What's New in Neurofeedback

Neurofeedback Jobs board - An online forum where positions sought and offered in the neurofeedback field (clinical, research, and administrative jobs) can be posted by anyone. Located at www.eegspectrum.com/html/jobs.htm

New Neurofeedback Clinicians / New Offices

Carol Kershaw, Ed.D.
J. William Wade, M.Div.,LPC (added)
2012 Bissonnet St.
Houston, TX 77005-1647
(713) 529-4588

Mark D. Chamberlain, Ph.D.
Family Center for Brief Therapy
415 South Medical Drive, Suite C-103
Bountiful, UT 84010
(801) 294-4133
Email: chamberlainm@ricks.edu
(new location)

John E. Kelley, Ph.D.
The Anxiety & Stress Center
151 N Kraemer Blvd, Ste 105
Placentia, CA 92870-5047
(714) 978-9571
(new location)

Ken Dunning
Bellingham, WA
Email: dunn@skat.net

Sarah Luth
San Diego, CA
Email: telenos@aol.com

Sally Church, Ph.D.
Norman,OK
Email: dr.sally@juno.com

Deborah Tannen, in her latest book titled 'The Argument Culture,' laments the tendency of the press to present issues in terms of pro and con. Even when certain scientific or environmental issues are rather clear-cut, an authority or spokesperson representing an opposing viewpoint must usually be found to balance the presentation. One issue she uses to document this tendency is that of global warming. There is very little dispute among meteorologists that our climate is now influenced by human activities, and that a long-term warming trend is underway as a result. Nevertheless, articles on global warming have continued to project a controversy that in fact no longer exists. It is becoming clear that this aura of uncertainty is being fanned by a lobbying campaign under the auspices of the American Petroleum Institute (Molly Ivins, The Los Angeles Times, August 16, 1998, page M5). The attempt is made to convert uncertainty about climate models, and about specific predictions, into a more fundamental uncertainty about the 'fact' of global warming itself. The claim is always couched in the best of scientific terms, namely that the evidence is simply not yet good enough. There is no higher ground in science than that of disputing evidence! Yet the nearly universal belief among knowledgeable scientists is that the data are sufficient to have a public policy impact.

A second illustration is the case of cigarettes as a factor in mortality, and as a delivery vehicle for the addicting substance nicotine. For decades, public policy has been held in thrall by presumptively scientific arguments that the evidence indicting cigarettes as a health risk was not yet good enough. In fact, it has been good enough at least since the 1950s, when a comprehensive article in the American Scientist showed exhaustive epidemiological data that unambiguously indicted cigarettes, cigars, and pipe smoking. Uncertainties about whether the culprit was nicotine, tar, or perhaps some other substance such as radioactive radon gas, are secondary to the basic issue of the health risk posed by consumption of cigarettes. Actual scientific issues about mechanisms and causation were ballooned up into more fundamental uncertainties regarding the validity of the research on morbidity. From the standpoint of public policy, essentially all that needed to be known has already been known since the fifties.

A third example is that of 'creation science.' There is no scientific ambiguity at all about whether evolution was the process by which we came to be homo sapiens. Evolution is the key organizing principle of the entire field of biology. There is considerable residual debate, however, about the mechanisms responsible'since evolution could apparently make major leaps in complexity quite quickly, rather than over eons of time as Charles Darwin had supposed. The 'creation scientists' would like to escalate ambiguity about the mechanisms of evolution (the theory of evolution), and disagreements about the data of paleontology, into uncertainty about the fact of evolution itself.

