July 28, 2004

Where do we go from here?

Author: Tom Allen

Last week’s newsletter about the Efficacy Document was widely distributed to the neurofeedback community at large. It gave rise to a discussion on the Biofeedback list which is still continuing. Tom Allen responded with a longer piece that is reproduced below in slightly edited form. Some introductory material is presented first.

Where Do We Go From Here?

Steve Rothman wrote:
Siegfried,

You say in your note below:
"The efficacy document is a clear declaration of war against most of what we do
on a daily basis."

To which I respond:
I think the above statement is over the top …

I suspect many of the folks who participated in the formation of the
statement are psychologists, as I am. As you know, the type of
efficacy research that is at the heart of the statement is the
bread-and-butter of clinical psychologists. One of my prelim areas
involved just this methodology. So I'm not sure we can fault
psychologists from bringing this particular prism to the party (sorry).
And clearly, the view such a prism affords is seen by many as
important, and by many as necessary.

Yet, of course, it is only one way of asking and answering the
important questions that all of us, patients, clinicians, referring
sources, and insurance companies are continually asking. Tom has
presented another prism of considerable merit.

I believe the art will be in the amalgamation of both. But
amalgamation that doesn't require government-mandated super glue
requires that we move away from the declaration of war rhetoric.

With concerted effort (and liberal doses of self-training for all of
us): I believe that there can be peace in our time.
Steve

First Siegfried answered Steve as follows:

I recall the days of the civil rights movement where blacks were first
invited to speak at the National Press Club, and where women were among those who
cheered on the speakers and welcomed the change. Yet women were restricted to
the gallery during all that time! For the entire duration of the civil rights
movement in the fifties women were not the issue; and women did not see their
rights as an issue. When women's rights later became the cause celebre, anger
gradually mounted even as things got better objectively. The injustice of the
status quo really came into focus only as it was already being dismantled.

The relevance to the present situation is as follows. Clinicians have
accepted their second-class status in the field of psychology, and thus the Efficacy
Document is not something that shocks and surprises. In the context of what
has existed, it is not terribly unexpected. As we know, clinicians even "bought
in" to the document in the course of its preparation.

But if one gains a little distance from this, the document is really quite
preposterous in its assertions. The acquiescence to victimhood on the part of
the clinicians involved is embarrassing. Clinicians are the women in the
gallery: It's ok. We'll just lock ourselves up here in the gallery. Don't worry,
we'll be all right. And those of you out there in the hinterlands having to bear
the consequences---you'll be all right, too.

So the more I think about it, the more I find anger and indignation to be a
justifiable response---anger on the one hand at the acquiescence and
obsequiousness of those who should be our allies and advocates, and anger at the
narrowness, reductionism, and intellectual arrogance that underpins the
evidence-based medicine movement, particularly in its application to the "soft" sciences.
In a context in which no more than about 14% of medical procedures have the benefit
of research behind them, one knows that the targets of the evidence-hawks will
be selective.

Finally, Steve, you must realize that my own personal perspective remains
that of the public being served, since I am not a clinician. For all the while
that these squabbles continue, the task of making this technique broadly
available is delayed. Nobody seems to be concerned about that. The public will simply
have to wait until these intramural skirmishes are sorted out.

I continue to marvel how in a period of remarkable growth of alternative and
complementary medicine, this field can fumble the ball so completely at the
organizational level. I am reminded of the Communist Party of the USA,
infiltrated as it was by the FBI. It could not get anything done, and never knew why.
Delivering health services does not seem to be the prime agenda here. Instead
it is doctrinal purity. What is the equivalent of the FBI in this case? It is,
I believe, the medical model. Infiltrators simply will not allow anything to
move forward unless it happens to be consistent with the medical model of
feedback. Since that model is largely inoperative within our field, very little is
allowed to move forward.
So telling us not to use the metaphor of an act of war is the equivalent of
telling Democrats not to talk about class warfare. The war is happening anyway.
And it is not impolite to mention it.

Siegfried Othmer, Ph.D.

Tom answered with a longer response:

The following are my thoughts about a new paradigm and a new profession. I too believe it is time to move away from the yardstick of academic psychology. It is time to do something truly radical and move outside the trap and think and act outside the box. The ideas and approach I am suggesting would open this thing wide open to a lot more people who want to do this professionally and it would open it more to the public as a well- defined form of self-regulation-oriented form of healthcare. This is in keeping with your self-regulation model and the one I was taught at Menninger along with the vision I caught from Elmer and Alyce Green. The new paradigm I am speaking about truly is "Beyond Biofeedback".

