished by the traditional methods is a kind of “mini-ECT” to the thalamus, serving to reset thalamic regulatory function.) Similarly, network models allow us to appreciate bodywork as a legitimate part of the healing arts.

The Challenge of the Tsunami

The last time our whole world was as self-aware as it is now was at the time of the millennium celebration, where we could observe the New Year’s festivities progressively around the world. How different the context on September 11, 2001, when the whole world was again watching, and how different the context now. There is such a desperate need for what we have to offer, after people’s immediate needs are taken care of. I was thinking the same thing after the genocide at Srebenica, after the slaughter in Rwanda, on the occasion of the Columbine massacre, and of course after September 11. And I am thinking it again now. We don’t lack for opportunity to give our services away. But major events like the tsunami certainly focus the mind.

It is in wartime that many medical innovations come about in surgery and elsewhere. The pace of innovation increases. People don’t ask hard questions. One could imagine working alongside personnel from “Doctors without Borders” or the United Nations Children’s Fund. If they saw what we could do first hand, it might have a galvanizing effect that under normal circumstances would take many years to accomplish. We are witnessing the coexistence of militants and American marines in Banda Aceh. Is our coexistence with conventional medicine in such a setting out of the question? Fortunately what we have to offer is not an emergency treatment. We don’t have to be on the front lines of the relief effort. There is time to organize. But if an avenue opens up for us to be involved, perhaps a response by the whole community can be mounted.

Should there be a Profession of Biofeedback?

This is an issue on which I am truly agnostic, and I have no axe to grind. But it is surely one that is on the horizon. More and more we have the sense that an expertise is developing here that goes well beyond common conceptions about what is involved in biofeedback. Secondly, biofeedback does not seem to fit comfortably within any existing discipline. Thirdly, we are beginning to encounter more and more professionals who see their primary professional identity as based in biofeedback. It has come to dominate their practices, even if they have come in through one of the counseling disciplines or something else.

On the other hand, biofeedback will not ultimately stand apart. The scientific revolution that is neurofeedback will succeed. There is no possibility that the world will remain divided between those who accept neurofeedback and those who don’t. In the future, psychiatry will not be practiced without neurofeedback any more than it is now practiced without meds. Likewise psychologists will just not be able to go about their professional lives untouched by neurofeedback. They would simply become uncompetitive. There may nevertheless be a niche for a recognized, distinct professional competence centered on strategies for physiological self-regulation. There is an obvious analogy here to acupuncture, which benefited from the establishment of a discipline, an educational program, and professional certification and/or licensure.

Much of what we now enjoy with respect to the pace of innovation might be lost in the formalization of what we do. But the process may be inevitable.
These are the good old days.

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