Volume 30, Number 2 Summer, 2002died – Maria Eugenia Carmagnani and Paul Bindler. Proposals and Abstracts are invited for special issues on: Applied Psychophysiology and the Performing

Volume 30, Number 2 Summer, 2002

Special Issue onMethodology and ResearchDesign

Summer 20022 Biofeedback

There is an increasing emphasis in main-stream health care today, as well as in com-plimentary and alternative medicine, onevidence-based medicine and on best prac-tices. Biofeedback and neurofeedback areunique in complimentary and alternativetherapies, in that from the beginning feed-back interventions have evolved directlyfrom laboratory research. In the 1950’sand 1960’s research by Neal Miller showedthe potential for voluntary control of vis-ceral processes, the work of JohnBasmajian showed the potential for volun-tary control of muscle physiology, and thework of Joe Kamiya demonstrated thecapacity of human beings to control corti-cal rhythms. A flood of research followedthrough the 1970’s and 1980’s extendingthe biofeedback paradigm to a variety ofclinical disorders, from headache toRaynaud’s, to blood pressure, and numer-ous studies since then have shown the effi-cacy of clinical biofeedback. Biofeedbackand neurofeedback practice has rested onthe twin pillars of 1) general relaxationeffects, and 2) strategic interventions toimpact on specific physiologic and neuro-physiologic mechanisms.

Nevertheless, today’s outcome researchin health care focuses almost exclusively on the paradigm of pharmacologicalresearch – large scale multi-center studies,using a randomized controlled trials(RCT) model, with double blinding, andlarge samples of subjects. The field ofbiofeedback has not kept up with the rest

of health care. Funding problems, the dif-ficulties in blinding both subjects andpractitioners in biofeedback, and ethicalquestions about denying effective treat-ments in clinical settings have hindered theaccumulation of this kind of large scaleoutcome research on biofeedback and neu-rofeedback.

This special issue, edited by GuestEditor Ted LaVaque, presents several prac-tical articles on research design andmethodology. It is our hope that these arti-cles will accomplish several purposes: 1)raise our readers’ understanding formethodological issues in research today, 2)improve our readers’ abilities to criticallyread and utilize research findings, and 3),most importantly, encourage our readers asclinical practitioners to engage in researchand contribute to the scientific under-standing of applied psychophysiology. TedLaVaque contributes an editorial onaccountability in research, and an articlewith Thomas Rossiter on “TreatmentEquivalence Analysis,” Sebastian Striefelprovides a discussion of ethical issues inresearch, David Trudeau discusses of obser-vational studies, and Douglas Mathesongives an overview of research design. FrankAndrasik, editor of AAPB’s journal,Applied Psychophysiology and Biofeedback,also contributes an article describing thejournal’s openness to research based on awide range of alternative and practicalmethodologies.

This issue also includes a summary of

the report of the joint AAPB/SNR TaskForce on Methodology and EmpiricallySupported Treatments. The Task Force’swork is critical, and will guide the futureratings of the efficacy of therapies inapplied psychophysiology. The entirety ofthe report will be published in both theAAPB and SNR journals.

Also in this issue are articles by SiegfriedOthmer on emerging conceptual and tech-nical trends in neurofeedback, by SpaffordAckerly on using heart rate variabilitybiofeedback in high school biology classes,and by Randy Neblett on a paradigm foractive sEMG training for chronic pain.This issue also includes reviews of twobooks, the first on behavior modificationand the second on “communication appre-hension” – social and speech focused anxi-eties.

The Association News and Events sec-tion includes the usual communicationsfrom AAPB’s leadership, and two memori-als for AAPB members who have recentlydied – Maria Eugenia Carmagnani andPaul Bindler.

Proposals and Abstracts are invited forspecial issues on: AppliedPsychophysiology and the Performing Artsfor Fall 2002 (Editor Marcie Zinn, PhD),Mind/Body Pediatrics for Spring 2003,and Complementary and AlternativeMedicine for Fall 2003. The editor alsowelcomes proposals for future specialissues of the Biofeedback Newsmagazine.

FROM THE EDITORS

Special Issue of Biofeedbackon Research Methodology,Summer 2002Theodore J. LaVaque, PhD, Guest EditorDonald Moss, PhD, Chief Editor

The articles in this issue reflect the opinions of the authors, and do not reflect the policies or official guidelines of AAPB, unless stated otherwise.

Donald Moss, PhDTheodore J. LaVaque, PhD

Theodore J. LaVaque, PhD, and Donald Moss, PhD 2

Scientific Misconduct and Other Research Issues 4Sebastian Striefel, PhD

Editorial: Accountability for Evidence Based Treatments 6Theodore J. LaVaque, PhD

“Not Different” Is Not “Equal” 7Theodore J. LaVaque, PhD, and Thomas R. Rossiter, PhD

Observational Studies vs. Randomized Controlled Trials: 10Implications for Biofeedback

David L. Trudeau, MD Research Methodology, Validity, and Evaluating Studies: 13What’s OK for Research in Psychophysiology?

Douglas W. Matheson PhD The Clinical Forum 17

Frank Andrasik, PhDTask Force on Methodology and Empirically Supported Treatments: 19Introduction and Summary

Donald Moss, PhD, Jay Gunkelman, QEEG-T, Theodore J. LaVaque, PhD, and D. Corydon Hammond, PhD

Emerging Trends in Neurofeedback: I 21On the Status and Future of Mechanisms-Based Training

Siegfried Othmer, PhDHeart Rate Variability and Enhanced Student Performance 24

Spafford C. Ackerly, PhDActive SEMG Training Strategies for Chronic 28Musculoskeletal Pain – Part 1

Randy Neblett, MA, LPC

Review of A. E. Kazdin (2001), Behavior Modification 32in Applied Settings (6th edition)

Samuel T. Gontkovsky, Psy.D., BCIA-CReview of Betty Horwitz (2002), Communication 34Apprehension: Origins and Management

Mary Lou Acimovic, MA, CCC-SP

From the President 1AIn Memoriam: Paul Bindler, PhDA Personal Note 2A

Ted LaVaque

About the Authors 36

Summer 2002 3Biofeedback

Biofeedback is published four times per year anddistributed by the Association for Applied Psycho-physiology and Biofeedback. Circulation 2,100.ISSN 1081-5937.

Editor: Donald Moss PhDAssociate Editor: Theodore J. LaVaque, PhDsEMG Section Editor: Randy Neblett, MAEEG Section Editor: Dale Walters, PhDReporter: Christopher L. Edwards, PhDReporter: John Perry, PhDManaging Editor: Michael P. Thompson

Copyright © 2002 by AAPB

Editorial StatementItems for inclusion in Biofeedback should be for-

warded to the AAPB office. Material must be in pub-lishable form upon submission.Deadlines for receipt of material are as follows:

• November 1 for Spring issue, published April 15.

• March 15 for Summer issue, published June 15.

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Articles should be of general interest to theAAPB membership, informative and, where possi-ble, factually based. The editor reserves the right toaccept or reject any material and to make editorialand copy changes as deemed necessary.

Feature articles should not exceed 2,500 words;department articles, 700 words; and letters to theeditor, 250 words. Manuscripts should be submittedon disk, preferably Microsoft Word or WordPerfect,for Macintosh or Windows, together with hard copyof the manuscript indicating any special text for-matting. Also submit a biosketch (30 words) andphoto of the author. All artwork accompanyingmanuscripts must be camera-ready. Graphics andphotos may be embedded in Word files to indicateposition only. Please include the original, high-res-olution graphic files with your submission – at least266dpi at final print size. TIFF or EPS preferred.

AAPB is not responsible for the loss or return ofunsolicited articles.

Biofeedback accepts paid display and classifiedadvertising from individuals and organizations pro-viding products and services for those concernedwith the practice of applied psychophysiology andBiofeedback. Inquiries about advertising rates anddiscounts should be addressed to the ManagingEditor.

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FROM THE EDITORS

PROFESSIONAL ISSUES

ADDITIONAL ARTICLES

ABOUT THE AUTHORS: PROFILES OF CONTRIBUTORS

BiofeedbackVolume 30,No 2Summer, 2002

FEATURED TOPIC:METHODOLOGY AND RESEARCH DESIGN

BOOK REVIEWS

AAPB NEWS AND EVENTS


Abstract: The demand for accountabilityand the protection of human research partici-pants is increasing and is resulting in a cleareremphasis on what researchers must do in con-ducting research and when engaging in schol-arly publishing. Changes are driven by factorssuch as scientific misconduct, including failureto protect the rights of research subjects, falsifi-cation of data, and plagiarism. TheInstitutional Review Board process is currentlychanging in a number of ways, yet little dataseems to exist to show that such reviews protectresearch subjects. Researchers are encouraged toenhance their knowledge in ethics and toremain current on IRB and scientific miscon-duct issues.

Some researchers have not protected therights of research subjects and others haveengaged in other forms of scientific miscon-duct (Koocher & Keith-Spiegel, 1998). Assuch, there is an increasing demand foraccountability and the protection of humanresearch subjects. These demands foraccountability are causing changes and cre-ating various issues for those who wish toconduct research or engage in scholarlywriting. These include, but are not limitedto, issues related to: scientific misconduct,plagiarism, and Institutional ReviewBoards.

Scientific MisconductIn scientific communities like universities

and research centers, scholarly publicationsare a means for career advancement, gainingmonetary incentives, and for enhancingone’s professional reputation (Koocher &Keith-Spiegel, 1998). As such, there is con-siderable pressure for professionals in suchenvironments to publish and to be the firstor sole author on publications (Koocher &Keith-Spiegel, 1998). Pressure to publishhas sometimes resulted in fraud where indi-viduals engage in scientific misconduct by

falsifying data (e.g., creating data that willlook good rather than collecting or usingthe real data) (Koocher & Keith-Spiegel,1998; Murray, 2002b). For example,Murray (2002b) reported that a facultymember at the University of Texas inAustin, recently resigned amid accusationsof having fabricated data for a potentialpublication.

Federal regulations have defined “scientificmisconduct as the fabrication, falsification,plagiarism, or other practices that seriouslydeviate from those that are commonly acceptedwithin the scientific community for proposing,conducting or reporting research.” (Steinberg,2002, p.11). Koocher & Keith-Spiegel(1998) reported that a survey of 99 aca-demic departments revealed that two-thirdsof the graduate students and about half ofthe faculty had direct knowledge of scientif-ic misconduct by others. So awareness pro-vides one key for the prevention ofscientific misconduct. Some years ago I wasjolted into an awareness that something waswrong with some data. I had to throw outall of the data from a three-year studybecause one of my research assistants falsi-fied data, which I questioned because thedata looked to good to be true. When ques-tioned, the research assistant admitted thatdata had been falsified periodically. Therewas no way to determine which data wasaccurate and which was falsified. It didhowever teach me to monitor the activitiesof my research assistants more carefully,including sometimes checking on themwhen they did not expect me.

Steinberg (2002) states that you can pro-tect yourself against the scientific miscon-duct of others by informing your staff andcolleagues that you will personally verifydata collection, entry, and corrections in thedata. Of course you have to follow through

by doing so and by letting your colleaguesand staff see you doing so. In the process ofverification you will need to ask questionsabout any and all changes, corrections, era-sures or anything else that looks potentiallyquestionable (Steinberg, 2002). Steinberg(2002) recommends that it may even benecessary to re-contact research participants(could be covered in the informed consentprocess) to see if researchers met with them,what happened, if the correct procedureswere used, and if sessions occurred on thecorrect dates and for the durations requiredby the study. In essence, such a processensures that everyone involved in theresearch knows that if they fabricate or falsi-fy data they are likely to be caught.Promoting the integrity of research and datacollection can be enhanced by holdingteaching sessions in your lab and in theclassroom to teach and update all concernedin research with the standards for the con-duct of research (Steinberg, 2002).

All researchers need to engage in thosebehaviors needed to prevent scientific mis-conduct. Misconduct can be reduced orprevented by providing students,researchers, and journal editors with moreeducation about research ethics, adherenceto such ethics, the penalties and damagethat can be caused when scientific miscon-duct occurs, and by setting up methods fordetecting and investigating fraud (Murray,2002b).. Fabrication and falsification ofdata are unethical (APA, 2001) and the pro-fessional penalties can be severe, e.g., loss ofmembership in professional organizations,loss of one’s professional license, being blacklisted and thus prevented from getting anyfederal grants, losing one’s job and one’sreputation. Koocher & Keith-Spiegel(1998) even reported a situation in which auniversity withdrew a former student’s doc-

Scientific Misconduct and OtherResearch IssuesSebastian “Seb” Striefel, PhD, Logan, UT

PROFESSIONAL ISSUES


toral degree because the student’s disserta-tion was largely a copy (plagiarism) ofsomeone else’s research which had previous-ly been published.

PlagiarismIt is unethical for professionals, and stu-

dents alike, to present portions of someoneelse’s work or research as being their ownwork (APA, 2001). Plagiarism seems tooccur because of a glitch in memory orbecause of pressure to publish in order toenhance one’s career or for students to pro-duce research or other papers, sometimeswithout appropriate guidelines on what is,and what is not, acceptable behavior.Koocher and Keith-Spiegel (1998) pointout the importance of giving others creditfor the work they did by citing them appro-priately and by not exceeding the “fair use”guidelines, even when citing the originalauthor(s) of a work. “Fair use” means not toinclude too much of another’s work in one’sown publications.