A New Paradigm, A New Profession, A New Alliance (Tom Allen)

What if there is a way to look at it a different way. There are many people who do this work who are not psychologists, in fact very many people. So, why should they have that prism foisted onto them? Why shouldn't there be some consideration of non-psychologists’ concerns and how they measure things?

Certainly other professions and healing arts have their own standards. Acupuncture and Traditional Chinese Medicine couldn’t care less about western laboratory or controlled science, because they come from a long systematic observational and historical tradition of what we would regard in our scientific tradition as natural science. They have their own history and method of natural observation to rely upon for their conclusions. And they have millennia of recorded history supporting the foundations of their healing arts and sciences.

I believe there may even be a place where an alliance with alternative medicine schools like those who educate Traditional Chinese Medicine practitioners could also educate fully trained biofeedback/neurofeedback practitioners over 3 years in their own right apart from any connection to any other profession.

I have suggested this before and even had a school willing to get accredited to do it, but the thing fell through because the idea came along way to early to take hold. That was close to 10 years ago and that may not be the case now.

This is essentially what happened with Acupuncture. At first, only Chinese practitioners in Chinatown areas were practicing their art underground; then state legislators determined that only established medical and chiropractic professionals could use Acupuncture. This was the case for many years in many states. That is when the paradigm shift came and the schools for Traditional Chinese Medicine (TCM) began to open in numbers. Non-physician people went to Asia and studied and brought these skills back to train others and they also brought back renowned Asian teachers to head up the effort of establishing highly competent academies.

A lot of these schools popped up in Florida and California and other western states and now Acupuncture is a licensed, certified or registered profession in 41 states at last count. It may be more now. Maybe such a paradigm shift is due for this field. How many people in this field are fully educated, from the ground up, to do this work from a self-regulation model of healthcare? This would include nutritional and dietary interventions, herbal medicine, meditation techniques, autogenics training techniques, exercise and performance training and biofeedback/neurofeedback therapy along with behavioral transfer training.

Now that is a paradigm shift that is in keeping with alternative medicine and that fits into the schools of alternative medicine's objectives, so they could easily become natural alliance partners for a new profession for Biofeedback/Neurofeedback and Self-Regulation healthcare if it were to emerge as a separate profession. It is clear this will not happen in the current professional schools of our state Universities or in our traditional private colleges because of the vested interests of the current traditional healthcare and mental health professions.

Since paradigm shift and the new profession I am proposing represents a real mix of hybrid skills and a new integration of theory and practice that is quite different than how biofeedback/neurofeedback has been practiced and theoretically understood, the educational basis for this profession would also have to be different than what is now the basis for current entry into the field. This would not preclude current practitioners from other professions and, perhaps not even those currently practicing as allied professionals.

Such an education would probably include a strong emphasis on learning anatomy, physiology, neurophysiology, neuroanatomy, psychophysiology, instrumentation, counseling, psychology, learning and behavior, nutrition, clinical pathologies and disregulation syndromes and somatoform disorders that can be treated with biofeedback/neurofeedback and other self-regulation therapies successfully, and clinical biofeedback/neurofeedback clinical skills, assessment, clinical office management, professional ethics, licensure requirements and patient/clinician interaction skills. This would be in addition to the 60 semester hours of normal college currently required by the Oriental Medicine schools to matriculate into their school. Some even require a B.S. or B.A. to matriculate. There are currently 52 colleges or academies of Traditional Chinese Medicine in North America alone and 42 are fully accredited and 10 are in candidacy status awaiting accreditation to grant degrees sufficient for licensure.

Many of these schools require two years of college prior to entering and a prerequisite course list is specified. These schools are not trite in their offerings and many of the classes are taught by physicians and other healthcare professionals. The quality of their
graduates speaks for themselves. There would not be independent licensing in 41 states if these schools did not produce very qualified practitioners. They had to fight off the medical and Chiropractic communities' powerful lobbying efforts in every state to win licensing, but they did it, because they were qualified to do what they were doing. The average TCM practitioner makes in excess of $100K after 5 years and $200K after 10 years.

