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Review of the 2005 ISNR ConferenceAuthor: Dr. Siegfried OthmerThis year’s ISNR Conference was the best attended, and membership is bumping up to 700. The organization is doing well when more than half of the membership shows up for the annual meeting. The exhibit hall reflected the creativity that continues to flourish in this field. One cannot imagine this conference without it. Instrumentation development is moving on from mere utility to concern with style and finish. The Nexus from Mind Media is a particular case in point. The smoothing of displays at user option is a delight. We always had that option on NeuroCybernetics, but it was not easily accessible, so it was hardly used. Zengar showed up with its four ZenX modes of sequential training by analogy to physical exercise routines, with warm-up and cool-down phases along with the working sessions. Thought Tech has incorporated our training modalities, and we showed the new Infiniti screens for two-channel sum and difference training at our booth. The EEG Info booth also featured the new games for the BioExplorer. Other implementations to follow. Finally, we brought the latest iteration of Sue’s Clinical Decision Tree, which now incorporates an update of lateralized training. Also on exhibit was the new Biofeedback Magazine, with high production values and good editing. The effort deserves to be supported. We need all the publicity to the public that we can get. Every clinician needs this magazine in their waiting room. The highlights at the conference are difficult to pin down because it is not easy for one person to cover the whole conference. So the following are simply my impressions after having attended only a portion of the talks. Joel Lubar talked about preferring the alpha-beta ratio to the theta-beta ratio as an assessment measure for ADHD under eyes-closed conditions. This is at Cz, so we are talking about frontal alpha. Ironically, if children so screened were to show up at Les Fehmi’s office for neurofeedback, they would be encouraged to undergo synchrony training in alpha under eyes-closed conditions. That may seem paradoxical, particularly since Cz is one of his five training sites in the synchrony montage. But it has already been pointed out before that posterior alpha reinforcement can have the effect of normalizing frontal alpha. Also, it may simply be the case that that well-regulated (i.e. state-appropriate) alpha is the best antidote to disregulated alpha. One would like to hear from Les Fehmi on the matter. Vince Monastra made a very interesting case during his keynote address. Careful assessment of ADHD does not so much improve significantly on what can be achieved with the more casual diagnosis that is commonplace in pediatricians’ offices; rather, it improves treatment compliance. Follow-up with more carefully characterized patients (using instruments such as the CPT, the ADDES questionnaire, or QEEG) shows compliance with stimulant medication up to the 98% level, compared to something near 56% conventionally. In comments after the talk, I characterized this as a case of the “bad driving out the good,” as Monastra did not see the likelihood of a change in the accepted casual way of diagnosing. But the analogy holds more generally. A diagnosis of ADHD is
much too crude a categorization for the complexity of what is
going on. So at that level also, the bad drives out the good.
Finally, in the matter of stimulant medication we have a remedy
that at best targets only a subset of factors involved in ADHD.
Moreover, careful dosing is rarely tended to. Once again we have
a case of the bad driving out the good, in this case the neurofeedback
or even the more comprehensive pharmacological remedy. Jay Gunkelman was welcomed back to the ISNR from his self-imposed exile with an invited talk on Mind/Brain relationships. I won’t dwell on this topic at length because I covered it in a previous newsletter, having heard Jay twice before on this theme. I remain skeptical. DC voltages do not beget 40-Hz rhythms. The DC potential is like the trampoline on which this all plays out, and of course the trampoline will reflect the vibrations of all that goes on. But that is not sufficient to attribute causation. There is no agency there. Dwelling on the dc potential confuses cause and effect. I much prefer David Kaiser’s view, starting with his idea of “Rogue Site Analysis,” the proposition that in some region a neuronal assembly differentiates itself and that is the beginning of something new. More specifically, there are probably a variety of spontaneous
mechanisms by which certain brain rhythms are kindled, and they
are then acted upon either favorably or unfavorably, depending
on the circumstances. The beginnings of these processes are indistinguishable
from noise, and will likely remain beneath our threshold of observation
at the scalp. Or the brain rhythms are always there at some level,
like the pilot light on a stove, ready to be called into service
at any time. Once they become dominant, the neuronal assemblies
will radically differentiate themselves from their neighbors in
the frequency domain, leaving only an infinitesimal demilitarized
zone that segregates one neuronal assembly from the adjacent ones