Individuals working in the same profes-sional specialty areas may inadvertentlyexpress themselves in very similar ways(using the same or similar words) whenwriting (Koocher & Keith-Spiegel, 1998);however, it seems to be rare for more than afew words to be identical. Carpenter (2002)points out that inadvertent plagiarism canoccur because of a glitch in memory.Memory glitches are fairly common ineveryday functioning (Carpenter, 2002). Socaution is encouraged when engaging inprofessional writing to ensure that the workof others is cited appropriately so as toavoid engaging in willful plagiarism.

Murray (2002a) points out that internet-based plagiarism is on the rise, e.g.. plagia-rism is being detected in more studentpapers at universities around the country.As such, it is important for university facul-ty to educate students about plagiarism,how to avoid it, how to correctly cite thework of others, and to set up, explain, andimplement rules on how students whoengage in plagiarism will be penalized(Murray, 2002a). Journal editors, co-authors of professional papers, and otherprofessionals must also be observant for pla-giarism and take appropriate action.

Changing InstitutionalReview BoardRequirements

Institutional Review Boards (IRBs) arefederally mandated ethics committees thatare charged with evaluating all federallyfunded and almost all institutional spon-sored research (Azar, 2002). Their primaryfunction is to protect research subjects,especially human subjects, by reviewing therisk-benefits analysis and the informed consentprocedures (Hansen, 2001). Finding the cor-rect balance between protecting humanresearch participants and preventing delaysand/or making requests that seem unreason-able has not been easy for IRBs (Azar,2002; Hansen, 2001). IRBs are often undertrained and over worked and many do notseem to readily understand the differencebetween the more serious risks inherent insome medical research and the milder risksinherent in most behavioral research (Azar,2002). In fact, Mueller and Furedy (2001)argue that there is very little evidence toshow that IRB reviews are effective inreducing risks to the public. Part of theproblem seems to be due to the lack of con-sensus on defining risk (Mueller & Furedy,2001). In addition, Mueller and Furedy(2001) argue that “the bad guys” are notgoing to come asking IRB/REB permis-sion.” (p. 27).1 Four potential categories ofrisk need to be assessed (social, physical,psychological, and economic), whichrequires that the membership of the reviewcommittee be carefully constituted and bal-anced to include the right expertise(Hansen, 2001). Informed consent alsorequires the right mix of individuals withthe right expertise (Hansen, 2001).

Minimal risk is defined in the CommonRule concerning social and behavioralresearch as “. . . the probability and magni-tude of harm or discomfort anticipated in theresearch are not greater in and of themselvesthan those ordinarily encountered in dailylife.” (Kessler, 2001, p. 15). Applying thisdefinition to actual research is difficult forboth researchers and IRBs. How do youeducate all concerned about what the risksare that are encountered by specific groupsof individuals in daily life? What are therisks for the individuals involved in your

research? Are these risks minimal or are therisks greater than what your subjects wouldencounter in daily life? Would your col-leagues and critics agree with your assess-ment of the level of risk? If the risks aremore than minimal, how do you obtainethical informed consent and how does thatimpact the design and methodology of yourresearch.

There seems to be general agreement thatIRB members need to be better educatedon what they are to do (Azar, 2002) andhow to do their job efficiently. TheNational Bioethics Advisory Commissionrecommended that all IRB members andregulatory staff be certified after demon-strating that they have the appropriateresearch related skills (Hansen, 2001). At least two groups are now developing programs to accredit IRBs (Azar, 2002). Seewww.ncqa.org/Programs/QSG/VAHRPAP/vahrpop.htm and www.aahrpp.org for moreinformation. The National BioethicsAdvisory Committee’s report on “Ethicsand Policy Issues in Research InvolvingHuman Participants” recommends thatthere be one set of regulations (rather thancompeting sets as now exist) to govern allresearch with human participants (Azar,2002). It is important for researchers towork closely with IRBs to help educatethem and to not try to circumvent theprocess by excluding information thatmight raise questions during the IRB reviewjust because it might be easier in the shortterm. In fact, it is useful for researchers tovoluntary to be on IRBs and to have col-leagues who conduct similar research alsoserve as members of IRBs to increase thelikelihood that the IRB has the right expert-ise. See http://ohrp.osophs.dhhs.gov for moreinformation on these issues. Evenresearchers now have to document that theyhave had appropriate education on how toprotect human subjects (Hansen, 2001;Striefel, 2001).

The issues related to the IRB processhave resulted in a federal advisory groupbeing formed to evaluate the issues relatedto protecting human research participants,especially in terms of social and behavioralresearch (Kessler, 2001). The advisorygroup gave imput concerning the IRB

continued on Page 9

In a social and economic climate thatincreasingly requires information about“evidence-based” treatments, practitionersof therapies that rely upon psychophysio-logical interventions are pressed to provideevidence that the methods they employactually work, are clinically effective, pro-vide outcomes that are equal to or betterthan other (often less expensive) therapies,and/or produce outcomes that are relativelymore free of undesirable ancillary effects(side effects) associated with the treatment.Additional information that is highly rele-vant to such evidence-based treatmentassessment may include the question oflong term outcomes and cost offset, e.g.,does the treatment produce meaningfulreductions in other treatment costs?Recently, this magazine carried an excellentarticle calling for standardization in instru-mentation, signal analysis, and practitionertraining, and highlighted the need for thedevelopment of normative databases (Sella2001). We cannot have effective standardi-

zation without effective studies demonstrat-ing efficacy and clinical effectiveness.

Recently, AAPB engaged in a collabora-tive effort with the Society for of NeuronalRegulation (SNR) to develop standards forevaluating research methodology and exam-ine the peer-reviewed literature for empiri-cal support of treatments. The resultingdocument, called the “Template forDeveloping Guidelines for the Evaluationof the Clinical Efficacy ofPsychophysiological Interventions,” wasaccepted and approved by the Boards ofboth organizations. It will be published inboth organizations’ journals and on thewebsites of both organizations. A summaryof the Template is included in this issue ofBiofeedback. The Template itself will beactively reviewed on a yearly basis to deter-mine whether it is serving the purpose forwhich it was intended or requires modifica-tion. Review panels will use the Template toproduce “white papers,”summarizing theefficacy of various biofeedback and neuro-

feedback applications. These white paperswill be available to organization members,other organizations and agencies, thirdparty payers, patients, and the general pub-lic. The results are intended to be educa-tional, provide information and guideresearch initiatives.

It is the hope and intent of the AAPBand SNR Boards that this joint effort willserve as a useful framework (template) andprovide the information and impetus topractitioners and researchers to organize,examine, analyze and report their data in atechnically and scientifically meaningfulmanner. This issue of Biofeedback is dedicat-ed to an initial examination of some meth-ods for data organization and analysis thatmay support that initiative.

ReferencesSella, G. (2001). To standardize or not to

standardize, that is the question. Biofeedback,. 29, 8-9,22.


Editorial: Accountability forEvidence-Based TreatmentsTheodore J. LaVaque, PhD, Green Bay, WI

PROFESSIONAL ISSUES

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FEATURE ARTICLE

“Not Different”Is Not “Equal”Theodore J. La Vaque, PhD, Green Bay, WI,Thomas R. Rossiter, PhD, De Pere, WI

Thomas R. Rossiter, PhD

Abstract: Clinic based research often is lim-ited by factors such as patient self-selection,financial limitations, and ethical constraintsthat are unique to private practice settings.The “gold standard” of sham (placebo) con-trolled, random assignment, double blindstudies is often not possible in clinical settings.One approach may be a multi-site TreatmentEquivalence design that directly compares aknown, effective “standard” treatment to theinvestigational treatment.

Introduction: TheImportance of EfficacyResearch

The design, implementation and analysisof studies to demonstrate the efficacy ofpsychophysiological procedures has becomemandatory. Increased social and scientificinterest in “Complimentary and AlternativeMedicine” has produced increased publicand scientific scrutiny of the claims madeby practitioners who offer other than“mainstream” treatments and therapies. Themost commonly accepted design for clinicaltrials in the medical literature is the ran-domized clinical trial (RCT) that reliesupon randomized assignment of patients totreatment conditions. The additional use ofa placebo or sham treatment condition hasbecome common and is regarded as the“best” design to assure the internal validityof the study. Additionally, the typical “dou-ble-blind” characteristic of the designrequires that neither the patient nor theresearcher (therapist, technician) be awareof who has been randomized into a particu-lar treatment “arm.” The resultant “doubleblind placebo controlled randomized assign-ment” design represents an attempt toassure internal validity of the study by

guarding against (or controlling for) factorsaffecting outcomes that have nothing to dowith the assumed “active ingredient” of thetrial (new) treatment.

Factors such as experimenter bias (alle-giance effects), outright fraud, natural histo-ry of the disease (natural recovery),statistical “flukes,” regression to the mean,and/or endogenous healing effects triggeredby participating in the study (the so-called“placebo response”) may give the appear-ance of improvement attributable to thenew treatment when, in fact, the treatmentitself may have had little or nothing to dowith the outcomes. Any improvement notattributable to the treatment is typically rel-egated to the category of a “nonspecificeffect” and or “placebo effect,” which is anunfortunate, confusing, and frequentlyinaccurate designation.

The standard placebo (sham) controlledRCT as a design choice usually is not possi-ble in studies of applied psychophysiology.Currently, clinical studies are unfunded andaccomplished in private clinical settings.There are constraints and limitations onresearch in the private clinic that may notbe present in research at an institutionallevel. Although it may be technically possi-ble to accomplish a sham controlled RCT(Cohen, Grahamn et al. 1977), it is anunrealistic and burdensome condition rarelyaccomplished in a private clinical setting.There are often ethical considerations thatcome into play if there is an effective treat-ment already available. In the ethical litera-ture, if one does not know that a particulartreatment is likely to be better than sham orplacebo treatment, “equipoise” (equal bal-ance) is said to exist. If that is true it cannotbe shown that a useful treatment is being

withheld for research purposes. Althoughthere is some dispute about the ethical limi-tations, generally speaking one cannot with-hold known, effective treatments forresearch purposes (La Vaque, 2001; LaVaque & Rossiter, 2001; WMA, 2001).

Obstacles to RandomizedClinical Trials inTreatment Settings

In a clinical setting, one does not havethe freedom to arbitrarily randomizepatients into various treatment conditions, alimitation frequently seen as critical bysome methodologists. However, particularlyin a clinic setting, the final arbiter of“equipoise” (uncertainty about which treat-ment is better) is the patient. As one authornoted “One cannot persuade a patient tojoin a behavioral treatment group if he orshe does not believe in the usefulness of thetechnique. Likewise, patients cannot be per-suaded to choose surgery if they prefermore conservative cures. In all these cases,goals and principles of the therapeuticmethods and the expected effects cannot behidden from the patient in a double-blindfashion” (Kotchoubey, Strehl, et al. 2001).

Further, trying to apply medical researchmethods to behavioral interventions mayhave unintended consequences. In at leastone study, for instance, the possibility wasraised that the use of non-contingent feed-back as a control (sham) condition, evenwhen the subjects were aware that the feed-back was non-contingent, may have mitigat-ed against the subjects’ ability to acquire theresponse when provided with the “true”(contingent) feedback (Kappes & Michaud,1978). It is therefore important to considerscientifically legitimate methods of data

Theodore J. LaVaque,PhD

acquisition and analysis that do not dependupon the placebo (sham) controlled RCT.

Alternate ResearchDesigns

Several approaches to data acquisitionand analysis in the clinic setting are certain-ly available, and some are presented in com-panion articles in this special issue by Drs.Trudeau and Matheson. The present articledescribes two statistical methods, the confi-dence interval approach (Westlake, 1981)and the nonequivalence null hypothesisapproach (Anderson & Hauck, 1983), thathave developed in the biomedical literatureover the past twenty years. The TreatmentEquivalence Analysis (TEA) allows twotreatments to be directly compared in ahead-to-head fashion. Rather than testingthe familiar null hypothesis (H0)of “no dif-ference” between conditions, the TEA setsan equivalence interval for a predeterminedrange of differences between treatment out-comes ( δ ) that might be found in a directcomparison. Since it is extremely unlikelythat a finding of exact equivalence (exactlyno difference) can ever be expected, theresearcher must provide an a priori state-ment of “how much difference” will beaccepted as indicating treatment equiva-lence (not clinically different), inferiority, orsuperiority. The reader is referred to excel-lent discussions by Hatch (1996) andRogers, Howard, and Vessey (Rogers,Howard et al. 1993), which detail the pro-cedures for analysis.

The first step for both the nonequivalencenull hypothesis and confidence intervalapproaches, as noted above, is to define theequivalence interval between the treatments.In the nonequivalence null hypothesisapproach, the next step is to carry out twosimultaneous one-sided hypothesis tests.The two treatments are considered equiva-lent if they differ by less than the equiva-lence interval (δ) in both a positive andnegative direction. Rather than performingtwo one-sided tests, the confidence intervalapproach constructs a confidence interval.The two treatments are considered to beequivalent if the confidence interval is con-tained within the equivalence interval ( +δand -δ).