I believe there is a constituency for the type of education that would combine the alternative medicine model that Traditional Chinese Medicine offers and the model of self-regulation care that biofeedback/neurofeedback offers and I see a natural cross-pollination occurring if an alliance can evolve within the context of the TCM academy to teach our skills to their students and have them teach their skills to our students. There would be much overlap anyway. Having this broad range of skills and clinical education in place would prepare the biofeedback/neurofeedback graduate to enter the healthcare world as a competent professional holding an identity of a profession apart from any other.

I believe strongly that biofeedback/neurofeedback in such a context can and will stand alone as its own profession without any support from the traditional professions and that it can carve its own creative path in the world in this fashion much more readily than it has through the traditional healthcare professions that are rife with conflicting interests.

This is a dream I have had for biofeedback as a field for a long time. I mean to see it begin to happen before I die. It is a life force goal of mine to nurture this idea along for younger hearts to see through. But, I want to begin to encouraging alliances with the schools of alternative medicine to buy into what we have been doing for a long time.

Most states' licensing laws for Acupuncture have statements regarding the teaching and use of self-regulation techniques as being within the scope of licensure for Acupuncture and TCM practitioners. But they have not been oriented yet to biofeedback as a group. I don't think it would be a difficult reach to get a school here and there to eventually look at the possibility of starting formal programs of training that intertwine with their own programs in such a way that allows people to cross-train and have both types of
practitioners come out the other end of the program with a lot of cross-pollination that would be beneficial to both. They may even come out dual licensed or certified.

This is how they do things the first two years in China. The traditional Oriental Medicine students train with the western medicine student. They cross-pollinate. There is a real potential here. In fact, it would be a program I would be willing to go through just to come out the other side and teach.

This idea would not have to take membership away from any group representing biofeedback professionals such as the AAPB or the iSNR. It would just be saying biofeedback/neurofeedback has come into its own and it is ready to set its own direction as a professional entity apart from other already existing professional entities. It is prepared to set its own educational standard and eventually appeal to state governments for independent licensure.

If anyone else sees such a vision as having possibilities I would like to hear comments. If anyone would like to work toward these types of goals I would also like to have discussions about this. We have a great future for this field if we can pull it away from all
the conflicting interests. Of course the traditional professions could still do their thing with biofeedback and neurofeedback. Those of us who want to participate in their organizations could and would. I would be one of them. I would even still try to do some
research and writing. But, for me it is time to move forward on something like this.

All we need is to forge a strong alliance with schools and a group of like minds who would be willing to give of their hearts and minds to realize such a goal. We have to make it look doable and profitable to the schools and we have to be willing to put the time into it to make it happen.

First thing that strikes me is that we have to find states that have Oriental Medicine schools that do not already have biofeedback captured by the psychology licensing law like Florida's is. That way the schools might have more interest in taking the risk to
implement the program.

Tom Allen

Siegfried’s Response to Tom Allen:

It is not at all clear to me what should happen here. I am all for increasing
access to this technology to a variety of professions. No one profession
should be able to lay claim to this technology as its own. And I have come to
think that whereas professions are constrained by ethical codes of practice, their
interests are sufficiently differentiated from those of the public that
independent thought must be given to how the public interest is to be protected.

Given all the potential uses and abuses of this technology, the only real safety lies in the public being cognizant of this technology, on the one hand, and having access to it and being conversant with it, on the other. This allows relationships with clinicians to become less authoritarian and less hierarchical. Instead, they become partnerships in promoting empowerment of the individual.

We have seen practices develop quite successfully that are oriented largely toward neurofeedback/biofeedback. Ours is one of them. This development could lead to specialty practices having to do with education, rehabilitation, addiction recovery, eldercare, pain management, optimum performance, sports performance, etc., that all largely wrap around self-regulation approaches. These would call upon a variety of professional skills.

But a better model for most of these is the multi-disciplinary practice---integrative medicine, etc., where self-regulation practice would play an important but not predominant role. Can biofeedback hold its own under either of these scenarios if there is not a biofeedback license? I don't know. Is the knowledge base required for competent practice sufficiently distinct from that of other health professions to require its own educational track? I don't know.

I could also argue that the understanding we have developed is so fundamental
to how human beings function that it simply must be infused into the curricula of the
other health professions as well. We may just represent the head of the phalanx
that is required to gain acceptance of the self-regulation paradigm, and that
when it is finally accepted it will be universally taught. In fifteen years'
time, will there be any psychologist not using neurofeedback? Probably only
those above a certain age...

