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

  • From: "Lesley Parkinson" <lesleyparkinsoncp@xxxxxxxxxxx>
  • To: esnr@xxxxxxxxxxxxx
  • Date: Fri, 25 Jun 2004 23:23:04 +0100

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

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 Stermanâ??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 patientsâ?? 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 beenâ??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 shouldnâ??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 hadnâ??t had that training and been available to her around the clock and if she hadnâ??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 donâ??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 organisationâ??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 â??Introvisionâ??. 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:

â??Evidence basedâ?? 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 organisationâ??s ruling as to what is evidence-based and what isnâ??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.


Ann Frick

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