And now we come to our favorite topic: EEG Biofeedback (neurofeedback). We have recently been treated to a pro- and con- in the pages of the Physician's Weekly (issue of Physician's Weekly, to be found at http://www.physweekly.com/archive/98/07_13_98/pc.html ) in which David Velkoff, M.D., presents the case for EEG biofeedback, and the redoubtable Russell Barkley, Ph.D., presented the case against. Velkoff speaks of having personally supervised more than a thousand cases in his office, and Barkley replied that he remains unpersuaded by the underlying research. The scientific case was made adequately more than twenty years ago with extensive animal research. This work established that EEGs could be trained to change and that behavior changed with it. Further, it was proved that this training was of clinical relevance to epilepsy, sleep, hyperactivity (as it was called at the time), and learning disabilities. All of this early research, good as it was, has been overtaken by subsequent clinical experience. EEG biofeedback is now being practiced on a daily basis in thousands of psychological and medical practices around the world, and it is experiencing rapid growth, as well as increasing breadth in its applications. That would simply not be the case if it didn't work. People are not fools.

If Barkley were consistent, he would have to call for the discontinuance of many established medical techniques because of the inadequacy of the underlying controlled research. The former Congressional Office of Technology Assessment found that less than forty percent of medical procedures had the benefit of any controlled studies behind them. James Gordon, M.D., reports that the figure for the gold standard of blinded controlled studies may be closer to 15%. Would Barkley counsel the discontinuance of shock therapy because of the lack of prior controlled research? Where is the literature basis for polypharmacotherapy, the giving of more than one drug to a person for the same condition at the same time? One could go on ad infinitum.

Barkley's critique of research on EEG biofeedback has a key feature in common with all of the examples cited above. Subsidiary questions about research design, and of what mechanisms may be responsible, are inappropriately escalated into fundamental questions about efficacy of the intervention and of validity of claims. Barkley's key complaint about the data is that controls were inadequate to rule out a placebo effect. This issue is secondary to the question of whether there was an effect in the first place!

This is an important point, so let us try to dissect this issue further: In drug trials, the medication must be shown to be more effective than 'placebo.' The latter includes all kinds of psychological effects and other means of self-remediation and self-recovery mediated by what we may call 'body-mind' (the entity that scientists like to take apart and we would like to keep together). Call the placebo hypothesis 'B,' and the medication 'hypothesis A.' In EEG biofeedback, there is no active agent like a drug, so the remediation is effected in some fashion by the body-mind continuum. It then doesn't make sense to ask whether the recovery was instead by the 'placebo effect.' That would be the equivalent of asking, was the remediation effected by the body-mind or was it instead effected by the body-mind? For a behavioral intervention, the placebo effect is not an independent 'hypothesis B,' but rather is part and parcel of 'hypothesis A.'

Of course it is meaningful to ask specifically what mechanism in brain physiology is responsible for the effects we see, but that question doesn't arise until you acknowledge that there are effects to be asking questions about, which Barkley has not done. [See Appendix for commentary on that issue.] The question is usually framed in the following terms: What are the 'specific' effects of the training, and what are the 'non-specific' effects? The specific effects are the direct effects of training the person to change his brainwave activity. The non-specific effects include the ancillary benefits of getting a lot of attention to a problem, of being in the presence of medical authority figures, and of being exposed to lots of fancy and expensive equipment. We hasten to acknowledge the scientific import of this question. (And to a certain extent it has already been answered in the early research. But that history is for another day.) The important point for present purposes is that Barkley is using the placebo argument to dismiss perfectly valid clinical findings, something he is not entitled to do. He is in effect arguing that because the possibility has not been ruled out that there may be only non-specific effects of the training, we need not attend to the data! Remarkable. What is being proved on a daily basis in the clinical world is that remediation of ADHD and other conditions is possible for the 'body- mind,' suitably challenged, and frequently without medications. Whether this is happening by specific pathways or by non-specific effects is secondary to the primary datum of observed, effective recovery, which should command attention and draw research interest all by itself. Moreover, even if in some fashion a non-specific effect was responsible for the remediation, then an important physiological process must also have been involved. In either event, the 'body-mind' accomplished effective remediation, and the fact of recovery cannot be annihilated by ambiguity about mechanisms.