James Gordon talks about the Manifesto for a New Medicine, one in which
self-care is central, and integrated perspectives dominate. The crisis in medicine
may be such over the next decade that a conversion to a self-care based model
is the only viable option. The self-care model may also be the only viable
option in the third world. We may see a development similar to what we saw with
cell phones, namely that the easier spread of our technology allows its more
rapid diffusion than the more capital-intensive allopathic medicine.

Technological developments over the long term will be such that the burden on
the clinician to understand sophisticated technology will be minimized. More
and more of the burden will be placed on the software. This means that the
therapist will be able to return to a preoccupation with the client, with
therapy, and not with technique. This means to me that technological complexity will
not by itself be a driver toward independent licensure. The technology will
become very accessible.

I see this technique as boundary-breaking in many ways, and I don't know how
the establishment of the boundary of licensure changes things. Having so many
unlicensed practitioners in this field may simply be an historical anomaly due
to the novelty of the field. Once NF is accepted and licensed people
everywhere are doing it, then it will be much less likely that unlicensed people will
find their way into the field. So providing an avenue toward legitimacy for a
cohort of unlicensed people may be a transient issue. An exception is the
field of education, where licensure is not commonplace. That might constitute the
societally acceptable option for the unlicensed practitioner over the longer term.

An alternative to licensure may be for us to find a home in and organization such as the Behavioral Health Guild. In any event, as chair of the Allied Professionals Section of the AAPB this year I don't want to appear committed to one or another option, since I have to represent many interests fairly. It is time for many others to be heard on these issues.

Siegfried Othmer

Tom Allen responds to Siegfried:

I see this as an all-of-the-above issue. I see biofeedback/neurofeedback as having its own unique knowledge base and theoretical foundations that goes far beyond what is taught in the short seminars where most people learn this stuff today. I see it from a very comprehensive psychophysiological, self-regulation and systemic point of view. My own training took years and did not happen in workshops.

This notion constitutes the basis for the foundation of self-regulation-oriented healing practice at many levels for the practitioner, and that is where I see a breakaway point for a separate licensure. It would not eliminate other professionals from the practice of biofeedback, but it would give those who just want to practice a biofeedback oriented self-regulation model of health and wellness care the right to get a defined education that outlines a knowledge and theory base for competency and then defines scope of practice and a process of internship practice and testing that leads to licensure and practice that involves biofeedback/neurofeedback and other self-regulation oriented care such as nutritional and other patient/self managed practices.

It is not an issue of setting further limits. It is rather one of widening the scope and the possibility of the vision what biofeedback as a discipline unto itself can become. We have done so much over the years to limit the possibilities that we have forgotten its great potential. I always read Elmer and Alyce Green’s book “ Beyond Biofeedback” when I want to remind myself of that. I go back to all the older papers of Gary Schwartz and see the sense of the future in his research. I also recall the late Chuck Stroebel and the late Antoine Remond who were probably the most brilliant men I have ever known, and I shared this vision with them. They saw this intuitively.

Here is another argument for licensure using TCM as an example. It’s clear that a lot of Chiropractors and Physicians use Acupuncture and herbal remedies in their practices; and that licensing of Acupuncture and Traditional Chinese Medicine has not changed that. But, what licensing TCM has done is expanded the availability of these services to the broader public, because as more and more people get licensed they set up practices and their numbers are greater than the Chiropractors and Physicians that use these practices in their work. So this is something to consider. Currently, there are close to 20K licensed TCM practitioners in the U.S alone. Now, imagine what could happen if we could get these schools to cross train and start a movement of our own!

Tom Allen

Tom Allen writes in answer to Val Brown, who stated among other things that licensure in biofeedback was not in prospect as a practical matter, and not even desired in principle:

Part 1 The Clinical Market Issue

Professions survive because they provide a service people demand and want, not because academic research supports the service. The reality is that the market demand supports the research. This is most recently evidenced with the tremendous market demand for alternative medicine leading to federal grant monies to study these areas. It may be the academic research expands the possibilities of what a professional can do and it certainly allows a profession to expand its vision and scope of practice, but ultimately, it is about rendering service. And the consumer of that service must be satisfied for the profession to thrive. If that does not happen then things die on the vine.

Chiropractors and Traditional Chinese Medicine practitioners do a lot of things that do not have a lot of "research support" but people keep coming back, because they experience "real-world" relief. Many times they pay out of their own pockets and they get
better, which keeps them coming back.