in frequency space. David Freides covered his recent experience with Jeff Carmen’s passive infrared-based training in the remediation of migraines. As video imagery was introduced to enhance the training experience, Freides found that IR readings would drop suddenly and persistently when certain emotionally salient events were portrayed on the screen. This demonstrates, if indeed more demonstration is still necessary, the profound influence of state shifts on our physiological measures. The real effects of external inputs can readily overwhelm our attempts to row upstream with the training. And it goes without saying that a traumatized person, as one example, needs no external inputs at all to generate such turmoil in the physiology. Here we have a relatively straight-forward measure by means of which population response to themes in films can be assessed in real time, something that David Kaiser looked at in his dissertation. It may be through the world of entertainment and sports that we will find entrée rather than through the minefield of medicine. Robert Coben presented on recovery from TBI using infrared-based training, and during a panel showed extensive infrared imagery showing the response to neurofeedback. Training sessions are typically brief, about 15 minutes, by which time fatigue is likely to set in. Longer trainings may also induce rebound effects. Privately Robert told me that he has had no treatment failures in application to migraine for a long time, and that is our experience as well using EEG neurofeedback. It turns out to be relatively easy in many cases to stabilize the brain with neurofeedback, something that is difficult to achieve with pharmacology. This finding is significantly stronger now that it has been shown with two highly divergent approaches. Coben also reported on EEG feedback for the autism spectrum, in an approach he calls “assessment-based,” which in this case refers to EEG assessment. Significantly, his results far exceeded the results of Betty Jarusiewicz in her pilot study published in 2002. Whereas Betty had achieved some 30% improvement in some 36 sessions, Robert saw nearly fifty percent gains in fewer sessions. He typically trains for brief periods, 15-20 minutes, after which time symptoms may again get worse. Sue Othmer suggested that this may have been due to the fact that the reward frequency was too high. We see no such limits when the frequency is optimized, and no effects of “over-training.” It is speculation at this point, but we may have here another demonstration of the proposition that the optimum reward frequency cannot yet be determined from the QEEG in generality. Robert chose his reward frequency on the basis of coherence deviations. If the principal coherence deviations do not predict protocol in autism, then we must draw on yet other mechanisms to explain the efficacy of the low-frequency bipolar training in autism. This is in contrast to findings by Joe Horvat and Jonathan Walker for TBI, where coherence deviations do index targets for training. One suspects that the specific efficacy of low-frequency reinforcement targets the very basic emotional disregulations that are characteristic of the autism spectrum. These disregulations involve sub-cortical nuclei that don’t necessarily have any obvious cortical representation. Another straw in the wind here is that Asperger’s sorts out very differently for us than autism in terms of protocol. Somewhat related to this work on the autism spectrum is that of Sebern Fisher, who talked on the use of low-frequency right-side training for affect regulation, in particular the taming of fear. Though making the case in her workshop for the combination of psychotherapy with neurofeedback, her case presentation on Antisocial Personality Disorder involved almost exclusively neurofeedback. Sebern emphasized that psychotherapy was not involved here. Yet the verbalizations that were spontaneously erupting out of this fellow as time went on were just what one would expect after long discursive psychotherapy. He was transformed by the experience, and by Fisher’s own report, the agency here was essentially entirely the neurofeedback training. One factoid in this case history stands out. Sebern talked about the intense body odor that the person brought into the session, despite the fact that he showered several times a day to counter it. So he himself was aware of the problem, even referring to it as “the smell of fear.” At some point during the training, his fear largely subsided, and the body odor problem resolved at the same time. This speaks to the generality of effects when our systems are disregulated. One imagines that if we were able to capture his body odor in a continuous measurement and reflect that back to him graphically, he could have trained on that as well. Any measure that indexes the disregulation can be used to effect a remedy. Body-odor feedback… hmmm. Consider the profound implications of this case history, dear reader, and hold in your mind at the same time the following: Russell Barkley; Chambliss criteria; double-blind studies… The mind revolts at the juxtaposition. A finding that belies all expectations, but has clearly been obtained with suitable care, deserves to be taken seriously all by itself. The above serves as a nice introduction to Sue Othmer’s presentation on the historical development of our own protocols, and the models that informed them, since we became active in this field twenty years ago (the DVD of Sue’s presentation is available through ISNR). We went from fealty to Ayers’, Sterman’s, Lubar’s, and Tansey’s protocols at the outset to the adoption of a lateralized training strategy, on the basis of a model largely around arousal regulation. Later came the adoption of bipolar trainings to address arousal instabilities. The unstable folk were always the most sensitive reactors, and hence became the ultimate test of any protocol. More recently, the focus on instabilities led to discovery that inter-hemispheric training at homologous sites held particular virtues for these conditions. Now to be absolutely correct about it, Douglas Quirk was already there. But he had not started anywhere else, whereas for us the inter-hemispheric training stood in contradiction to everything that we thought we knew. Inter-hemispheric training was a hurdle for us, and it took us years to fully flesh this out. The same thing then happened in the user community. The greatest barrier to the acceptance of what were now trying to teach was what we ourselves had taught before…. The key departure mandated by inter-hemispheric training was that the frequency rules we had devised for lateralized training were all out the window. Inter-hemispheric training was much more sensitive to reward frequency, and this could just not be