Let me make this argument concrete with an example. If we have a child who comes in for EEG training, with parents at the end of their rope, and his IQ improves by thirty points over thirty-two sessions; his reading grade level is boosted by 3 grades; he stops bedwetting; he stops his chronic lying; he starts being nice to his sister; and the teacher's phone calls stop coming, then this could in principle all be due to the fact that we talked to him nicely for a few minutes before each of this training sessions, or that he actually had to sit still in the chair for all those sessions. Alternatively it could be due to a real effect of training his brain in a manner which more than 100 studies over the past twenty-five years have suggested might be specifically effective. We allow for the possibility that our clinicians have a real knack for talking to kids like this who don't seem to want to listen to anyone else. But one way or another, their physiology is now changed; their functionality has improved. Barkley would have you believe that because of the possibility of a non-specific effect being responsible for this progress, you should not be misled into thinking that these data are significant.

Barkley also argues that we cannot make our case by example, as we attempted to do above. True scientific progress is only to be made with a research design based on homogeneous groups. This is difficult for clinical settings, where clients come one at a time, and they are not homogeneous! The problem is that if we report on individual clinical results, we could be guilty of cherry-picking the data. Out of a group of thirty kids, perhaps one of them happens to improve his IQ by thirty points for other reasons (change in diet or sleep patterns, or change in family circumstances), and yet we claim credit for the training. First of all, that is highly unlikely. It would be more likely to find a seven-foot tall person among thirty kids than one whose IQ improves by thirty points in a few weeks. Secondly, IQ improvements are commonplace'even expected'among children who undergo this kind of EEG training.

Clinicians gain a sense over time of what is to be expected with the training, just as they do with regard to any other technique or procedure that they use. If their clinical judgment is not valid in the appraisal of EEG biofeedback, then it isn't valid anywhere. Barkley would quickly find the answer he doesn't seem to want if he were to talk to the clinicians doing the work, or even undertake the work himself. But he absents himself from the scene of action, and wraps himself in the cloak of the scientific method seeking refuge from the emerging cacophony of claims! This is reminiscent of the Church prelates who refrained from looking through Galileo's telescope because that would only confuse the issue for them.

Barkley is in fact modeling behavior for you. He has known about this technique since at least 1991. Yet he has never bothered to see for himself what this technique is all about. And if he is not interested, with his professional commitment to the field of ADHD, then the clear implication is that he feels parents would be wasting their time (and money) to show interest in it as well. He has said as much.

As already suggested, we have seen this tendency to escalate a subsidiary scientific question into an indictment of a whole discipline in all of the above examples: global warming, cigarette hazards, creation science, and now EEG biofeedback. We may have in Barkley's critique perhaps another case of turning one of the highest traditions of the scientific method, that of a thorough-going skepticism, into a bludgeon that needlessly confuses issues and posits uncertainty where none in fact exists. In the other examples cited above, one can see a rationale for this kind of perversion of the scientific method. The American Petroleum Institute has a lot at stake in the issue of global warming. It prefers to maintain the status quo in public policy as long as possible. The tobacco industry has an obvious interest in the confusion sown by its scientists and acolytes. And an entire worldview is at stake in the issue of how our creation came about.

Is it possible that the hegemony of the drug model of ADHD is giving life to Barkley's curious obstinacy? This is the theory that ADHD is attributable to a neurochemical deficit that is at least partially remedied by administration of stimulant medication. The theory admittedly has lots of empirical and theoretical support. We are not saying it is wrong or invalid. But that doesn't mean there cannot be a better theory! It is our human propensity to misread and misinterpret data because of our biases that made the scientific method necessary. It is ironic that the methodological structure thus established can also be used to inhibit scientific progress. When the enterprise of science is dragooned into service of a particular mission or viewpoint, it can be entrained for a time to that mission like a caboose on a train. Ultimately, of course, the charade becomes unsustainable, as we have already seen with tobacco, as we are currently seeing with global warming, and as we will soon see with EEG biofeedback. (I suppose the creation scientists will always be with us.)

