[esnr] science and clinical practice in our organisation
- From: "Frick, Ann" <a.frick@xxxxxxxxxxxxxx>
- To: <esnr@xxxxxxxxxxxxx>
- Date: Fri, 25 Jun 2004 22:50:15 +0100
To the list,
First let me introduce myself. I was at the original meeting that set up the
eSNR and have been at every meeting since. I am an academic who has also been a
clinician for more than a decade. I was first certified in neurofeedback by a
group that was widely respected in its time, but no longer exists. I was also a
member of a European organisation that was founded by neurologists to raise the
scientific tone of neurofeedback practice on the continent. It also went out of
existence. From this vantage point, let me add a few observations and comments
to this debate.
We are at an important moment in the relation of the science and clinical
practice of NF. Here timing is everything. If good science on its own were
enough, then Barry Sterman’s work on SMR and seizures many years ago would
have meant that neurologists would at least have been trying NF before they cut
out parts of their patients’ brains as treatment for epilepsy. However, we
are in a time when technology has changed neuroscience and neuropsychology in
particular. The enormous development of imaging with its obvious appeal to
academic communities has still left the field where it has been—stuck at the
diagnosing stage. Medication treatments have not developed at a meaningful pace
and have been disappointing in many respects. That leaves a small army of
trained scientists who want to figure out how to do something with all this
technology. TMS has been one answer. NF is a very obvious candidate as another.
This is an exciting window of opportunity for a massive shift in medical
practice as we know it. However, the way we, the NF community, conduct
ourselves now will affect whether this window stays open and how wide.
The proposal that has been put forth is to create an organisation of scientists
and clinicians that will be directly involved through training, certification,
and maintenance of standards, in clinical practice in a number of different
countries and in a variety of treatment/training settings. While I applaud the
intentions 100%, I am concerned that many of the risks involved are being
overlooked.
Let me briefly discuss just 2 of the risks that I hope will be addressed before
these steps are taken.
Firstly, as professionals, both scientists and clinicians function by very
different rules. Scientists are looking for what, on average, can be
demonstrated to have an effect. Clinicians are looking for what might result in
a meaningful effect in an individual. This difference in perspective makes for
the basis of a dialogue between the two groups. However, there is another
difference that is more problematic for the project we are considering.
Scientists, in the course of their work, are subject to peer-review. The
results of their research is carefully read by other scientists at the top of
their fields and revised and corrected until it meets appropriate standards.
Funds are raised for research in a similar manner. This is a very decentralised
process in which no one group of scientists is accountable for the performance
of each and every member of the profession. Scientists are not used to bearing
that sort of responsibility for each other as a group.
In contrast, clinicians get their peer-review through their professional
organisations. This centralises the responsibility and makes everyone in the
organisation accountable for the actions of each of its members. The
organisation that is currently being proposed entails extreme levels of
accountability. This is a very exciting marriage of science and clinical
practice we are talking about. However, before we rush into it, I think it is
important that we consider carefully what we, both as individuals and as
members of our professions, are tying ourselves to and what we need to do to
minimise the risks during implementation.
All professional organisations need to maintain standards among their members.
This includes protecting potential patients/clients from obvious misconduct by
practitioners such as sexual impropriety, intoxication during sessions, etc.
However, an organisation that undertakes to train practitioners in its own name
and certify them bears an added ongoing responsibility that carries through
each and every session that its trainees/certificants conduct. That means each
of us has something at stake in these sessions. Does this mean that we
shouldn’t train and certify in our own name? Not necessarily. However, each
scientist and clinician involved, needs to know what the risks are and has a
responsibility to see to it that the risks are managed. What we need to know is
how we are going to guarantee that these risks do not materialise.
In this regard, let me avoid the debate about clinical credentials for work
with psychotics, etc, and turn to the performance track that has been proposed.
Much of the peak performance work in our field has incorporated alpha-theta
training. It is well known in the neurofeedback clinical community that the
alpha-theta protocol can result in full-blown abreactions that can be startling
in their intensity. This is especially true for those who have had a traumatic
past. In fact, highly trained clinicians use these reactions to help the
client/patient resolve long-standing and deep-seated issues. I saw this at
close hand in work with Vietnam veterans when I did my internship in
neurofeedback at a clinic in a hospital in the state of Georgia in the US.
However, one day while I was there we had a visitor. She was a respected
medical professional who wanted to know about NF. Since she wanted to try it,
we hooked her up for a few minutes and all was fine. Several hours later, the
Director of the clinic left for a meeting in another town. I took our visitor
out to dinner, during which she proceeded to break down sobbing and relive
traumatic past experiences, including a serious heroin addiction many years
earlier.
I stayed up with her all night doing the sorts of things I had spent many hours
watching qualified people do. But if I hadn’t had that training and been
available to her around the clock and if she hadn’t been such a highly
trained, qualified, and experienced person herself, the outcome might have been
much worse. There was a potential for some serious harm. I tell this story to
this list with her permission and at her urging.
This happened to someone who would most often not be considered a risky client.