ignored. The strength of inter-hemispheric training appears to be particularly at low frequencies, i.e. less than 15 Hz, but in fact the entire frequency range from zero to some twenty-five Hz was now in play. There was a whole host of people who responded best to reinforcement at 0-3 Hz, for example. The challenge of the new was most keenly felt by those who had hewn most closely to our teachings in the past, and the flames were fanned by the self-regimented thinkers in the QEEG community who just “knew” to a certainty that this was all a bad idea. Those who have accused us in the past of operating on the basis of anecdotal data have it precisely backwards. It is those who are spooked by one adverse experience and decide that the techniques are no good that are operating on anecdote. Some were prepared to meet us half-way, adopting the inter-hemispheric training but somehow remaining unwilling to follow the patient’s inclinations and go to low frequency. That is, of course, a formula for mischief. One either buys into the whole procedure, or one should avoid it entirely for the sensitive responder. Once the strong dependency on reward frequency had been uncovered, the question arose as to the implications for lateralized training. Unsurprisingly in retrospect, the frequency dependence replicates there as well, only the effects are not as dramatic. The dependence had always been there, but we had never had the opportunity to see it until flexibility was built into our filters. So, finally, we came to lateralized training at low frequency for the most extreme cases of emotional disregulation such as the case history that Sebern Fisher presented. We have opened the door to the remediation of deep trauma, and even of the personality disorders, which are largely grounded in disorders of attachment. At the time that these protocols were developed, the hostility to our work was so great that it compelled our exit from the company that we had founded. But there was lingering hostility to this approach also in the larger community. So it was necessary to prove two things: 1) inter-hemispheric training is superior to the traditional lateralized training, and 2) there are no significant risks of adverse outcomes. This I did in my presentation, which covered the analysis by John Putman of his and Sue’s clinical work over the past several years with the inter-hemispheric training approach, complemented at times with some frequency-optimized lateralized training. The cumulative CPT (TOVA) results for over 100 participants were compared to early compilations that were done for us by David Kaiser. Surprisingly, the modern data were distinctly better in a direct comparison. We did not actually do a statistical analysis because the respective clinical populations were not equivalent. I was prepared to make the case that our more recent clinical populations are far more impacted than those we saw some ten years ago. That being the case, if the modern data were merely comparable to the earlier data, it would already be good news. There is yet another factor at work. All the data refer to cases where we have twenty-session retests. Those who attrition out between one and twenty sessions are not counted. In that regard also, our recent history is favorable with respect to past history. So not only do we see more heavily impacted cases at the outset, but we bring more difficult cases to completion. On both counts, then, we should be surprised to be doing so much better than we were before. The second question I addressed by looking at those cases in the inventory of more than 100 that looked most like treatment failures at twenty sessions. On closer inspection, they could not be called treatment failures at all. Twenty sessions were just a milestone on the pathway to progress. Nevertheless, Sue was just a bit distressed that I would choose to feature her most difficult clients in my talk. But it is important to document that we have no cases in which the outcome of inter-hemispheric training is adverse. The fear that reinforcement in the low-frequency regime can lead to exacerbation of symptoms is simply misplaced. The stipulation, of course, is that the reward frequency has been optimized, and that optimization may have to be down to the half-Hertz level. The flipside is that any other reward frequency may not have such a favorable outcome. It is therefore easy to see how someone might try inter-hemispheric training arbitrarily and not like the results. The clinching argument against risk is the observation that bipolar training can be seen in terms of the promotion of desynchronization of the EEG, which is generally stabilizing, rather than in terms of traditional amplitude up-training. I presented theoretical modeling on this during my talk as well. Finally, this data compilation gave me an opportunity to check in on how we are doing with respect to Hershel’s favorite figure of merit, progress in TOVA score on a per-session basis. We calculated progress on one TOVA subtests of as much as 2.88 points per session over twenty sessions. This is the equivalent of 3.8 standard deviations of improvement in people who were in deficit by four standard deviations at the outset. It would be difficult to do better. In sum, there appear to be no contraindications to the protocol, provided that the training is suitably optimized and training sites suitably selected. I dwell on my own presentation at such length because we were answering all of the challenges that people in the field have been throwing our way. So it was a disappointment to find that my presentation was scheduled for the last full day, opposite Barry Sterman’s invited talk, and that my time of thirty minutes had been cut to twenty minutes. When we have data to resolve the key controversies generated within this organization with respect to inter-hemispheric protocols, then the organization is obliged to offer a suitable forum for the presentation of a rebuttal. Under the circumstances, I will cover our presentation at greater length in a future