EEG Biofeedback appeals to the brain's means of self-regulation in the bio- electrical domain. No theory of neurochemical brain regulation can be expected to explain it. Entirely new models are needed. These new models must also explain what we already know. Hence they must 'encompass' the model of stimulant efficacy for ADHD as well. We are on the threshold of such a model, and it postulates that stimulants and anti-depressants actually serve to re-regulate our brain physiology. They don't simply furnish missing neurotransmitters. The same kind of reregulation can, apparently, be accomplished by appropriately training the brain! What a revolutionary proposition.

EEG Biofeedback was recently featured in Parade Magazine [June 28 issue], which is indicative of nothing except that it can be seen as a measure of 'readiness for prime time.' Neurofeedback is clearly no longer a research curiosity, but is now actively being used in schools, hospitals, and prisons, in addition to thousands of private office settings. In its current issue, Parade featured an article on acupuncture ['Acupuncture Goes Mainstream (Almost)', by Isadore Rosenfeld, MD, Parade, August 16, 1998, p.10]. Again, this is indicative of nothing beyond the fact that a certain level of public and professional acceptance has been reached.

Acupuncture represents a case study of a discipline that cannot rely on the gold standard of medical research, namely blinded controlled studies. Acupuncture cannot be done blind. The clinician has to put the needle in, and the client knows he is getting the needle. Hence, the field can only establish itself by observation of outcomes. And it is doing so. At this point, some 10,000 practitioners offer acupuncture, including 4,000 M.D.s. Nearly all of these clinicians had a practice before acupuncture came along. The only reason for including it in their practice is that it gives them an additional tool. Otherwise it would gradually be abandoned.

The same holds for EEG biofeedback. It cannot be done blind. The clinician has to make choices, and the client is part of the loop in the training. Hence, clinical outcome data must be looked to in order to establish efficacy, just as in the case of acupuncture. [If you are getting cerebral palsy children to walk (in some cases), and autistic children to talk (in some cases), it would be churlish to suggest that these results be ignored until controlled studies are done.] The question of efficacy is one that in any event needs to be faced with every intervention, with every client or patient, irrespective of any prior research. Whether Ritalin helps a particular child cannot be answered out of research, but has to be answered through observation of that very child. That is not a controlled study. For researchers to suggest that controlled research governs the clinical world is a delusion.

A Question of Scientific Ethics

Years ago, the story went out over the wire services that two adolescents had gone blind looking at the sun after consuming LSD. The story originated with an M.D. who had in fact fabricated it from whole cloth. But never mind. The story was deemed to be salutary for teenagers, whether it was true or not. There was no ethical violation here. The doc had used his best medical judgment to effect behavioral change. And Barkley is no doubt using his best judgment. My perspective is clearly different. Having lived with this technique now for more than a decade, and seen literally thousands of people benefit from the training in our own offices and those of colleagues, I see a real ethical issue in Barkley's representations to the public. However, there are no committees on scientific or research ethics concerning themselves with such issues.

At a minimum, the public expects that all (self-proclaimed) experts of a field have done the necessary literature review to inform themselves about the subject that they are repeatedly asked to comment upon. Clearly, any "expert" must be aware of the presumption on the part of the public that he or she has made himself or herself an expert on this field. My impression, by contrast, is that many experts has avoided immersion in this literature, even after all these years. For example, one ADHD "expert" has been quoted to the effect that it has never been proved that EEG biofeedback can change physiological functioning. That statement is false based on a number of published studies in the refereed literature. (We refer the interested reader to our website, www.eegspectrum.com).

