[esnr] Re: science and clinical practice in our organisation

  • From: "Frick, Ann" <a.frick@xxxxxxxxxxxxxx>
  • To: <esnr@xxxxxxxxxxxxx>
  • Date: Mon, 28 Jun 2004 04:33:34 +0100

Leslie,
I respect your opinion as a clinician, and that of others on this list, about 
the qualifications necessary to enter our training programs.  However, I think 
this is also about what the content of our training programs will be.  I am 
hoping you and other clinicians will play a role in developing those programs.  
 
However, I don't think it is adequate to think of these issues only with 
respect to the clinical setting.  The doctor in the example I gave would never 
have come to us for clinical work.  We would have only ever seen her as a 
client for some kind of peak performance.  She was a respected and high 
functioning medical professional in her community.  She was known by staff at 
our clinic.  I am not aware of any published material that has identified an 
EEG-signature of those who will abreact although I have heard some anecdotal 
evidence of some indicators for some individuals.  And screening out by other 
means can be tricky as well, even by highly trained individuals.  
 
But most especially, I don't want to turn this into a discussion of abreaction. 
 It is only one of the reasons to be careful about how we train and certify in 
our organisation's name.  I agree with Knut that if our methods are capable of 
producing good results then we have to be aware that they are capable of 
producing some bad results as well.  It is wrong to think that attention work 
and peak performance work are somehow 'less demanding' and that we can 
therefore be more lax about the level of training and supervision required for 
NF certification.  I am not sure what our standards should be, but at least we 
are becoming aware of the issue and beginning to talk it through.  I think we 
need to go slowly enough in launching this new organisation so that we can do 
the work that's needed at each step of the way.  
 
We have never had so much attention focused on us from the scientific 
community.  What we are doing now may make a difference for a long time to 
come.  It is more important than ever that we do it well.
 
Finally, I like Marco's proposals--especially about the shared database and 
investigation of the capabilities and specs of equipment--and introductions.
 
Ann Frick
Imperial College London
 
 
-----Original Message----- 
From: esnr-bounce@xxxxxxxxxxxxx on behalf of Lesley Parkinson 
Sent: Fri 25-Jun-04 11:23 PM 
To: esnr@xxxxxxxxxxxxx 
Cc: 
Subject: [esnr] Re: science and clinical practice in our organisation



        Dear Ann,
        Thank you for this thought-provoking, open, contribution, with its 
realistic
        cautionary example.
        You raise serious points that need to be debated and considered.
        Not least is an implied support for the clinical track.
        Also that the clinical training section should  include a "warning" 
section.
        There appear to be EEG patterns associated with repressed trauma, for
        example.
        This, amongst other factors makes the assessment process critical.
        I have not seen as dramatic an  example as yours, but I have been 
alarmed by
        the reations of some individuals who have just been used to demonstrate 
a
        Neurofeedback process in a workshop.
        If the clinical track is restricted to individuals with a graduate or
        postgraduate qualification in a clinical field then those individuals 
would
        also be responsible to their professional bodies. That may help.
        Best Wishes
        Lesley
        
        
        >From: "Frick, Ann" <a.frick@xxxxxxxxxxxxxx>
        >Reply-To: esnr@xxxxxxxxxxxxx
        >To: <esnr@xxxxxxxxxxxxx>
        >Subject: [esnr] science and clinical practice in our organisation
        >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
        >
        >
        >
        ><< winmail.dat >>
        
        
        
        

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