The problem is that a finding of “no sig-nificant statistical difference” is not the

same as a finding of “equivalent” or “notinferior”. A statistical finding of “not signif-icantly different than” cannot be taken tomean “the same as.” A finding of “no signif-icant difference” can be accomplished sim-ply by running a shoddy study, such thatthe variance in the measures and other fac-tors would result in a finding of no statisti-cal difference, i.e., a failure to reject thenull hypothesis (H0) of “no difference”(Ellenberg & Temple, 2000; Temple &Ellenberg, 2000). Leber (1989) provides avery good example from drug studies sub-mitted to the FDA that clearly demon-strates how a series of clinical trials mightindicate “no significant difference” betweena standard antidepressant and a new drug.If the outcome data comparing only thedrugs are examined one would concludethere is clearly no difference in efficacybetween the new and standard drug. Whendata from the placebo control conditionsare included, however, it is quickly apparentthat neither the standard drug nor the newdrug differed from placebo in those trials.Observations such as these offer compellingevidence for the importance of placebo(sham) controls.

The TEA, on the other hand, can only besuccessful if the study is effectively accom-plished with as little “shoddiness” in themeasures as possible. The reader is cau-tioned that the issue of “assay sensitivity” isan important consideration. The examplefrom Leber (1989) serves to highlight thefact that a “standard treatment” may not bevery effective to begin with, so in such acase using the standard treatment as a stan-dard or benchmark against which a newtreatment is compared is not very informa-tive. For instance, comparing a behavioralintervention for depression (such as cogni-tive-behavioral therapy, or EEG biofeed-back) to an antidepressant drug providesuseless information, since it is known thatantidepressant drug studies are notoriouslysusceptible to “placebo” effects (the assaysensitivity is poor). In such a case, the useof a placebo pill or sham condition wouldbe quite acceptable ethically, but perhapsdifficult to accomplish clinically. By way ofcontrast, however, when the standard treat-ment is known to be very effective with asmall placebo effect (as with psychostimu-lants and attentional deficits), a TEA is not

only acceptable but may be ethicallymandatory (to avoid withholding an effec-tive treatment for purposes of research).The “upside” to the TEA is that it is at leastone option available to ethically accomplishstudies in a clinic setting without using aplacebo or non-treatment control. It canprovide evidence regarding the clinical effi-cacy of a new treatment, and is regarded asstrong evidence of efficacy, particularly ifthere is a similar finding by two independ-ent researchers (Chambless, 1995;Chambless, Baker, et al., 1998). The down-side is that the TEA requires a relativelylarge sample of subjects (N) to be success-ful, a factor that may mitigate against itsfrequent use in a clinic setting. This diffi-culty is illustrated in the study by Rossiterand La Vaque (1995) who directly com-pared psychostimulant medication to EEGoperant procedures in the treatment ofattention-deficit/hyperactivity disorder. Inthat study, using traditional analyses, “nodifference” was found between treatmenteffects, that is, the H0 of no difference wasnot rejected. The authors interpreted thefinding of “no statistical difference” betweentreatments as indicating there was equiva-lence between drug and biofeedback treat-ment outcomes. Both authors now agreethat a more appropriate analysis would havebeen the TEA. Re-analysis of the Rossiter &La Vaque (1995) data using both the non-equivalence null hypothesis and confidenceinterval approaches indicated that EEGbiofeedback (19/23 improved) was non-inferior, but did not meet the requirementsfor equivalence, to psychostimulant drugs(20/23 improved). Hwang and Morikawa(1999) conclude that the sample sizerequired to demonstrate equivalence in anactive control study is at least four timesthat for a placebo controlled superioritystudy, when the equivalence interval is cho-sen as one-half or less of the control treat-ment effect size.

ConclusionThere are both practical and ethical

advantages of seeking alternatives to therandomized clinical trial for research inapplied psychophysiology. The authors pro-pose the Treatment Equivalence Analysis(TEA) as a viable research design for effica-cy research in biofeedback and applied psy-


chophysiology. The TEA compares a newtreatment to a currently accepted therapywith well-documented efficacy. The TEArequires a relatively large sample of subjects,and careful adherence to the researchdesign. The TEA leads to a conclusion thatthe new therapy is equivalent in its efficacyto the established therapy.

ReferencesChambless, D. L. (1995). Task force on promo-

tion and dissemination of psychological procedures.The Clinical Psychologist, 48(1), 3-23.

Chambless, D. L., Baker, M. J., Baucom, D. H.,Calhoun, K. S., Crits-Christoph, P., Daiuto, A., etal. (1998). Update on empirically validated thera-pies, II. The Clinical Psychologist, 51(1), 3-21.

Cohen, H. D., Grahamn, C., Fotopoulos, S.S.,& Cook, M.R. (1977). A double-blind methodolo-gy for biofeedback research. Psychophysiology, 14,603-608

Ellenberg, S. S., & Temple, R. (2000). Placebo-controlled trials and active-control trials in the eval-uation of new treatments. Part 2: Practical issuesand specific cases. Annals of Internal Medicine,133(6), 464-470.

Hatch, J. P. (1996). Using statistical equivalencetesting in clinical biofeedback research. Biofeedbackand Self-Regulation, 21(2), 105-119.

Hwang, I. K., & Morikawa, T. (1999). Designissues in noninferiority/equivalence trials. DrugInformation Journal, 33, 105-1218.

Kappes, B., & Michaud, J. (1978). Contingentvs. noncontingent EMG biofeedback and handtemperature in relation to anxiety and locus of con-trol. Biofeedback and Self-Regulation, 3(1), 51-60.

Kotchoubey, B., Strehl, U., Uhlmann, C.,Holzapfel, S., Konig, M., Froscher, W.,Blankenhorn, V., & Birbaumer, N. (2001).Modification of slow cortical potentials in patientswith refractory epilepsy: A controlled outcomestudy. Epilepsia, 42 (3), 406-16.

La Vaque, T. J. (2001). Pills, politics, and place-bos. Journal of Neurotherapy, 5(1), 73-86.

La Vaque, T. J., &. Rossiter, T. (2001). The ethi-cal use of placebo controls in clinical research: TheDeclaration of Helsinki. Applied Psychophysiologyand Biofeedback, 26(1), 23-37; Discussion, 61-65.

Leber, P. D. (1989). Hazards of inference: Theactive control investigation. Epilepsia, 30 (Suppl. 1),S57-63; Discussion S64-8.

Rogers, J. L., Howard, K. I., et al. (1993). Usingsignificance tests to evaluate equivalence betweentwo experimental groups. Psychological Bulletin,113(3), 553-565.

Temple, R., & Ellenberg, S. S. (2000). Placebo-controlled trials and active-control trials in the eval-uation of new treatments. Part 1: Ethical andscientific issues. Annals of Internal Medicine, 133(6),455-463.

World Medical Association (2001). Declarationof Helsinki. 52nd WMA General Assembly,Edinburgh, Scotland. http://www.wma.net.

NoteOur appreciation to Dr. Bruno Kappes,

University of Alaska Anchorage, for drawing ourattention to this study


process to the National Bioethics AdvisoryCommittee. That committee ceased to existin October 2001, but several federal agen-cies are already implementing some of thecommittee’s recommendations (Hansen,2001). See La Vaque & Rossiter (2001),Glaros (2001), Striefel (2001), and Young(2001) for a series of articles and argumentsabout the ethical use of placebo controls,levels of risks, and associated ethical issues.

Good Sources ofGuidance

The American Psychological Association(APA) is in its sixth draft for the revision ofits ethics code which includes a number ofuseful guidelines for research and publica-tion (see www.apa.org). Discussed in thedraft, which will be finalized in August2002, are issues such as, what to include inthe informed consent process, wheninformed consent is not necessary, how todecide authorship for publications, dealingwith deception in research, plagiarism, etc.The APA ethics code provides some veryexplicit guidelines on dealing with ethical

issues in research, yet many issues remainunresolved. In addition, Sales and Folkman(2000) have published an excellent bookthat covers a wide range of ethical issuesrelated to conducting research with humanparticipants.

ReferencesAmerican Psychological Association (2001). APA

ethics code revision draft 6. www.apa.org.Azar, B. (2002). Ethics at the cost of research.

Monitor on Psychology, 33(2), 38-40.Carpenter, S. (2002). Plagiarism Monitor on

Psychology, 33(2), 38-40.or memory glitch. Monitoron Psychology, 33(2), 25-26.

Glaros, A. G. (2001). A comment on La Vagueand Rossiter. Applied Psychophysiology andBiofeedback, 26(1), 61-66.

Hansen, C. (2001). Regulatory changes affectingIRBs and researchers. Observer, 14(7), 13-14 & 25.

Kessler, A. (2001). Behavioral science workinggroup looks at IRB regulations. Observer, 14(10),15 & 40.

Koocher, G. P., & Keith-Spiegel, P. (1998).Ethics in psychology: Professional standards and cases..New York: Oxford University Press.

La Vaque, T. J., & Rossiter, T. (2001). The ethi-cal use of placebo controls in clinical research: TheDeclaration of Helsinki. Applied Psychophysiologyand Biofeedback, 26(1), 23-38.

La Vaque, T. J., & Rossiter, T. (2001). Responseto Striefel and Glaros. Applied Psychophysiology andBiofeedback, 26(1), 67-72.

Mueller, J. H., & Furedy, J. J. (2001). Reviewing for risk: What’s the evidence that itworks? Observer, 14(7), 1 & 26-28.

Murray, B. (2002a). Keeping plagiarism at bay in the internet age. Monitor on Psychology, 33(2),22-24.

Murray, B. (2002b). Research fraud needn’t happen at all. Monitor on Psychology, 33(2), 27-28.

Sales, B. D., & Folkman, S. (2000). Ethics inresearch with human participants. Washington, DC:American Psychological Association.

Steinberg, J. A. (2002). Misconduct of others:Prevention techniques for researchers. Observer,15(1), 11 & 40.

Striefel, S. (2001). Ethical research issues: Goingbeyond the Declaration of Helsinki. AppliedPsychophysiology and Biofeedback, 26(1), 39-60.

Young, L. D. (2001). Editorial: The ethics ofplacebo controlled clinical research and applied psy-chophysiology. Applied Psychophysiology andBiofeedback, 26(1), 17-22.

Footnote1 A REB is the Canadian version of an IRB.

Scientific Misconductcontinued from Page 5


Abstract: Recent research indicates thatobservational studies done prior to random-ized controlled studies (RCT’s) usually pro-duce the same results. Arguments are advancedto recognize the validity of well-done observa-tional studies. While both RCT’s and observa-tional studies can be poorly done, several goodstudies of both types (observational and RCT)in agreement may be the appropriate “goldstandard.” When randomization is not possi-ble or ethical, we need to rely on observationalstudies. The research cited in the present arti-cle demonstrates that observational studies canbe valid, and should not be discarded on thebasis of RCT orthodoxy alone.

IntroductionIn a recent editorial in the Journal of

Neurotherapy (Trudeau, 2001) I discussedthe value of observational studies in brainwave biofeedback. Since that editorial therehas been further discussion of the issue, andI think it is important to expand on whatwas originally put forth. Much of what Isaid could be applied to the field ofbiofeedback generally and discussing theissue more broadly seems appropriate. Oneof the shortcomings of biofeedback is thatthere are few published studies of random-ized controlled trials (RCT’s), especiallylarge N studies and multi-center studies.This is particularly true in the areas of myinterest – brain wave biofeedback, audiovi-sual stimulation and other neurotherapymodalities. This paucity of papers is due inlarge part to the difficulty of implementingrandom assignment to blind study condi-tions in a clinical practice situation involv-ing biofeedback. As editor of the Journal ofNeurotherapy, it is my impression that manybiofeedback and neurotherapy studies areobservational, submitted by authors who

are clinicians working with participants inpractice settings, and in some cases, in aca-demic settings that are also mainly clinical.Despite some attempts to do so, adequateblind placebo conditions have been difficultto implement, because biofeedback inher-ently involves direct participatory learningof feedback control to obtain a reward.Without reward, subjects are unlikely topersist with sham conditions, and will notput forth the effort of subjects receivinggenuine feedback. Additionally, the man-aged care revolution in health care makes itincreasingly difficult to do clinical researchin a practice setting. Those researchers whocarry out such research typically do so on avolunteer basis; they donate their time andeffort to collect data pertaining to clinicaleffectiveness. The result of this is that stud-ies are generally small due to cost restraint.Only recently, funding has become availablefor studies of “alternative” therapies(through the National Center forComplementary and Alternative Medicineof the National Institutes of Health.)

As an example of some of the issues thatmay be encountered in biofeedback relativeto study design, consider Attention DeficitDisorder. Brain wave biofeedback studies ofAttention Deficit Disorder have been heldto the same standard as drug studies, buthave lacked the randomized clinical trialstudy design of drug studies, as well as thelarge number of subjects in such studies.The pharmaceutical industry has supportedmultiple large-N randomized drug studiesof ADHD, and these studies have beenembraced as definitive, because they arethought to leave no room for selection bias,although they may be highly limited interms of inclusion/exclusion criteria.