There are two possibilities: 1) this expert is truly uninformed, which I submit constitutes one kind of misrepresentation to the public; or 2) s/he dismisses the published data by virtue of his or her force as an authority in the field of ADHD. This is the scientific equivalent of Louis IV's 'L'etat, c'est moi.' Or, 'the data mean what I say they mean, neither more nor less.' I submit that this should (should, not does) constitute an ethical indiscretion as well. A scientist should not be at liberty to make this kind of thing up, even if he thinks he is doing the public a favor.

Ultimately, it is not Russell Barkley who matters here. If he did not exist, or if he changed his mind, the media would find someone else to quote in opposition, and we would confront a similar litany of arguments. For those of us in the field of EEG biofeedback, this new kind of training is a living reality. Essentially no one engaged with this field manages to keep their skepticism intact for very long. The issue of efficacy simply subsides as a live issue. On the other side, there is a carefully constructed mental edifice tailored to dismissing the mounting evidence at hand. On the one hand, clinicians like David Velkoff empower the parent and the child to manage this problem, whereas on the other side the traditional opposition is disempowering, warning the parents that they may be deluded into thinking that their child is actually better! (These are the same parents whose judgments are implicitly trusted when the pediatrician asks how the child is doing on Ritalin! After all, the doc isn't taking him home.) We find that most parents are quite competent to make the appraisal of whether their child is actually getting better. The ultimate battle here is between a method that empowers the child, and one that retains the locus of power among the traditional authorities. What may finally be at stake here is power and authority rather than science.

Appendix

Siegfried Othmer

In an interesting sidelight, one of the pediatricians who referred his patients to that study was so impressed with what he saw that he is now providing EEG biofeedback in his own office. Who is more credible, the pediatrician who actually witnessed the effect of the training, or the researcher who is doing his best to discount the evidence?)

NEW BOOKS

Written by a therapist with over 20 years experience in identifying and treating addictive behavior. Perhaps not a great book, but definitely a great title!

For more information, see [http://www.amazon.com/exec/obidos/ASIN/076151628X/]

Prozac Diary
  by Lauren Slater
  224 pp, Random House, $22 (Amazon $13)

A 26-year old psychologist's revealing memoir of ten years on Prozac.

Click title for review. To order, [http://www.amazon.com/exec/obidos/ASIN/0679457216/]

Making Sense of Illness : Science, Society, and Disease
  by Robert A. Aronowitz
  256 pp, Cambridge Univ Press, $30 (Amazon $21)

Much has been gained and some lost by the current science-oriented, reductionist approach to the practice of medicine. Notably, the presence of a patient has been lost in his or her own condition. That is, the role or influence of individual characteristics, including emotions, lifestyle, and social class, on a disease process have been relegated to the dustbin by the tsunami of molecular biology research. The holistic approach, championed by the author, counters this revolution in medicine. This book is especially for readers whose mantra is NOT "one gene, one protein, one disease... one gene, one protein, one disease"

For more information, see [http://www.amazon.com/exec/obidos/ASIN/0521552346/]

JOURNAL PAPERS

Selected articles:
• Neuropsychopharmacological mechanisms of stimulant drug action in attention-deficit hyperactivity disorder: a review and integration.
• The continuous performance test revisited with neuroelectric mapping: impaired orienting in children with attention deficits.
• Frontal, temporal and lateralized brain function in children with attention-deficit hyperactivity disorder: a psychophysiological and neuropsychological viewpoint on development.
• Sex differences in operant discrimination behaviour in an animal model of attention-deficit hyperactivity disorder.
• Altered reinforcement mechanisms in attention-deficit/hyperactivity disorder.
• Response inhibition and response re-engagement in attention-deficit/hyperactivity disorder, disruptive, anxious and normal children.
• Inhibitory dysfunction in hyperactive boys.
• Clinical foundations of hyperactivity research.
• Attention deficit/hyperactivity disorder--from brain dysfunctions to behaviour.

Neuropsychopharmacological mechanisms of stimulant drug action in attention-deficit hyperactivity disorder: a review and integration.
  Solanto MV
  Behav Brain Res 1998 Jul;94(1):127-152