newsletter. This brings me finally to the meeting of members on the last day, at which Roger deBeus assumed the Presidency. His facial expression gave away that he may have had second thoughts about taking on the job. There was controversy around the name change of the organization to “International Society for Neurotherapy and Research.” Val Brown in particular objected that the word neurotherapy framed things more narrowly than neurofeedback, cutting out the broader non-clinical applications. But in another sense the word is more inclusive, as our community now encompasses non-feedback techniques such as the passive stimulation technologies. It was in fact an attempt at inclusiveness that caused the term “Neuronal Regulation” to be adopted initially in favor of neurofeedback. But the term is considered somewhat offbeat, and begets quizzical looks on first exposure. I am sympathetic to Val’s viewpoint, but the head overrules the heart. Realistically what most NF practitioners are spending their lives doing is therapy. People who come to see us need help, most need it desperately, and they have failed other therapeutic interventions. We offer more than conventional therapy, not less, and we cover the ground more comprehensively. How can we expect to get away with a soft-shoe act? Our target is disregulation, and for disregulation our approach is therapeutic. Most of the DSM consists of one or another disorder of disregulation. Our technique resolves DSM conditions more effectively across the board than pharmacology. How can it not be therapy? Hank Weeks brought up the fact that educational institutions will stay away from anything labeled therapy, so we might have more difficulty making inroads there. I would lament such a loss, but the truth remains that the membership as a whole sees neurofeedback as part of the therapeutic enterprise. So there we are. The Board has now been charged with revisiting this issue one more time. On the occasion of the previous vote, there was no opportunity for the membership at large to be exposed to the arguments on each side, and only two options for names were on offer. The Board was hoping to move on to other things, I’m sure. At the end of a long and intensive conference, and with brain oxygen levels diminished because of the high altitude in Denver, feelings in the room ran high. I expressed my own frustration that Sue’s solicited contribution to the clinical corner of the Journal had not seen the light of day in nearly a year and a half, and that a technical paper on IQ improvement in mental retardation took about a year to be accepted. The Journal is not the sole issue in this case. The paper had previously been rejected by the Journal on Mental Retardation and by the AAPB Journal. The result is that the eight-year-olds on which we were reporting five-year follow-up data have long ago graduated from high school as the paper is about to see print. The effort involved here took longer than the Viet Nam War. What a waste. Finally, I’ll throw in for good measure that our recently published paper on inter-hemispheric training had been subjected to a lot of unnecessary hazing on the path to publication. The obvious answer is that we should write better papers. That was even suggested to me by our own Director of Research. Indeed, papers can always be improved. But at this juncture I delight in reciting the case of Mario Beauregard, of the University of Montreal, who reported at this conference on a controlled study involving straight-forward NF training in the SMR/beta paradigm at Cz for ADHD, accompanied by functional MRI testing of cerebral activation. Significant differences showed up as a consequence of the training between the experimentals and controls. When he submitted the results to mainline journals, the paper was routinely rejected, in some cases being simply returned without any review whatsoever. Here we have a case of ground-breaking research that everyone has been hoping for, of impeccable research design, from a legitimate research setting, and offered by an established researcher—yet none of that made any difference. So it’s not just us. Roger deBeus is to be congratulated for motivating a more inclusive atmosphere at the ISNR, a process that has been underway now for some three years. But changing the culture is a long-term process, and everyone is not yet singing in tune. It occurred to me at the meeting that this is another unfortunate fallout of the pressure under which we are placed by the withering criticism from the mainstream. Those within the organization leadership who are most exposed to this rejection in their daily lives feel that if we were just a little more scientific, just a little more professional, just a little more circumspect in our utterances and parsimonious in our claims, and perhaps a lot more modest in our ongoing promotional scripts, mainstream acceptance would finally be forthcoming. As a result, their imposition of organizational homogeneity and rejection of “creative deviance” may indeed be well motivated. But the effort may be wasted. This is not how the world actually works. Chiropractors were not at some point invited into the club. They invited themselves and rearranged the furniture. Likewise acupuncturists and doctors of Traditional Chinese Medicine invited themselves. Pharmacology did not even take over psychiatry by such a process. Acceptance did not come through a sequence of nicely controlled studies, not then and not now. Throughout the development of biological psychiatry, clinical practice has led research, not the other way around. It would be far better to look inside at all the resources and
creative forces within the organization and without, and to give
latitude to those resources to do their best work. The bum ideas
will fall by the wayside soon enough. What we build here will
get respect, not our isolated studies in isolated journals. No
one who built a castle on the Rhine ever asked permission. Dr. Siegfried Othmer |
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