Furthermore it is difficult (if not impossi-ble) to come up with placebo conditionsthat can be studied against attentional brainwave biofeedback. Consequently, the bulkof studies of ADHD that do exist are byclinically oriented neurotherapists reportingon small randomized controlled or observa-tional studies and cases. These studies gen-erally have been underreported in themainstream literature.

Meta Analyses ofObservational Studiesversus RCT’s

For many years RCT’s have been the onlyaccepted gold standard of efficacy. They arebelieved to provide much stronger evidencethan observational studies such as cohort orcase control studies. Two published reportsin the New England Journal of Medicine(Benson & Hartz, 2000; Concato, Shah, &Horwitz, 2000) find that the results ofobservational studies are very similar tothose of controlled clinical trials. Althoughthere is controversy surrounding the conclu-sions of these reports, which I shall describein more detail, I believe this is importantinformation for biofeedback researchers,who are often unable to undertake expen-sive and difficult to perform randomizedcontrolled studies.

Benson and Hartz (2000) examined 136reports of 19 diverse medical and surgicaltreatments. The studies were contemporary,occurring between 1985 and 1998. In only2 of the 19 analyses of treatment effects didthe combined magnitude of the effect lieoutside the 95% confidence level whenobservational studies were compared to ran-domized studies. These authors used fourselection criteria for observational studies.

FEATURE ARTICLE

Observational Studies vs.Randomized Controlled Trials:Implications for BiofeedbackDavid L. Trudeau, MD, Cornucopia, WI David L. Trudeau, MD


The first is that the study was not experi-mental - that is to say treatments were notassigned for purposes of research, and assuch could be retrospective. Secondly, thestudy looked at differences between twotreatments or between one treatment andno treatment. Thirdly, the treatments wereprescribed by the health care giver, and notself prescribed. Each of the observationalstudies included a control group, similar insocial demographics and symptom intensityto the treatment group. In most cases theobservational studies were done first, withrandomized controlled trials following.Interestingly, the general effect of conduct-ing the more expensive and difficult to per-form randomized controlled trials was thatthey confirmed the observational studies.The authors acknowledge that the funda-mental criticism of observational studies isthat unrecognized confounding factors maydistort the results. “According to conven-tional wisdom this distortion is sufficientlycommon and unpredictable that observa-tional studies are not reliable and shouldnot be funded. Our results suggest thatobservational studies usually do providevalid information” (Benson & Hartz, 2000,p 1884).

In a second study, Concato, Shah, andHorowitz (2000) examined meta-analyses ofeither randomized, controlled trials or thoseof cohort or case control studies assessingthe same intervention. Using this somewhatdifferent approach, they reached a similarconclusion as Benson and Hartz, namelythat well designed observational studies aresimilar in validity to randomized controlledclinical trials. In their words, “the ‘average’results from well-designed observationalstudies (with a cohort or case controldesign) did not systemically overestimatethe magnitude of the associations betweenexposure and outcome as compared withthe results of randomized, controlled trialsof the some topic” (Concato, Shah, &Horowtiz, 2000, p. 1890). In fact theauthors assert that trustworthy resultsobtained from several quality observationalstudies may sometimes give the rightanswers when the results from a single ran-domized study do not. They suggest thatthe time honored hierarchy of researchdesigns (i.e., randomized controlled studies

are evidence of the very highest grade andmuch superior to observational studies)needs to be re-evaluated.

These articles generated a great deal of discussion. An accompanying editorial by Pocock and Elbourne (2000) as well as an editorial in the British Medical Journal(Ioannidis, Haidich, and Lau, 2001) werefollowed by correspondence (Kuntz, et al., 2000) in the New England Journal of Medicine and online at the British Journal of Medicine site:http://bmj.com/cgi/eletters/322/7291/879#EL1

I will attempt to summarize this discus-sion, both pro and con in the following sec-tions:

Discussion in Favor of the Validity ofObservational Studies. Supporting thefindings of Concato, Benson and col-leagues, Ionades, Haidich and Lau (2001)reported that “A correlation analysis weperformed on their combined databasesfound that the correlation coefficientbetween the odds ratio of randomised trialsand the odds ratio of observational designsis 0.84 (P<0.001)” (p. 879). This is indeedexcellent agreement. These authors alsonote that in certain circumstances observa-tional studies are appropriate, and in dis-cussing appropriate conditions consider thebalance of treatment effect, ethical consider-ations and sample size requirements.Observational studies are especially suitedfor interventions that show very large harm-ful effects. Likewise, with “interventionsthat have already shown large beneficialtreatment effects in observational trials (riskratios less than 0.40) the ethics of random-ization may also be questioned” (Ionades,Haidich, & Lau, 2001, p. 880). However,“interventions with modest postulatedeffects (risk ratios in the range 0.40-0.90)are likely to be targeted by randomized tri-als; in this setting, observational studiesmay not be given comparable credit andmay be unjustifiably discarded once ran-domised trials have been performed. Finally,for interventions with very small postulatedeffects (risk ratios 0.90-1.00) adequatelypowered randomised trials may be difficultto perform given the sample size require-ments, and thus only observational evidencemay be generated” (p.880).

Pockock and Elbourne (2000) note that

in some areas, such as monitoring for drugtoxicity or studying risk factors for disease,we must rely on observational data.“Detection of serious but rare side effectsrequires very large numbers of patients andcan be achieved only through analysis ofrecords from routine clinical practice”(p.1907 ). More importantly for biofeed-back, they note “for some treatments, ethi-cal considerations, practicality, clinicaljudgment, or unwillingness on the part ofpatients make randomized trials unrealistic,especially when the alternative treatmentsare radically different — as in the case ofsurgery and medical management. Problemsalso arise if the investigators themselves sim-ply refuse to accept randomization. In gen-eral, there is insufficient evaluation byrandomized, controlled trials of medicaldevices and surgical procedures” (p.1907). Iwould think this especially applies to situa-tions in biofeedback where the monitoringdevice is essential to the feedback loop pro-cedure, and effective control conditions fortherapist and patient blinding are difficultto design because their interactions areinherent elements of the feedback loop. Forinstance, I find it difficult to imagine thecoaching role of the therapist and thereward seeking role of the patient co-exist-ing with sham biofeedback treatment, inwhich neither party gets any response forhis or her efforts. On the other hand it isentirely possible to conduct non-blindedrandomized prospective studies comparingbiofeedback with established therapies.

In reviewing the discussions cited, severalpoints become apparent. Trustworthyresults obtained from several quality obser-vational studies may sometimes give theright answers when the results from a singlerandomized study do not. That is to say,there is no automatic ranking of veracity onthe basis of preconceived hierarchies.Furthermore, observational studies measureclinical utility in a way that RCT’s do not.In order to achieve homogeneity, RCT’stend to eliminate the outliers in a popula-tion in terms of severity, comorbidity, treat-ment refractoriness and chronicity. Becauseof this inherent bias in selection - lesscomorbidity, less severity, clinically non-rep-resentative population – the informationfrom RCT’s may not be applicable to clini-


cal treatment settings. None of us has aclinical practice consisting of typicalpatients who match predefined exclusionand inclusion criteria. Thus RCT’s maydemonstrate efficacy of an intervention fora defined population, but observationalstudies may be more likely to demonstrateeffectiveness – that is to say practical do-ability of an intervention in a practice set-ting. Most discussants seemed to agree thatit is valid to report on existing databasesusing well matched historical controls, as aprelude to RCT, especially when there is lit-tle or no information forthcoming fromRCT’s.

Furthermore, one can argue that for anyresearch conducted within a fee for serviceclinical practice, randomization becomesvery impractical. If the bulk of biofeedbackresearch that is being reported comes fromthe fee for service sector, and if most of thisresearch is non-funded or marginally fund-ed, then randomization becomes very diffi-cult, even if one compares two similarbiofeedback protocols, or compares biofeed-back to a known and accepted therapy.

Taking the above points into accountlends more credibility to observational stud-ies when done under certain circumstances.When the treatment effect is very large orvery small, when control design is inade-quate, when information is desired regard-ing clinical effectiveness, or when RCT’s aretoo expensive or complicated or impracticalto do, then observational studies have aplace. Using well-matched historical con-trols or contemporary controls is essential.

Discussion Rejecting the Validity ofObservational Studies. In their accompany-ing editorial, Pocock and Elbourne (2000)argue that the two cited meta analysis stud-ies of observational studies are selective andthat their results cannot necessarily be gen-eralized. “It is likely that the studies used inboth reports are a highly selected sample,since it is rarely sensible for a therapeuticquestion to be equally and simultaneouslyaddressed by both experimentation andobservation. This factor may explain whythe authors refer to the overall paucity oftherapeutic questions evaluated in both ran-domized, controlled trials and observationalstudies. Regulatory authorities appropriatelyrequire randomized, controlled trials as theprime acceptable evidence for drug licens-

ing, and medical journals have becomereluctant to publish claims for treatmentsbased on observational data.” (p.1908).This criticism is mirrored by Ioannidis,Haidich, and Lau (2001).

Several discussants pointed out that thereare still examples of misleading observation-al studies, some infamous, although theauthors pointed out that none of thosestudies met the criteria used in either meta-analytic study. The authors (Concato,Benson, and colleagues) were seen by manydiscussants as stacking the cards, so tospeak, selecting a small sample of studiesthat favored their conclusion in the face ofthe established RCT orthodoxy. Most criticscalled for substantially more evidence beforethey would be willing to place observationalstudies on any par with RCT’s in the hier-archy of evidence.

The Middle GroundThere seems to be a place for observa-

tional studies that is important. For one,observational data bases can be usefuladjuncts to randomized, controlled trials, tosee whether efficacy under controlled condi-tions in specialist centers translates intoeffective treatment in routine practice, sayPockock and Elbourne (2001). “Traditional,academically based, randomized clinical tri-als test an intervention against a placebo oralternate treatment control condition,focusing on a single, specific main outcome.Community-based intervention trials alsotest a treatment intervention but in thecontext of the community environment”(Hohmann & Shear, 2002, p.201). If stud-ies are to provide meaningful informationfor community clinical practice, then theymust take into account many factors thatare controlled or are not considered in tra-ditional clinical trials. Because they caninclude broader ranges of severity, co-mor-bidity and chronicity, observational studiescan be better suited to account for thesocial and cultural norms, expectations, andconflicts of the community and of the set-ting.

Secondly, observational study designs canbe substantially more flexible and exe-cutable, especially in situations where ran-domization is difficult or impossible.Concato and colleagues, in response to vari-ous critics (see Kunz, et al. 2000), state that“we sympathize with all who find intellectu-

al security in randomization as a method ofensuring the validity of study results. Surely,however, other methods (matching, stratifi-cation, adjustment, and restriction) areavailable to ensure validity when random-ization is absent.” (Kuntz, et al. 2000, p.1197). Concato and colleagues continue,stating that one of the implications of theirresearch is that randomized trials havetaught investigators how to design and ana-lyze better observational studies than single-group trials and case series. “We shouldcelebrate this enhanced quality of observa-tional studies and the opportunity it pro-vides for evaluating therapies in clinicalmedicine” ((Kuntz et al., 2000, p. 1197).

In summary, while both RCT’s andobservational studies can be poorly done,several good studies of both types (observa-tional and RCT) in agreement is the appropriate “gold standard.” When ran-domization is not possible or ethical, weneed to rely on observational studies. Theresearch cited in the present article demon-strates that observational studies can bevalid, and should not be discarded on thebasis of RCT orthodoxy alone.

A joint committee of SNR and AAPBheaded by Ted LaVaque and D. CorydonHammond will soon publish a “Templatefor Developing Guidelines for theEvaluation of the Clinical Efficacy ofPsychophysiological Interventions.” Thetemplate paper will be published simultane-ously in the Journal of Neurotherapy and inApplied Psychophysiology and Biofeedback1. Inthis template, observational studies aredefined as “Retrospective or prospectivestudies that are case controlled but not ran-domized or blinded. These are moreinformative than case series that are uncon-trolled, but suffer from the same limitationsof other designs that do not have either ran-domized or blinded assignment” (LaVaque& Hammond, in press). This statementembraces the orthodox research design hier-archy. The template goes on to state that“replication, using appropriate designs andanalysis, by two or more independent sitescontributes significantly to the credibility ofthe reports. While randomized assignmentto treatment conditions may represent thecurrently accepted scientific ideal, recent

continued on Page 16


FEATURE ARTICLE

Research Methodology, Validity, andEvaluating Studies: What’s OK forResearch in Psychophysiology? Douglas W. Matheson PhD, Stockton, CA USA Douglas W. Matheson

PhD

Abstract: The author proposes that practi-tioners need to understand the elements of sta-tistics and research design, in order to read,understand, and critically assess researchreports on the efficacy of clinical interventions.The article reviews basic concepts in researchdesign, including true experiments, quasi-experiments, random sampling and assign-ment, internal and external validity, effectsize, and false knowledge. Several researchreports are introduced to illustrate and clarifyprinciples of research design.

