[esnr] Re: science and clinical practice in our organisation
- From: Jorge Alvoeiro <ex_ip276239@xxxxxxx>
- To: esnr@xxxxxxxxxxxxx
- Date: Sat, 26 Jun 2004 21:29:36 +0100
Dear Ann and all,
This e-mail has sent be back to the time when I started using biofeedback,
during the 70/80's. The first methodology I was training upon was something
called "Sequential Analysis". This methodology was, and still is, very
powerfull to extract levels of traumatic past events and behaviours, and is
based on GSR and Jung work on emotions and cognitive triggers like
words/phases. Yes, one can trigger sometimes 3/4 levels of traumatic
events in one session that can take almost a whole day and which can carry
on during the next session but at a less pace. This can be overwhelm and one
has to keep 'cold blood' and carry on and on. Unfortunately this training was
done just by supervision and workshops and very little literature (just one
article as far as I know). So, I think that there aren't many people with this
training now (I do it to my students though) After that I have received
training in methods of relaxation and imagery training as well as CBT, NLP,
clinical hypnosis and 'alpha personal growth' which I considered them all to
be very useful and important in NF work. (Besides the MSc on the excitatory
cycle of alpha rhythms and the PhD on mental imagery). This brings me to my
first point. I have meet a few people, in particular those that had driving
accidents and AVCs, coming to NF training for recovery of attention
processes and half way through it the the client's world goes loose. Past
experiences and emotions come to the surface and I have to stop NF and do
psychotherapy. I then finishes off with NF of alpha with 'inner cognitive
personal reinforcements'. This can take the whole morning or afternoon which
means just ONE client.
Why does this happen? Well, if one goes "deep" into the research of alpha
rhythms (leaving theta for later) we can find that most, if not all people who
goes into alpha, experience hallucinations and past experiences. This is why
training in NF CANNOT be done by people who does not have clinical
training in some mental health like psychology or psychiatry. I am sorry but
I am very strong on this point. The whole 'disrepute' one talks about for the
'first wave' of biofeedback training during the 60/70's is because people
started claiming this 'new therapy' was 'equivalent' and in some cases much
better than an 'acid trip'. I hope we are not going AGAIN through the same
'trip' as before. I am having some 'problems' over here in Portugal because we
don't have a professional organisation, like the BPS in the UK, to supervise
training and continuing training in areas like NF. And this bring me to the
second point, is the 'new' ESNR going to take charge of this like the EFPA is
doing in Europe in relation to psychologists? NF was, is and will always be
the 'direct' door to people's inner mind. We, at least, have to know and train
as much as we can in order to cope with what might come up during our work.
ESNR needs to divulge this as much as possible to every country in Europe
so that we don't end up again with 'more pies on our faces'
To finish I would like to point out something from Ann's e-mail:
> 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.
I have to disagree on this because this may be what we 'are used to' see in
most scientific articles. The work on fMRI and PET on the brain has shown that
not only 'one person's article' can provide more information about the brain
and its working than the 'average' but also that we have reached a level of
understanding about the brain that we are now 'looking' for what is meaningful
in people. The recent work on the working of the unconscious and fMRI and PET
is such a case. Right now, 'my brain' is giving me 'information' to write
this e-mail. The funny thing is that 'I know' (up to a point) which part is
doing this and where to 'consciously' activate those parts to give me more
information. I feel that I 'don't need' NF to do this but some people do.
Isn't this what we would like our clients do knowing that they have us to go
to for some unexpected brain event?
All the best
Jorge Alvoeiro
On Friday 25 Jun 2004 22:50, you wrote:
> 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's 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
--
-------
Prof. Dr. Jorge Alvoeiro, Ph.D.(Hull,UK), C.Psych.(BPS,UK)
2000-119 Santarem
Portugal
URL: http://www1.terravista.pt/Enseada/8146/
E-Mail: jorge.alvoeiro@xxxxxxx
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