For many years the medical community fought the Chiropractic community by reporting catastrophic case studies, which usually turned out to be misrepresentations by the medical community to demean the Chiropractic profession. Then the medical community took another direction by doing their own controlled comparative research studies only to find out that Chiropractic was as good, if not a little better in some cases, than Orthopedic care for most back injury and back pain complaints. The Chiropractic community did not
have to invest in that research at all and it ultimately it backfired on medicine's efforts to chastise Chiropractic into submission to their will. The same thing is happening with TCM now. But each study of TCM is also showing that it has value as well.

The medical community is doing all sorts of research on TCM and they will find the same thing. In fact the few studies that have come out with preliminary reports are promising in some areas. They have a lot of TCM to study yet, but I am sure they will find a lot of robust findings that may even exceed the effectiveness of western medical approaches in some areas. Chinese research has already found this in government directed studies to compare TCM remedies with western medicine remedies.

A western-trained Chinese doctor friend of mine from Shanghai says he does not understand why the US government is doing this research. He says this because the Chinese government has invested a great deal of money over many years into this research as a way of deciding how best to invest their healthcare maintenance dollar in a
socialist society. Their position is that they have to know what TCM does best and what western medicine does best for economic reasons. He laughed when he told me this and said: "We are, for thousands of years, a very methodical people. It is part of our culture, even more so than in yours, and we have done good work in this area. If the US government just had good sense and good translators to translate our journals they would find out what they want to know."

TCM is one of the fastest growing alternative healthcare sectors in the states where it is licensed for a very good reason. It works! But there is very little western style science in western journals to support it. I would say there is much less western style science
to support it than there is biofeedback and neurofeedback, unless you go to the Chinese literature that uses western scientific method to compare the TCM and western medicine disciplines. I do not see the TCM professional societies drafting documents like the hierarchies of efficacy documents. The TCM community is much larger than biofeedback and they are facing a much brighter future because they are not shooting themselves in the foot. In my little city of Oviedo, a small suburb of Orlando, there are 6 TCM practitioners and no biofeedback practitioners currently practicing. Like I said earlier, there are close to 20K licensed practitioners in the U.S. alone. And their healthcare sector is growing rapidly.

The practitioners of Massage Therapy, Chiropractic and TCM make claims all the time based on the practice experiences accumulated in their respective traditions. No law says they are wrong and no ethic says they are wrong unless there is absolutely no basis for the claim and outright fraud can be proven. A diverse community of professionals who share the common use of biofeedback and neurofeedback has a right to set its own standard for what constitutes the basis for such claims.

But, since there are multiple professions and multiple standards for what clams can be made and which ones cannot there is a dilemma in drafting a common line of thinking that addresses everyone's needs. Furthermore, the same is true regarding research standards that should serve as the foundation for efficacy documents. It is clear that the hierarchies document was generally written and certified by a majority of people who are psychologists and many of them are academic psychologists.

Psychology has decided it cannot, and will not, use the gold standard of medicine of very large n's and multiply replicated, double-blind, placebo-controlled studies, as well as long-term longitudinal studies as the basis of its scientific standard. They have set their own less stringent standard. Guidance and Counseling and Family and Marriage Counseling have set their own standards, which are even less stringent than those adopted by clinical psychology. Now that education and performance professionals are included in our diverse group their standards are different even more.

The point is that biofeedback can stand alone in determining its standard for assessing its levels of efficacy and efficaciousness. It can also stand alone as a profession and until it does that this bickering between vested professional interest groups will continue to stall the growth of the field and its proliferation as a healing force for our healthcare system, our communities and ourselves. We are the ones that stand in its way. If we could just start in one place by developing review of practitioner consensus, traditional practices and the research with the understanding that all have equal weight then we could see if we could move from there. Such a balance and weighting value between such documents can honestly consider the more general standards of the diverse group of practitioners rather than just impose the standards of the psychologists onto the entire group.

Biofeedback/neurofeedback as a field of endeavor does not have to take on the standards of psychology in determining these matters and I realize from Cory that the hierarchies document does not reflect those standards precisely, but it reflects them closely enough that it makes it clear who runs the show. It would have been nice to have a representative group of people with the diverse and rich backgrounds represented in our field involved somewhere along the way in this process. I think we would have a better document if we had such representation when the document was written and then certified.

Part 2: The Issue of Addressing the Holes and Setting Future Directions for Research in Biofeedback.