The Relevance ofResearch Methodologyfor Clinicians

Students taking their first course inResearch Methods are asked to learn thebasic tenets including determinism, trueexperiments, quasi-experiments, threats tointernal and external validity, control ofextraneous factors, the logic of statisticaldecision theory (hypothesis testing), type Iand type II errors, power and sample size, apriori vs. a posteriori testing, and the gospelaccording to folks named Student, Fisher,Pearson, and Campbell and Stanley. Whyshould clinicians be concerned about theseissues?

Generally speaking, clinical practice reliesto some extent on the literature andresearch findings of the discipline. Researchand its design provide the engine that drivesmost quality clinical procedures. Researchdesign is the plan of an experiment. For apractitioner to follow the evolving researchliterature on effective therapies, at least anelemental understanding of research designis critical.

True ExperimentsTrue experiments involve the manipula-

tion of independent variables in experimen-tal designs utilizing two or more groupscalled between groups designs, or counter-balancing treatment effects in within sub-jects designs by giving all possible sequencesof events in order to control order effects.An independent variable is defined as a fac-tor, under the control of the experimenterthat has at least two levels, one level calledthe experimental treatment and the otherthe control treatment.

Between groups designs utilize an experi-mental group that gets the active level ofthe independent variable and a controlgroup that gets the null or no effect level ofthe independent variable. If the experimentshows differences after the treatment isgiven, the difference is attributed to theexperimental treatment level of the inde-pendent variable, assuming that the partici-pants are randomly assigned to groups andthat the treatments are randomly assignedto groups. Randomization provides that, on the average, groups are equivalent at the outset of the experiment. True experi-ments use random sampling of participantsfrom a specific population, and/or randomassignment of participants to groups.Randomization controls for sources of vari-ation such as individual differences, historyand maturation effects, and reactive effectsin the participants (due to participation inthe experiment). True experiments consti-tute the model for what scientists wouldlike to do in order to identify and provecause and effect relationships in nature.

A counter-balanced design controls for

order effects and is one where many if notall possible sequences of independent vari-able are used. The design assumes that anysequence effects are eliminated.Counterbalanced designs are not withoutproblems that make them more subject toerror than between-groups designs.

In sum, the major ingredients in a trueexperiment are random sampling andassignment, and manipulation of an inde-pendent variable. True experiments are noteasy to achieve. First a large population ofparticipants from which to sample is oftennot available. The available pool might besmall, and more importantly, may not rep-resent the real world. Secondly, in an effortto do the right thing regarding sampling,scientists often set up a sampling strategythat does not reflect the actual nature of thepopulation. Let’s take a look at a couple ofexamples.

Leibovici (2001) conducted a randomizedcontrolled outcome study (between subjectsexperiment) using 3393 participants whohad bloodstream infections and were admit-ted to a hospital between 1990 and 1996.He referenced two previous studies thatclaimed that remote retroactive intercessoryprayer had had a positive effect on personsadmitted to coronary care units 5 to 10years previously.

The participants in the Leibovici studywere randomly assigned to two groups, anexperimental group and a control groupwith the hypothesis being: remote, retroac-tive intercessory prayer reduces the mortali-ty and shortens the length of stay in thehospital and the duration of fever for theintervention group. Remote intercessory


prayer is defined as praying for personsunknown. Retroactive means that the“experimental group” received prayer fortheir well-being and recovery some five toten years after they had been dischargedfrom the hospital. For the experimentalgroup, a list of first names was given to aperson who offered a short prayer for thewell being and full recovery of all those inthe experimental group. No mention wasmade of equal attention given to the con-trol group. The names were drawn from thehospital computer database by diagnosisand were randomly assigned by computerto the treatment conditions.

The results showed that there was no sig-nificant difference in mortality rates, butdid show statistically significant differencesin length of stay in the hospital and dura-tions of fever in favor of the intervention(experimental) group. In his discussion,Leibovici claimed that retroactive interces-sionary prayer was associated with shorterstays and lower fever in patients with blood-stream infection. His claim fell short of acause and effect statement, but it certainlyclaimed association.

The author further stated there is “noknown mechanism” to explain the effects ofretroactive prayer on blood infection relatedvariables. No known mechanism may betranslated into “no known effect.” Theeffect size is the amount of influence theindependent variable has on the dependentvariable. In the prayer study, the effect sizecan be loosely defined as the differencebetween the mean hospital time and themean fever duration in the two groups.Since remote retroactive prayer was predict-ed to have an effect, we must assume thatthe author intends to make a statementabout effect size even though he fails todefine a mechanism for the effect.

Cohen (1994) outlined how small, medi-um, and large effect sizes can interact withfactors such as sample size, error, and bothstatistical and practical significance.Essentially, the larger the sample size, theeasier it is to get statistical significance.From a statistical perspective, the larger thesample size the better the sample meanpoint estimates the population mean, andthe narrower the sampling distribution. Itfollows that the narrower the sample distri-

bution, the less the distributions overlapand the more likely we get statistically sig-nificant differences. In the large N prayerstudy, it is easy to see why there were statis-tical differences, even with a tiny effect size.In other words, given a large enough samplesize, it is easy to show statistically signifi-cant differences. Does it have any clinicalsignificance? Apparently it doesn’t.

True experiments, like this one, are saidto have higher external validity than smallsample or N=1 studies. That is, they can begeneralized more easily to the real world.

Internal and ExternalValidity

Let’s look more closely at two importantconcepts that affect the ability of researchersto control for factors in an experiment --internal and external validity. These con-cepts were made famous by Campbell andStanley (1963). Essentially internal validityis the degree to which an experimentalscheme is methodologically sound and freeof the influence of extraneous variables. Anexperiment is internally valid if it shows acause-effect relationship between the inde-pendent and dependent variable.

Leibovici (2001) came up short of claim-ing internal validity in his experiment, butdid hint that prayer is associated withreduction of hospital time and fever. Theproblem here is the changes could also beassociated with phases of the moon, thetides, and changes in the Dow Jones aver-age. Why? Because these other variableswere not taken into account. In fact, itcould be safely said, the perfect experimenton human behavior has yet to be done. Ifwe look long enough and hard enough, wecan always find both fault and virtue with atrue experiment.

Social Psychologist Donald Campbell,late of Lehigh and NorthwesternUniversities, led psychology in an effort toclean up its research nest. Campbell, whoproposed what he called “evolutionary epis-temology” as a unifying theory of knowl-edge, had as a major focus throughout hiscareer the study of false knowledge -- thebiases and prejudices that poison everythingfrom race relations to academic disciplineswhere erroneous theories are perpetuated bythose with vested interests inthem”(Northwestern University, 1999).

Let’s review some of the basics:External validity is the degree to which

experimental results may be generalized toother situations and populations, i.e., thereal world. Typically, group researchemploying random sampling and randomassignment to groups will initially possesshigher external validity than will studiesthat do not use random selection/assign-ment such as case studies and single-subjectexperimental research that do not use ran-dom selection/assignment. Traditionally,single subject designs and case studies,using subjects as their own controls, havehigh internal validity and low externalvalidity while completely randomized groupoutcome true experiments are the reverse,lower in internal validity and higher inexternal validity (Matheson, Beauchamp, &Bruce, 1978). There are thousands of con-trolled outcome studies that claim to haveyielded significant treatment effects butmay in fact not have (Matheson, 2002).

Quasi-Experiments“For generations, virtually no respectable

researcher this side of the orbiting space labhas designed or carried out a reputable sci-entific study without an understanding inwhat Campbell called quasi-experimenta-tion, the highly sophisticated statistics-based approach he invented to replicate theeffects of the truly randomized scientificstudies that are all but impossible in thecomplex world of human behavior”(Northwestern University, December,1999). Quasi-experimentation literallymeans “almost” experimental implying thatthe procedure tries to emulate a true experi-ment without the support of random sam-pling or has incomplete control overfundamental variables. Quasi-experimentsare done more frequently in psychophysiol-ogy than true experiments because randomsampling is often not possible.

After the smoke clears and the dust set-tles, the prayer study then was not a “trueexperiment”, but rather a quasi-experimen-tal design because extraneous variables werenot controlled. So, random sampling maynot be the panacea previously thought.What happens if the sampling procedure isso restrictive that it prevents a study fromadequately representing a population?Zimmerman, Mattia, and Posternak (2002)


observed that methods used to evaluate theefficacy of antidepressant medication differfrom treatment for depression in routineclinical practice (Zimmerman et. al. 2002)

The inclusion/exclusion criteria in suchresearch on anti-depressants narrow thedemographics of the sample in order tolimit the effects of extraneous variables.Used primarily in drug trials, the set ofinclusion/exclusion criteria specified inthese clinical trials applies primarily to effi-cacy trials evaluating the potential of atreatment (drug) when taken as prescribed.Zimmerman et al. (2002) found that theinclusion/exclusion method seriouslyrestricts the size of the usable sample. Ofthe 803 participants in their clinical sam-ple of depressed individuals, 86% wouldhave been excluded from clinical trialsbecause they had co-morbid symptomsincluding bipolar or psychotic disorders,suicidal tendencies, were not depressedenough, or had other symptoms leading toexclusion. The authors concluded that theremaining patients (N=252) were not repre-sentative of real world of clinical practiceand in fact represent a minority of patientstreated in clinical practice. If clinicalresearch is reduced to not being applicableto clinical practice, what good is it?

The inclusion/exclusion method runs theserious risk of reducing the external validityof a study to make it of questionable valueto the clinical practitioner. If we can’t gener-alize to our situation, where is the utility?

Research in Psychology,Psychophysiology, andBehavioral Medicine

What do we do as clinicians andresearchers to glean some truth out of theliterature? Obviously the answer is com-plex, unclear, and may sound vague. We dothe best we can to evaluate the literaturerealistically. We must keep in mind the factthat most of the literature of psychology isbased on sophomores in college takingIntroductory Psychology classes and partici-pating in experiments for extra credit orclass requirement or rats kept in galvanizedcages in some dark laboratory colony. Theconcepts of internal and external validityare guidelines that help readers evaluate theutility of studies (proposed or published).

One solution is to keep the internalvalidity high by doing N=1 studies. There isno problem with individual differencesbecause there are none. To evaluate thesestudies Gottman and Leiblum (1974) offera solution. They suggested using a ShewartChart (used in quality control in manufac-turing) to evaluate behavior change in N=1studies. Essentially, it involves using a confi-dence interval approach about the mean ofongoing behavior over at least 40 or moretrials. To visualize, draw an X and Y axis.Plot the data for a baseline period beforeintervening. One must be careful here toinsure that the baseline shows random vari-ation and independence. If the baseline isnot independent, the concept of autocorre-lation is introduced (Gottman & Leiblum,1974, pg. 144) and steps must be taken totransform the data to alleviate autocorrela-tion.

Autocorrelation exists if knowing aboutone thing reduces the uncertainty about theother. With autocorrelation, we can predictthe future by knowing the past and obvi-ously the data are not independent. Oncewe know that the baseline is independent,we calculate the mean and standard devia-tion of the data over this period. Extend ahorizontal line from left to right represent-ing the mean. Similarly extend two otherhorizontal lines representing 2 standarddeviations above and below the mean. Plotthe behavior. Whenever the behavior driftsbeyond the 2 standard deviation interval,we might say the behavior has changed sig-nificantly.

The other approach is to actually do arandomized controlled outcome study usinga sample that does not include college soph-omore or a restricted inclusion/exclusionmethod. This approach is difficult, if notimpossible. How do I find a large sample ofparticipants suffering from spasmodic torti-collis or OCD while controlling for age,gender, and length of time the disorder hasbeen present?

The answer lies somewhere in between.Our government (FDA) has taken seriousstrides to improve the interpretation of drugeffects, claims about biofeedback instru-ments, and clinical research, in general toprotect the citizenry from harm, and that’sgood. However, some think it’s overkill.

Sampson (1978) complained that the FDAoften drags its feet because efficacy studies,double blind studies, and hugeinclusive/exclusive studies are not availableto support the use of some drugs. The casein point is the drug Chymopapain, anenzyme injected into damaged spinal lum-bar spinal disks to reduce pain and sufferingby relieving the pressure from the nerveroots. The drug is widely used in Europeand Canada, but at the time, is not avail-able in the US because of the control issuelisted above. Sampson clearly felt that polit-ical issues were involved and the lack of bigstudies that yield questionable results mightbe problematic.

Meanwhile, back at the ranch, peoplewere suffering. Wittenberg, Oppel,Rubenthaler and Steffen (2001) found, in arandomized study, done in Germany, thatafter 5 years, good and excellent results wereobserved in 72% of the Chymopapaingroup. That is, nearly 3/4 of the patients inthe trial benefited from the enzyme.

ConclusionAn issue with our body of knowledge is

that only significant results are usually pub-lished. What about all the studies that don’tmake the cut? Driving up a one-way streetthe wrong way (assuming you don’t crash)can be a learning experience. We learn whatnot to do the next time. The only way forbiofeedback clinicians to improve their clin-ical services is to be aware of the pitfalls ofbad research and try not to make the mis-takes of others. There is no substitute forknowledge of and about research methods. Iremember a quote from one of my statisticsprofessors who related, “if you don’t believein something, you will fall for anything.”Most of us believe in the scientific method,but we must use it judiciously and correctlyif we are going to flourish as a discipline.We have to have more than Dr. Dean Edellreviewing the literature, telling us what isgood and bad, and understanding the issuesinvolved in research.