She had neurofeedback for 5-10 minutes and seemed absolutely fine for several
hours afterward. What would it mean to the field, and our developing relations
with the scientific community, if this were to happen with some very high
profile athlete or virtuoso musician of the type that is currently interested
in these applications? What do we need to do to train peak performance
practitioners to minimise this risk? Do we want to consider dropping
alpha-theta from the list of protocols that we sanction? I don’t think so.
The work of John Gruzelier and Tobias Egner in my department lends an evidence
basis to the protocol. However, if our group trains and certifies the
practitioner, our group will bear moral and legal responsibility for this sort
outcome. Of course, we will have insurance for the financial side of this so
that members of our Board will not be personally liable for the actions of
those they certify, and we will have to satisfy our insurance carrier that we
have adequate controls in place to minimise the effect of such events. However,
the marriage of science and clinical practice that is being outlined here means
that these sorts of things will reflect back not only on other clinicians, but
on the scientists, who as members of our group will have declared themselves
accountable for the clinical practice of each and every practitioner that is
certified in their organisation’s name.
I am not advocating that we drop alpha-theta training from our NF tool
box--just that we have adequate training, supervision, and oversight of those
who bear our certification. This includes alpha-theta as well as all of the
protocols and modalities for which we train and certify. One of the most
sensible approaches I have heard comes from our colleagues in Holland who
practice a form of supervision called ‘Introvision’. Perhaps others in
Europe do as well. Practitioners in an area meet regularly and discuss cases.
In that way, all are helped to maintain standards and there is some oversight
if someone begins to stray from best practices. Wytze van der Zwaag discussed
this practice at the first e-SNR training in Portugal 2 years ago when he led
the group in a discussion of Ethics. I highly recommend that he be asked to
repeat his presentation at our next meeting. If we are to construct a very
centralised structure that puts training, certification, and maintenance of
standards in one organisation of scientists and clinicians, I think we need to
look seriously at the decentralised ways that we will organise this process
day-to-day.
Another area of risks is much less dramatic, but may be more difficult to deal
with, and it may have even more potential to seriously disrupt
scientific-clinical relations for a long time to come. In this regard:
‘Evidence based’ is not a badge an organisation wears, but a process to
implement. What constitutes the specific levels of evidence that exist? What
type of studies have there been? How many of them? Exactly what has been tested
in the studies? In the course of putting together the ADHD/NF study at Imperial
College in London, we have learned that there is very little agreement on
anything related to the actual conduct of NF sessions. Almost all agree that it
requires more than 20 sessions and that we use sensors placed on the head and
computerised feedback based on real time EEG data. Other than that, everything
else is controversial. This includes training sites, frequencies to train,
montages, training contingencies, etc. And this is for the protocol that has
more evidence-basis than any other in the NF field! In fact, it has been
decided recently in our department that there is not enough scientific
validation for us to be able to say that QEEG is not "electronic phrenology."
What will we teach in our training courses? Will we teach only that which a
committee of scientists and clinicians formally rule as efficacious? Or will we
teach methods that we consider worthy of further investigation, but are not yet
fully evidence based? And how will be sure that trainees/certificants know the
difference? It will do great harm to the field if individuals with our
certification stray from the organisation’s ruling as to what is
evidence-based and what isn’t. For example, this means that clinicians will
have to have a signed consent form for training with experimental treatment for
any protocol that the organisation has not explicitly ruled evidence-based.
And what about claims made for NF and/or the other modalities that are being
considered in the remit of this organisation? What will we do if members of our
organisation make grand claims about NF that are beyond those that our
organisation rules as evidence-based? Over-hyping of NF has been and continues
to be one of the areas that most damages our scientific credibility.
For all of these reasons, I am glad the Board has decided that training will be
delayed until the longer term so that we can have a chance to work out what the
training will be and how we will adequately assess those we certify.
I am very heartened to read the messages that have been sent to this list. I
think that people across Europe are seriously discussing important issues, and
I hope this list will continue to be open beyond this current debate. I think
it is very important that Europe have a strong neurofeedback organisation. I
think it is a courageous decision to merge science and clinical practice in the
format that is being proposed, with scientists accountable for the clinical
practice based on their work. However, I am especially concerned that everyone
involved understand the ramifications of these decisions and that the ground
work that is absolutely essential for this organisation to succeed be done
properly.
For these reasons, I formally move that we strike the section in the proposal
from the Board regarding international membership. I think that it is crucial
that the ground work be properly constructed so that the organisation will have
most effective oversight and the greatest ability to proactively adjust our
developing policies as we fine tune them. It will be no small feat and will
require extensive debate and participation as well as many, many hours of
unpaid, tedious labour from our Board and committee members. I think that the
challenge is large enough in Europe alone. If we are spread too thin and are
unable to maintain our standards, then I am afraid that this new organisation
will join the others before it that have passed out of existence. In the
meantime, we may have done some harm to field of neurofeedback and
self-regulation in general.
Respectfully,
Ann Frick
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