This is where I put on my scientist hat and start thinking like a lab and field psychophysiology person. Now, don’t get me wrong here, I am adopting a standard that is held in psychophysiology for methodologically sound research. I am playing the devil’s advocate on the side of an even more stringent standard than that the current authoring committee used to draft the document as it now stands. I am not talking about clinical research per se. I am addressing instrumentation and recording issues and that sort of thing to demonstrate that there is a lot to consider about the body of literature that supports our field and that was used to develop the hierarchies of efficacy document.

Let's address the issue of creating a document that really reveals the holes in or research base and truly gives us some direction for future research by looking at the poor nature of our research. It seems better to do this than to take a body of generally poor research literature and use it to construct an efficacy document. This was a "butt-backwards" enterprise in my estimation.

If it is true that the intended goal of constructing the hierarchies of efficacy document, and I have no reason to believe it wasn't, then what I am writing here has a lot to offer toward thinking about this in a different way and I think it addresses some of
Siegfried's, Val's, Cory's and even Jay's concerns.

Now, taking this a little beyond the issues of the hierarchy but onto something not unrelated, it is always easy to be exclusive, elitist and hard-nosed about anything. It is difficult to be inclusive. If I wanted to get really hard-nosed and elitist about this it would be easy to say that biofeedback/neurofeedback is really clinical psychophysiology; therefore anyone practicing any type of it should have at least a masters degree level of knowledge in psychophysiology and adequate clinical psychotherapy, testing and
assessment, behavioral modification and learning skills to be professionally qualified to provide services in this area.

To complete such a program would take at the very least a 90 semester hours, 45 hours for psychophysiology and 45 for the clinical side of things and such. This would be equivalent to a Psy.D., Ph.D. in Clinical Psychophysiology which currently does not
exists as a discipline, but perhaps it should.

There are very few people in biofeedback today who even meet such a criteria of knowledge. There are some. But many are retreads who were experimental psychologists who then went back to become clinical psychologists, and there are others I know who got masters degrees in neuroscience or psychophysiology and then got clinical
degrees in Social Work or some other clinical discipline so they could practice, but the number is small.

This brings into question some of the issues about the research. If most of the people who are doing biofeedback are not really adequately familiar with the graduate level knowledge base associated with psychophysiology and its methods and designs of
research, its engineering and other common concerns, then how can we know that a lot of the clinical psychologists and graduate students who do a lot of the research in our field are adequately familiar with these concerns when they do there research? Most of them have not had the education required to be so.

I can tell you as a person who knows a lot of this information from my education, my laboratory and field psychophysiology research and psychophysiology instrumentation and software experience that there are always a lot of factors to consider that go unconsidered if someone is not around with an intimate knowledge of these things to help direct and guide the research process along in the right way regarding these matters.
Even when I was involved with the very experienced team at Menninger as a co-researcher on a project, they did not factor certain things in about EEG research that I knew and they did not. Two of the co-investigators there were well educated in psychophysiology and EEG, but EEG topography was not their thing. Having me there was important to a successful study.

This is all to say that I am almost certain that if a person adequately educated in psychophysiology is not involved in a biofeedback study there will, more often than not, be method and design flaws, oversights and omissions that can impact the outcome
of the study. These things may be because of simple things beyond the clinical method and design of the study. This is probably more crucial in studies involving EEG or multiple system measures than in anything else.

The other part has to do with what conclusions one draws from the data. Once such research is completed, a psychophysiologist would quite often draw completely different conclusions from the data than what most clinical psychologists would and their conclusions would be far more conservative, because there are so many "what if"
factors that they would be aware of that the psychologist would usually not be aware of.

More than not it would have more to do with the proper understanding of the instrumentation amplifiers, the modalities being used and their electronics and how they interface with the instrument amplifiers, sampling rates and signal acquisition issues, the
physiological variables measured, how the data is analyzed and whether it is reviewed and analyzed in time series fashion in an intrasession context and over multiple sessions, and finally, what the data means once it is analyzed. They would look at the dependent and independent variable relationships in quite different ways, because they usually have a much more intimate understanding of the underlying physiology and anatomy involved.

Psychophysiologists do a lot of their analysis in different ways than biofeedback researchers and for good reason. A lot of their analysis looks at things like area under the curve in times series and more involved statistics, because psychophysiology is a dynamic process that occurs through time. They are increasingly using more and more non-linear methods of analysis, because they are gaining a greater appreciation for the complex systems nature of psychophysiological process dynamics. More and more psychophysiologists, physiological psychologists and biological psychologists are talking in terms of control, natural and meta systems theory to describe the mechanisms observed in the psychophysiological data to describe the system linkages they see.