ReferencesCampbell, D., & Stanley, J. (1963). Experimental

and quasi experimental designs for research. Skokie,Illinois: Rand McNally.

Cohen, J. (1994). The earth is round (p<.05).American Psychologist, 49, 997-1003.

Leibovici, L (2001) Effects of remote, retroactive

meta-analyses have indicated that non-ran-domized observational studies can producesimilar results.” This cautious and conserva-tive statement does at least acknowledgethat there is a place for well designed andcontrolled observational studies in biofeed-back. This position of the joint committeeis important considering the arguments thathave been advanced regarding the place ofobservational studies where clinical effec-tiveness and difficulty with controls forcondition and with randomization areissues.

ConclusionsWhat does this mean for biofeedback

research and reporting? For one thing, thereis much existing data in clinical practicedatabases that can be examined for consis-tency of inclusion criteria, treatmentmethod and outcome assessment. Thesepooled data could be applied to a historical-ly matched case cohort observational study.If such a study could be done from severallarge clinical centers, this would enhance itscredibility. This approach could be appliedto biofeedback interventions for ADHD,learning disabilities, addictive disorders,post-concussive disorder, optimization ofperformance, anxiety, affective disorders,pain control, continence control, and other

clinical applications of biofeedback.Clinicians, students and academics interest-ed in brain wave biofeedback and otherforms of biofeedback may have access toclinical treatment databases that can bedeveloped into more valid observationalstudies of treatment effectiveness. Whilethese retrospective case cohort studies, ifwell designed, can stand on their own mer-its, they will add to the growing body ofvalid studies showing efficacy, and could bethe basis for fundability of longer-termlarge-n randomized multi-center controlledstudies.

From my perspective as an editor, review-ing submitted papers in brain wave biofeed-back, it seems to me that this field is readyto move on from case reporting and openclinical trials, but may not be altogetherready for funded large scale RCT’s.Observational studies are needed and exe-cutable. The evidence that observationalstudies can be as valid as randomized stud-ies supports the credibility of publishedreports of biofeedback efficacy that arebased on observational design. No one isready to say that well designed observation-al studies are equally valid with welldesigned RCT’s, but they may be muchcloser than we have thought.

ReferencesBenson, K.,, & Hartz, A.J. (2000). A compari-

son of observational studies and randomized con-trolled trials. New England Journal of Medicine,342(25), 1878- 1886.

Concato, J., Shah, N., & Horowitz, R. (2000).Randomized controlled trials, observational studies,and the hierarchy of research designs. New EnglandJournal of Medicine, 342(25), 1887- 1892.

Hohmann, A. A., & Shear, M. K. (2002).Community-based intervention research: Copingwith the “noise” of real life in study design.American Journal of Psychiatry, 159(2), 201-207.

Ioannidis, J. P A, Haidich, A.B., & Lau, J.(2001). Any casualties in the clash of randomisedand observational evidence. British Medical Journal,322, 879-880.

Kunz, R., Khan, K. S., Neumayer, H.-H., Sacks,H. S., Liu, P.-Y., Anderson, G., Crowley, J. J.,Friedman, H. S., Smith, R. P., Meier, P., Benson,K., Hartz, A. J., Concato, J., Shah, N., & Horwitz,R. I. (2000). Observational studies and randomizedtrials. New England Journal of Medicine, 343,1194-1197.

LaVaque, T. J., & Hammond, D. C. (in press).Template for developing guidelines for the evalua-tion of the clinical efficacy of psychophysiologicalinterventions. Applied Psychophysiology andBiofeedback.

Pocock, S. J., & Elbourne, D. R (2000).Randomized trials or observational tribulations?New England Journal of Medicine, 342, 1907-1909.

Trudeau, D.L. (2001). The value of observation-al studies in brain wave biofeedback. (Editorial).Journal of Neurotherapy, 4 (3), iii-iv.

Observational Studies vs. Randomized Controlled Trialscontinued from page 12

intercessory prayer on outcomes in patients withbloodstream infection: randomized controlled trial.British Medical Journal, 323 (7327), 1450-1451

Matheson, D., Beauchamp, K., & Bruce, R.(1978). Experimental psychology: Research design andanalysis. New York. Holt, Rinehart, and Winston.

Matheson, D. (2002, Spring). Hardball withDoug Matheson Biofeedback Society of CaliforniaNewsletter.

Northwestern University (December,1999).Retrieved from Northwestern University social psy-chology website (reprint from the New York Times,1996), March 5, 2002.http://www.psych.nwu.edu/Academics/Social/Campbell.htm

Sampson, P. (1978). Chymopapain: A case studyin federal drug regulation. Journal of the AmericanMedical Association, 240 (3),195-205, 215-9.

Wittenberg, R., Oppel, S., Rubenthaler, F., &Steffen, R. ( 2001). Five-year results fromchemonucleolysis with chymopapain or collagenase:A prospective randomized study. Spine, 26 (17),1835-41.

Zimmerman, J., Mattia, J., & Posternak, M.(2002). Are subjects in pharmacological treatmenttrials of depression representative of patients in rou-tine clinical practice? American Journal of Psychiatry,159 (3), 469-473.



Abstract: The current Editor-in-Chief ofAAPB’s journal, Applied Psychophysiologyand Biofeedback, describes the ClinicalForum section of the journal, which welcomescase studies, clinical replication series, extend-ed treatment protocols, and clinical notes andobservations. The Clinical Forum is designedto facilitate innovation, and to disseminateclinical findings and intervention techniques,before large scale research has been conducted.The author introduces each of the formatsmethodologically, and encourages readers tosubmit clinical papers for publication in thejournal.

As Editor-in-Chief of our association’sscholarly journal, Applied Psychophysiologyand Biofeedback (APB), I am pleased to begiven the opportunity to discuss theClinical Forum section in our journal. Thisarticle allows me to reaffirm the journal’slongstanding interest in clinical aspects andto encourage readers to consider submittingtheir clinical papers for publication consid-eration.

The seeds for this forum were sownshortly after I assumed the duties of overalleditor. During the first year of my initialappointment I announced the formation ofa “new” feature, that being the “CaseStudies and Clinical Replication Series”(Andrasik, 1995) as a way to increase thefocus on clinical cases, clinical innovations,and small-n research. I say “new” becausethe journal in actuality has always includeda focus on case studies. A search of the earlyissues of the journal (late 1970’s) revealssections variously labeled as “Case Reportsand Training Techniques” and “Case Studiesand Clinic Management,” with a number ofinteresting and ground breaking cases

appearing in these sections. Somewherealong the way, though, some of the sectionlabels fell into disuse, perhaps communicat-ing to some that the journal had becomeless interested in such papers. This is not so.

A more expanded section, now renamedas the “Clinical Forum” was inaugurated inthe March 1999 issue of APB (Andrasik,1999). It included the two earlier men-tioned categories (case studies and clinicalreplication series), plus two additional cate-gories (extended treatment protocols andclinical notes and observations). TheClinical Forum, thus, was launched toreemphasize the journal’s interest in clinicalmatters and to provide an expanded arrayfor publishing clinically-oriented material.It is hoped that this type of publication out-let will be more feasible and accessible forclinicians who might lack the resources andopportunities to conduct more traditionalresearch, but who have valuable informa-tion to share with clinicians and researchersalike. This forum contains four submissioncategories, and each is discussed in briefbelow.

Case Studies: Science and practice bothowe a great debt to well-conceived casestudies, both controlled and uncontrolled.Historically, intensive analysis and study ofthe individual was preeminent in psycholo-gy, psychiatry, and physiology. It wasthrough the intensive study of single casesthat significant findings with wide applica-bility emerged. Examples include localiza-tion of the speech center by Broca,determination of sensory thresholds andjust noticeable differences by Fechner,development of the introspective method byWundt, establishment of basic principles of

human learning, most notably the retentioncurve, by Ebbinghaus, classical conditioningby Pavlov, and many others (see Barlow &Hersen, 1984, for a more expanded discus-sion).

APB places a high value on small-nresearch, which is particularly suited todevelopment and initial testing of new con-ceptual, assessment, and treatmentapproaches, to the study of rare or unusualcases where aggregation of large sample sizesis not possible, and to cases that are inimmediate need of treatment and cannotendure the extra time so often required forparticipating in larger scale clinical trials. Infact, an article discussing the potential ben-efits to and encouraging the use of small-nresearch was contained in one of the firstissues of our journal (then namedBiofeedback and Self-Regulation) (Barlow,1977). The aforementioned text by Barlowand Hersen (1984), as well as the compan-ion text of Barlow, Hayes, and Nelson(1984), a chapter by Kratochwill, Mott, andDodson (1984), and the other papers inthis series discuss strategies for approachingsingle cases or small groups of individuals inways to optimize the yield.

Clinical Replication Series: Barlow andHersen (1984) define clinical replication asbelow:

… the administration by the same investiga-tor or practitioner of a treatment packagecontaining two or more distinct treatmentsprocedures. These procedures would beadministered in a specific setting to a seriesof clients presenting similar combinations ofmultiple behavioral and emotional prob-lems. Obviously, this type of replicationprocess is advanced in that it should be theend result of a systematic, technique-build-

FEATURE ARTICLE

The “Clinical Forum” in AppliedPsychophysiology and Biofeedback,or Something Old, Something NewFrank Andrasik, PhD

ing applied research effort, which shouldtake years (p. 367).Thus, in conducting a clinical replication

series, the clinical investigator implements awell-defined and established intervention(with supporting empirical data) with alarge number of clients (typically 10 ormore), whose characteristics are clear andwell described. This research strategy is par-ticularly well suited to clinical and otherapplied settings that are known as havingspecial expertise for working with certaintypes of clients or for administering certaintypes of treatments. Each successive system-atic application of treatment adds to thepotential impact of the series. The mainpurpose is to determine generality of find-ings in the actual field setting (what hasbecome to be known as an “effectiveness”study, Seligman, 1995), to establish size ofeffect (statistical as well as clinical import;see Jacobson & Truax, 1992), and toexplore subject/treatment interactions, not-ing in particular what might account fordifferential responding (successful versusunsuccessful response).

Classic examples include the clinicalreplication series by Masters and Johnson(1970) that led to widespread adoption ofnew approaches to sex therapy by practi-tioners, the seminal work by Wolpe (1958)for the treatment of clinical phobia, thedetailed and systematic work of Lovaas andcolleagues with autistic children (Lovaas,Koegel, Simmons, & Long, 1973), and,within our own association, the early workof Elmer Green and colleagues with auto-genic feedback. The journal has publishedseveral clinical replication series since theintroduction of this section. Readers con-templating preparation of such a submis-sion may wish to consult these past articles(Deepak & Behari, 1999; Donaldson,2000; Lehrer, Smetankin, & Potapova,2000; McGrady, Bush, & Grubb, 1997), aswell as the text by Barlow et al. (1984).

Extended Treatment Protocols: This cat-egory is designed to permit a more detaileddescription of new, innovative treatments orsubstantive treatment modifications than ispossible in the typical article. The intent isto describe a treatment with sufficient detailso that the treatment can be employed asintended by other clinicians and researchers.Contributions are not to be construed as

containing highly detailed treatment manu-als, however. The protocol must be accom-panied by some data that support its utilityand a limited number of supporting refer-ence citations. The first (and to date, theonly) extended treatment protocol appearedjust a short time ago (Lehrer, Vaschillo, &Vaschillo, 2000). Further such protocoldescriptions, with supporting data, arehighly welcomed.

Clinical Notes and Observations: Thisfinal category is a partial reinstatement ofthe Notes and Observations section thatwas initially introduced during the co-edi-torship of Edward B. Blanchard and MaryR. Cook (Blanchard & Cook, 1985); theonly revision is that this section is now lim-ited to clinical phenomena). Papers for thissection are brief in nature, informative, andnovel. They may address topics such as, butnot limited to, the following: rare or unusu-al disorders responding positively to treat-ment, serendipitous findings, and unusualor negative reactions that have surfaced dur-ing treatment. Articles may include selectreference citations and a limited number ofillustrations or tables. Brief letters com-menting on clinical studies previously pub-lished in the journal are appropriate for thissection as well. The journal awaits the firstpublication of an article in this “new” cate-gory.

In conclusion, APB remains open andsympathetic to clinical work of all types.Many important advances have come about because of innovative case studies,carefully conceived single-case experiments,intensive clinical replication series, andsharing of clinical insights and discoveriesin publications. If your work fits into any of these categories, I hope you will considersubmitting and sharing it. If you are uncer-tain or otherwise would like to discuss yourpotential contribution, the editorial office is only a phone call (850-202-4460) oremail ([email protected]) away.

ReferencesAndrasik, F. (1995). Editorial announcement.

Biofeedback and Self-Regulation, 20, 203-204.Andrasik, F. (1999). Editorial Announcement.

Applied Psychophysiology and Biofeedback, 24, 1-2.Barlow, D.H. (1977). Single-case designs and

clinical biofeedback experimentation. Biofeedbackand Self Regulation, 2, 221-239.

Barlow, D.H., Hayes, S.C., & Nelson, R.O.

(1984). The scientist practitioner: Research andaccountability in clinical and educational settings.NY: Pergamon.

Barlow, D.H., & Hersen, M. (1984). Single caseexperimental designs: Strategies for studying behaviorchange (2nd ed.). NY: Pergamon.

Blanchard, E.B., & Cook, M.R. (1985).Editorial. Biofeedback and Self-Regulation, 10, 1.

Deepak, K.K., & Behari, M. (1999). Specificmuscle EMG biofeedback for hand dystonia.Applied Psychophysiology and Biofeedback, 24, 267-280.

Donaldson, V.W. (2000). A clinical study ofvisualization on depressed white blood cell count inmedical patients. Applied Psychophysiology andBiofeedback, 25, 117-128.

Jacobson, N.S., & Truax, P. (1992). Clinical sig-nificance: A statistical approach to defining mean-ingful change in psychotherapy research. In A.E.Kazdin (Ed.), Methodological issues and strategies inclinical research (pp. 631-648). Washington, DC:American Psychological Association.

Kratochwill, T.R., Mott, S.E., & Dodson, C.L.(1984). Case study and single-case research in clini-cal and applied psychology. In A.S. Bellack & M.Hersen (Eds.). Research methods in clinical psychology(pp. 55-99). NY: Pergamon.

Lehrer, P., Smetankin, A., & Potapova, T.(2000). Respiratory sinus arrhythmia biofeedbacktherapy for asthma: A report of 20 unmedicatedpediatric cases using the Smetankin method.Applied Psychophysiology and Biofeedback, 25, 193-200.

Lehrer, P.M., Vaschillo, E., & Vaschillo, B.(2000). Resonant frequency biofeedback training toincrease cardiac variability: Rationale and manualfor training. Applied Psychophysiology andBiofeedback, 25, 177-191.

Lovaas, O., Koegel, R., Simmons, J.Q., & Long,J.D. (1973). Some generalization and follow-upmeasures on autistic children in behavior therapy.Journal of Applied Behavior Analysis, 5, 131-166.

Masters, W.H., & Johnson, V.E. (1970). Humansexual inadequacy. Boston: Little, Brown.

McGrady, A.V., Bush, E.G., & Grubb, B.P.(1997). Outcome of biofeedback-assisted relaxationfor neurocardiogenic syncope and headache: A clin-ical replication series. Applied Psychophysiology andBiofeedback, 22, 63-72.

Seligman, M.E.P. (1995). The effectiveness ofpsychotherapy: The Consumer Reports study.American Psychologist, 50, 965-974.

Wolpe, J. (1958). Psychotherapy by reciprocal inhi-bition. Stanford: Stanford University Press.



In June 2001 Donald Moss, thenPresident, Association for AppliedPsychophysiology and Biofeedback (AAPB) and Jay Gunkelman, then President, Societyfor Neuronal Regulation (SNR), appointeda Task Force to develop standards onresearch methodology and on the empiricalsupport of treatments. Theodore J. LaVaquerepresented AAPB as co-chair, and D. Corydon Hammond representedSNR as co-chair. The AAPB Neurofeedbackand sEMG Divisions supported the TaskForce and named delegates.

There have been several recent instancesin which researchers have made criticalstatements about biofeedback lacking effica-cy. For example, last year the Associationfor the Advancement of Behavior Therapynewsletter (The Behavior Therapist) pub-lished an article critical of neurofeedback(Lohr, Meunier, Parker, & Kline, 2001).Practitioners announce new applicationsregularly, yet as a field we fail to discrimi-nate among first line well documentedtreatments, and experimental new applica-tions. The current health care movementstoward evidence based medicine and “bestpractices” standards will leave biofeedbackbehind, unless we better validate/supportand rate our own treatment protocols.

The Task Force worked diligently for fourmonths, reviewing a massive body ofresearch reports on methodology and effica-cy studies. The American PsychologicalAssociation addressed many similar issues indeveloping its guidelines on the empiricalvalidation of psychological treatments.

Review of the APA efforts provided signifi-cant guidance and some of the frameworkfor the AAPB/SNR Task Force in develop-ing guidelines for rating the efficacy ofbiofeedback and neurofeedback treatments.

The Task Force produced a “Template,”which has now been approved as a policyguideline by both the AAPB and SNRBoards. This Template provides our fieldwith a strong set of methodological stan-dards, by which we can classify applicationsat one of five levels of efficacy, according tothe quality and quantity of available out-come research. A summary of the Templatefollows here, and the full text of theTemplate will be published in the journalsApplied Psychophysiology and Biofeedback andJournal of Neurotherapy.

Both AAPB and SNR extend gratitude tothe Task Force, its chairs, members, andreviewers, for providing guidelines for rat-ing applications of biofeedback and neuro-feedback.

____________________________SUMMARY: TEMPLATE FORDEVELOPING GUIDELINES FOR THE EVALUATION OF THECLINICAL EFFICACY OF PSYCHOPHYSIOLOGICALINTERVENTIONSEfficacy Template Taskforce

Co-chairs:Theodore J. La Vaque, PhDand D. Corydon Hammond, PhDCommittee: David Trudeau,MD,Vincent Monastra, PhD, JohnPerry, PhD,

and Paul Lehrer, PhDReviewers: Douglas Matheson, PhD,

Richard Sherman, PhDAs a result of the charge to the Task Force

Committee to develop guidelines for theevaluation of efficacy in biofeedback stud-ies, Dr. D. Corydon Hammond (co-chairappointed by the board of the Society forNeuronal Regulation [SNR]) and Dr.Theodore J. La Vaque (co-chair appointedby the Association for AppliedPsychophysiology and Biofeedback [AAPB])invited members from the respective organi-zations to serve as either committee mem-bers or consultants to the process. A special(closed) internet group was formed viaYahoo for the purposes of rapid communi-cation and the posting of relevant articles,comment and contributions to theGuidelines. The process began on June13,2001 and the final version was postedand accepted by the committee bySeptember 24, 2001. The final version wassubmitted to the board of SNR and AAPBand was accepted by both boards withoutrevision. The Guidelines are intended toprovide guidance to those committees thatwill be reviewing studies in the area of clini-cal psychophysiology and biofeedback forpurposes of producing “white papers” andefficacy reviews. The Template is not to beregarded as a fixed document, but will besubject to review and modification on ayearly basis based upon experience and rec-ommendations from members.

FEATURE ARTICLE

Task Force Report onMethodology andEmpirically SupportedTreatments: Introduction and SummaryDonald Moss, PhD, and Jay Gunkelman, QEEG-T

Jay Gunkelman, QEEG-TDonald Moss, PhD

There are seven main headings in the Template:A: Preamble: Outlines the purpose of the document.B: Panel Procedures:

1: Panel Membership: Procedures for establishing Panelmembership and

2: Panel process.C: Efficacy:

1: Overview2: Scientific Considerations3: Specificity4: Clinical Utility

D: Hierarchy of Evidence: Clinical Trials and Efficacy Studies1. Anecdotal Evidence2. Uncontrolled Case Study3. Historical Control4. Observational Studies5. Wait List or “Intention To Treat” Controls6. Within Subject and Intra-subject Replication Designs7. Single Blind, Random Assignment using either sham

or active treatment controls.8. Double Blind, Randomized Assignment9. Treatment Equivalence, Non-inferiority, or Superiority

Design.10. “Other Designs ( Double Dummy, Solomon Four

Group, etc.)E: Criteria for Levels of Evidence of Efficacy

1. Level 1: Not empirically supported. Supported onlyby anecdotal reports and/or case studies in non-peerreviewed venues.

2. Level 2: Possibly Efficacious: At least one study of suf-ficient statistical power with well identified outcomemeasures, but lack randomized assignment to a con-trol condition internal to the study.

3. Level 3: Probably Efficacious: Multiple observationalstudies, clinical studies, wait list-controlled studies,and within subject and intra-subject replication stud-ies that demonstrate efficacy.

4. Level 4: Efficacious: a.) In a comparison with a no-treatment control

group, alternative treatment group, or sham(placebo) control utilizing randomized assign-ment, the investigational treatment is shownto be statistically superior to the control con-dition or the investigational treatment isequivalent to a treatment of established effica-cy in a study with sufficient power to detectmoderate differences, and

b.) The studies have been conducted with a pop-ulation treated for a specific problem, forwhom inclusion criteria are delineated in areliable, operationally defined manner, and

c.) The study used valid and clearly specifiedoutcome measures related to the problembeing treated and

d.) The data are subjected to appropriate dataanalysis, and

e.) The diagnostic and treatment variables andprocedures are clearly defined in a mannerthat permits replication of the study by inde-pendent researchers, and

f.) The superiority, non-inferiority, or equiva-lence of the investigational treatment has beenshown in at least two independent researchsettings.

5. Level 5: Efficacious and specific:a.)The investigational treatment has been shown

to be statistically superior to credible shamtherapy, pill, or alternative bona fide treatmentin at least two independent research settings.

F: Other Considerations that Contribute to Confidence inEfficacy of a Study

G: Ethical Standards for ResearchThe full text of the Template has been submitted for publication

in the journals Applied Psychophysiology and Biofeedback and Journalof Neurotherapy. The document is also available online atwww.aapb.org/ and at www.snr-jnt.org/



Emerging Trends in Neurofeedback:I. On the Status and Future ofMechanisms-based TrainingBy Siegfried Othmer, PhD, Encino, CA

Siegfried Othmer, PhD

Abstract: Historically, the technique of neu-rofeedback developed around understandings ofbasic mechanisms. These provided a rationalefor intervention of neurofeedback in its earlyyears. To this day, most neurofeedback beingpracticed is still performed according to ratio-nales that can be traced to these early models,and can therefore be considered “mechanisms-based.” However, several new trends haveemerged in neurofeedback treatment that chal-lenge our traditional conceptions and compelus to expand our model assumptions. On theone side is the emergence of QEEG-basedtraining, and on the other the development oftraining models based on more general consid-erations of the brain as a self-organizing, non-linear dynamical system (and referred to hereinas NLD-based models). Both of these develop-ments have influenced the author’s approach tomechanisms-based training.

The History ofMechanisms-basedNeurofeedback TrainingThe Evolution of aNeurofeedback Protocol

The following review of the history ofneurofeedback is a limited perspective toldvery much from our own vantage point.When Sue Othmer and I came into thefield in 1985, because of the dramaticimpact of neurofeedback on our ownepileptic son (Robbins, 2000), we wereaware only of the work of Barry Sterman(2000), Joel Lubar, Michael Tansey (1991),and Margaret Ayers, who was treating ourson. (See Nash, 2000; Lubar, 1995; andOthmer, 1999a, for a review.) All were con-ducting variations on Sterman’s originalSMR-training, involving reinforcement inthe 12-19Hz region, on the sensorimotor

strip of the brain.In this time frame, Barry Sterman was

committed to his standard approach ofSMR-training, referring in this instance tothe sub-band of 12-15 Hz, combined withinhibition of paroxysmal activity in therange of 4-7 Hz, and of muscle artifact inthe 20-30 Hz region. The rationale for theSMR-training was one of training down theset-point of motor excitability of thegamma motor neurons, with anticipatedbenefit for the control of motor seizures.Training sites were typically left side on thesensorimotor strip, at C3-T3.

Joel Lubar had added “beta”-training,which in this instance refers to the beta sub-band of 15-18 Hz for his work withADHD and learning disabilities. The samelow-frequency inhibit was used. Since thelow-frequency excess is a steady-state ratherthan epochal phenomenon in ADHD chil-dren, EEG normalization became therationale. Michael Tansey restricted himselfto training with narrow-band reinforcementcentered on 14 Hz on the midline aroundCz, with the rationale of training the sup-plementary motor area. He also employed alow-frequency inhibit, only he communi-cated that information verbally to theclient. Margaret Ayers largely restricted her-self to beta training on the left hemisphere,with a C3-T3 placement. A low-frequencyinhibit was also used. Her focus was on thetreatment of minor traumatic brain injuryand stroke. When EEG phenomenology orsymptoms warranted it, she would also dotraining at C4-T4, and occasionally shewould employ the SMR band for reinforce-ment.

Out of the work of these four pioneers inthe field, our own protocols evolved in sev-

eral stages. (For a recent comprehensivereview, see Othmer, 1999b). In the fall of1987, when the instrument we developed(NeuroCybernetics) first became available,we started our clinical work with theSterman/Lubar approach of training at C3-T3, but with Ayers’ focus on beta training(15-18 Hz) (Ayers, 1995). The thrusttoward brain-mapping and quantitativeEEG led generally to a shift toward referen-tial placement, which we adopted as well.

For more than a year, most of the train-ing was conducted at either C3 with thehigher frequency sub-band (“beta”), or atCz with the lower frequency sub-band(“SMR”). As we became conversant withlaterality issues, it was observed that theC4-training often yielded stronger resultsthan were being obtained at Cz, and alsoinvolved fewer negative side effects. Thisdifference was brought home to us mostdramatically while we were conductingresearch at a group foster home in LosAngeles. One youngster was resistant to thetraining at Cz, so at session 17 we movedthe training site to C4, with dramatic andimmediate results (Putman, 1994). The fel-low came excitedly to his next training ses-sion and declared himself to be a new man.He had been the terror of the household,but with his new-found self-regulation skillswas soon graduated from the home.