Biofeedback literature likes to report measures that are descriptive and related to correlation, group variability and clinical outcomes unrelated to these more dynamic measures used in psychophysiological research. Biofeedback research usually does not use measures related to real dynamic psychophysiological processes except in cases of frequency analysis and then JTFA would be better because it renders a fuller picture of the dynamic range of the data. In this area I agree with Val. I am not sure about using nonlinear filters for feedback yet, because I think there is yet a lot to be learned, but for assessment and data analysis, yes, I think Val Brown has introduced us to something valuable in JTFA analysis. His idea of emergent variability is very systems-consistent and psychophysiologists would not have a problem with this concept and neither do I. In fact I have also thought this way for a long time. I just did not apply it in the same way he did.

Some of the newer work with heart rate variability biofeedback research is an exception to this the rule of not being psychophysiologically sophisticated, but this actually grows out of research that started in psychophysiology and is an application of that basic work. So good methods from psychophysiology are well developed and established that can transfer readily over to the clinical application research and into biofeedback. Also a lot of that work has psychophysiologists associated with it.

Psychophysiologists also do time series analysis on objective measures of symptom abatement using ambulatory monitoring devices. You have seldom seen that in the biofeedback literature using real ambulatory monitoring. Some of the clearest mistakes and flaws I have seen in the biofeedback and neurofeedback literature have to do with turning assumptions gathered from the laboratory data into conclusions without doing further tests to confirm them for clear signs of generalization of learned behavior through objective ambulatory monitoring like that used in psychophysiology research. If you
cannot show learning learned in the lab transferred outside the treatment lab, and to what degree it is transferring, then you do not know.

I have seen instrumentation and recording methodology issues where the researchers do not go into the proper detail about their instrumentation, the details of their recording method which do not include a clear description of the recording environment where their psychophysiological recordings and feedback sessions were completed. I quite often do not see a discussion of the hypothetical utility of certain feedback paradigms in the hypothesis sections. This suggests to me these were not well thought out, which could easily explain less robust results in a number of studies.

I have rarely seen benchmarks on signal acquisition to feedback time, which is very important. Neither have I seen other benchmarks and specifications all that well documented in many papers. This is especially the case in EEG biofeedback studies. I have not seen impulse response curves for EEG filters used in much of the research, nor have I seen that much reference to the specification and types of filters used in many EEG biofeedback studies.

You used to see this in the early days of biofeedback research when most of the biofeedback researchers were psychophysiologists. You still do when psychophysiologists are involved. There is a long list of things to mention here. In fact there is a long list from a psychophysiologist's point of view that could bring pause to considering much of the biofeedback literature as being very valid at all. That is one reason many professional psychophysiologists don't take it very seriously and consider it an overall wash.

So, why are we taking a body of research seriously that, from a psychophysiology point of view, has a great deal of flaws in it and then elevating it to a level that says it is adequate enough to use for developing the basis of a hierarchies of efficacy document?

Why don't we review the literature and evaluate it for its merit as science independent of its ability to reveal anything to do with regard to efficacy first? That is a better thing to do to find the holes in our research. Much of it is not good science at all. It is riddled with flaws. Make sure what studies are worthless and get rid of them. Then we can reverse this effort and put the horse back in front of the cart where he belongs.

If you took a panel of good psychophysiologists and clinical psychology researchers and had them review the literature for the good and the bad science and had them construct a document that outlined an overview of the most common mistakes and oversights
making note of the areas where most studies were incomplete, and where improper use of, or inadequate use of statistical analysis was found for psychophysiological data analysis you would do the field a better service.

Then, if you had them draft a set of suggestions about how to improve data analysis and method and design criteria to meet the specific and unique needs of the various areas of biofeedback research you would do the field a better service. It would not impact the practitioner, as much and it would serve as a document that would direct the researcher and not everyone else.

This would produce a document for researchers and not practitioners about where the holes are in the research if this is the real goal of the hierarchies document. I hope I have made sense here because I took Cory's statement and the stated intent from inside the
document itself and gave it a great deal of thought. I was trying to sort out for myself what it was I was objecting to so much and this is how I sorted it out. I hope it makes some sense to others and that it adds something constructive to the dialogue.