Right-side training was typically mosteffective with the lower frequency training.Eventually, the predominant protocolsbecame “C3-beta” and “C4-SMR.” Themechanisms-based understanding of thiswas that our primary impact was on theregulation of arousal, and that this thrustrequired some hemisphere-specific opti-mization. The left hemisphere typically


required training toward more activation,and the right hemisphere toward morecalming. A subsidiary argument is that theleft hemisphere is more involved with local-ized function, which is organized at higherfrequencies. A third consideration is thatthe higher-frequency training promoted acontrolled sympathetic or ergotropic shift ofautonomic arousal, and the lower frequencya parasympathetic, or trophotropic shift.Even with EEG biofeedback alone we werecumulatively seeing improved self-regula-tion with respect to autonomic arousal thathas been the traditional preoccupation ofperipheral biofeedback.

Some limited frontal and parietal trainingoff the central strip was used as well toaddress specific issues such as dyslexia orarticulation problems. The latter in particu-lar showed high site-specificity. Early on inour work, one nine-year-old girl who wasmaking good progress in her attentionalfocus with left-side training still did notchange in terms of articulation until theelectrode was moved from C3 to Broca’sarea not far away. The effect was observablein a single session, and over the course ofonly about ten sessions the girl made threeyears’ progress in speech development. Sitespecificity indeed!

Over time, it was found that both of ourstandard trainings, C3 beta and C4 SMRcould be usefully combined into a singlesession, particularly for those who respond-ed too dramatically to a singular focus onone hemisphere. This brought our thinkingto the whole matter of hemispheric balanc-ing. The clinical burden was one of teasingout respects in which the patient appearedover- or under-aroused which, along withthe relative strengths of left and right hemi-sphere functioning generally, governed therelative amount of beta and SMR training.Then there was a class of individuals whereinstability of arousal was the principal con-cern, and hemispheric balance appeared tobe the critical issue with these individuals.Considerations of attentional functioningand of emotional regulation also had animpact on the titration of the basic proto-cols, with right-side training having agreater impact on emotional regulation andemotional access.

The Emergence of More

Complex Training ModelsIn 1995 we became aware of the work of

Suffin and Emory in establishing subtypesof ADHD (Suffin, 1995). The three mainsubtypes identified were:

1) frontal theta dominance;2) frontal alpha dominance; and 3) inter-hemispheric hyper-coherence at

the dominant frequency.These sub-types correlated with efficacy

of stimulants, anti-depressants, and anti-convulsants, respectively. They also correlat-ed with EEG biofeedback protocols. Thefrontal excess alpha group tended to be thelow-arousal depressives who respond to leftside beta training, combined with an alphainhibit. The excess frontal theta constituen-cy was largely our ADHD population thatrequired both SMR and beta training, andthe hyper-coherence contingent includedwhat we have been calling the instabilities.For a time, however, we had no specificallytailored approach for this subtype.

Since we were already oriented towardthe view that each hemisphere exhibits itsown characteristic failure modes, the bi-hemispheric model of ADHD by Malone,Kershner, and Swanson (1994) held consid-erable appeal for us. They proposed a spe-cial relationship between the frontal lobeand the left hemisphere to organize sequen-tial activity and tonic activation, and a spe-cial relationship between the righthemisphere and the parietal associationareas to organize higher level sensory pro-cessing and phasic arousal. This work moti-vated a trial with bipolar placementinvolving these two important cortical link-ages. Initially, C3-Fpz (beta) was tried alongwith C4-Pz (SMR). With this more specificprotocol for ADHD, new gains could oftenbe achieved that were not as readily avail-able with the basic C3/C4 paradigm. Bygoing to bipolar training of long corticalloops, however, we were moving away fromthe model of amplitude training on the sen-sorimotor strip to modulate local activationand arousal. Presumably we were somehowexercising the communication link betweenthese sites to good effect.

The bipolar placements led directly totwo further developments. The first was anevaluation of T3/T4 placements in place ofC3/C4, an obvious choice in the face of

temporal lobe issues and emotional disregu-lations. The second was a trial of Fp1-T3and Fp2-T4 pairings, to bring the pre-frontal region into play. We were unable toget good results with the latter placement,however, so instead the pairing becameFp1-T3 and Fp1-T4. This became for atime the preferred approach for those withprominent instabilities in brain function. Itwas also the first time we trained systemati-cally across the hemispheric fissure. Thisstrange choice came about through anastute and adventuresome home user, whotold us about it. She had already scoped outthe fact that Fp2-T4 could be emotionallydestabilizing, so she tried Fp1-T4 instead.We already knew about Fp2-T4, so herreport had credibility with us. We con-firmed her report.

Once the basic protocol schemas were inplace, it became a matter of fine-tuning.The most obvious change was to tailor theinhibit bands more closely to what wasobserved in the EEG. This was the secondinstance of the influence of developments inthe QEEG field on our mechanisms-basedtraining. Another and more importantchange was to introduce frequency-shiftingto the reward bands. By enabling shifts inincrements of as little as 0.5 Hz and opti-mizing the choice of reward band for eachindividual, training became more quicklyand reliably effective, and “negative effects”attendant to the training were minimized.

This also opened up the training formuch more intractable populations of cere-bral palsy, the autistic spectrum, andReactive Attachment Disorder. We hadgiven up on autism years earlier when wewere doing mainly left-side beta training(under the naïve assumption that we weredealing with a language deficit). Now thatwe viewed it more appropriately as an emo-tional deficit, and as a condition character-ized by extreme over-arousal, we madeprogress with mainly right-side training(C4, T4, C4-P4) at relatively low frequen-cies. Even the emotional volatility and dis-connectedness of Reactive AttachmentDisorder was found to respond to this pro-tocol. Curiously, we observed cerebral palsyto respond even down to the lowest fre-quencies.

The resulting spread in the frequency

spectrum over which we were usefully train-ing people brought in train an abandon-ment of reference to the “standard bands,”as Sterman has been urging for some time.However, this also loosened the conceptualmoorings that we were simply training thesensorimotor rhythm. We still held to thenotion that we were training arousal regula-tion, first and foremost (central and auto-nomic).

Unstable Brains and Inter-Hemispheric Balance

In reflecting on our approach to neuro-regulation, both the strength and weaknessof our methods was the work with the mostunstable brains---bipolar disorder, traumaticbrain injury, and fibromyalgia. The exqui-site responsiveness of these brains drew usforward, but our techniques left much to bedesired. In working with migraines, forexample, working the left hemisphere some-times drove the migraine over to the right.Working on the right then drove it back. Itwas found that training simultaneously onboth sides with a bipolar montage pinnedthe migraine and usually expunged it withinthe session, or at least significantly mini-mized its severity. We saw migraines as aparadigm for what we call “brain instabili-ties,” and we quickly found that the inter-hemispheric training with bipolar montagecould be helpful quite generally with theinstabilities: seizures, rages, vertigo, brux-ism, hot flashes, panic, irritable bowel,PTSD, narcolepsy, and asthma. Once again,the technique breached the usual diagnosticboundaries with a simple, elegant approach.We were addressing the abstraction of regu-latory instability itself, largely irrespective ofits symptomatic presentation or even oflocus within the cerebrum.

The focus on inter-hemispheric balancewas not a novel idea. We were aware of thework of Douglas Quirk (1995) with violentoffenders in Canada, which employed thistechnique exclusively for a period of twen-ty-five years. And Rosenfeld’s focus on left-right alpha amplitude ratio frontally alsoconcerned itself with hemispheric balance(Rosenfeld, 2000). We found great value inoptimizing the reward band for each per-son. In this quest, the rules we had devisedfor the hemisphere-specific training were oflittle help. We were doing something differ-

ent with this training. Somehow, one hemi-sphere was being recruited to help stabilizethe other. Our work initially focused on theC3-C4 and T3-T4 placements along thecentral strip where we had done most ofour training. However, we also investigatedother homologous placements such as Fp1-Fp2 for executive function, F3-F4 formotor initiation and planning, and F7-F8for language access. Each of these was addi-tive, and confirmed the general utility ofthe new approach. In particular, with Fp1-Fp2 we found ourselves benignly trainingpre-frontally, with much greater ease thanwe were able to train Fp1 and Fp2 separate-ly. The extension of our interest to othercortical sites was the third instance of sig-nificant influence of ongoing QEEG workon our mechanisms-based approaches.

Conclusion: Theory and Practicein Neurofeedback Today

This recitation of our developmental his-tory brings us up to the present. The overalltrend is clear. There has been movementover time from the limited protocols of thelate nineteen eighties to a much more com-prehensive set of tools which we now utilizewith nearly every patient during the courseof EEG training. This shift has been accom-panied by an elaboration of the conceptualunderpinnings that support the mecha-nisms-based approach. The newfoundimportance of inter-hemispheric trainingsuggests that bi-hemispheric integration is akey failure mode in psychopathology.

Neurofeedback training can manifestlyimprove the “zone of operational stability”for any compromised nervous system, irre-spective of the specific diagnosis. The brainmust also maintain set points of function,i.e. to manage the activation-relaxationdynamics of cortical networks. We haveargued that the technique of neurofeedbackaddresses the regulation of central arousal infirst order. Les Fehmi has long argued forthe coupling of arousal and attention(Fehmi, 1998). Finally, emotional valence isan aspect of any commitment of attentionalresources. Hence, neurofeedback thataddresses arousal must of necessity alsoimpinge upon attentional mechanisms andemotional regulation. These are all coupledsystems.

Through a combination of mechanisms

considerations, clinical observations, andincorporation of characteristic QEEG find-ings, a robust and comprehensive mecha-nisms-based approach to protocol selectionhas been developed. The pace of change,however, is not declining. We expect a con-tinuing trajectory of refinements over thenext several years.

A second article will pursue the neuro-feedback approaches emphasizing QEEGand NLD (Brown & Brown, 2002), andexamine their implications in greater detailfor both the theory and practice of neuro-feedback.

ReferencesAyers, M.E. (1995) A controlled study of neuro-

feedback and physical therapy with pediatric stroke,age seven months to age fifteen, occurring prior tobirth. Biofeedback and Self-Regulation, 20 (3), 318.

Brown, V., & Brown, S. C. (2002). The Period Three approach to neurofeedback.www.neurofeed.com

Evans, J. R., & Arbanel, A. (Eds.). (1999).Introduction to quantitative EEG and neurofeedback.San Diego: Academic Press.

Fehmi, L. (1998). Attention to attention.www.openfocus.com

Lubar, J.F. (1995). Neurofeedback for the man-agement of attention/hyperactivity disorders. In M.S. Schwartz & Associates (Eds.)., Biofeedback: Apractitioner’s guide, (pp. 493-522). New York:Guilford Press.

Malone, M.A., Kershner, J.R., & Swanson, J.M.(1994). Hemispheric processing andmethylphenidate effects in attention-deficit hyper-activity disorder. Journal of Child Neurology, 9(2),181-189.

Nash, J.K. (2000). Treatment of AttentionDeficit Hyperactivity Disorder with neurotherapy.Clinical Encephalography, 31 (1), 30-37.

Othmer, S., Othmer, S.F., & Kaiser, D.A.,(1999a). EEG biofeedback: Training for AD/HDand related disruptive behavior disorders. In J. A.Incorvaia, B. S. Mark-Goldstein, & T. Tessmer(Eds.), Understanding, diagnosing, and treatingAD/HD in children and adolescents: An integrativeapproach (pp. 235-296). Northvale, New Jersey:Jason Aronson Press.

Othmer, S., Othmer, S.F., & Kaiser, D.A.,(1999), EEG biofeedback: An emerging model forits global efficacy. In J. R. Evans & A. Arbanel(Eds.), Introduction to quantitative EEG and neuro-feedback (pp. 243-310). San Diego: AcademicPress.

Putman, J. A. (1994), The usefulness of EEGtraining for behavioral management in group homesettings. Unpublished monograph, EEG SpectrumInternational, 16500 Ventura Blvd., Suite 418,Encino, CA 91436.

Quirk, D.A. (1995). Composite biofeedback




Abstract: The author utilizes heart ratevariability biofeedback as a tool to teach highschool biology students about the body’s auto-nomic nervous system. The article introducesthe concept of heart rate variability, reviewsrelevant physiology of the cardiovascular sys-tem, and summarizes the role of specific HRVpatterns in higher level wellness and perform-ance. The author summarizes some personalexperiments with HRV biofeedback and dis-cusses the use of HRV instrumentation toteach individuals about autonomic nervoussystem balance.

IntroductionHour after hour, day after day, year after

year …, the heart contracts over 2 billiontimes in an average lifetime. The heart’srhythm reflects the tempo of life, accelerat-ing and decelerating with the waxing andwaning of the day, and with one’s physio-logical and emotional state. The heart’srhythm is highly variable, over both shortand long time intervals (Figure 1), exhibit-ing behaviors characteristic of complex,nonlinear systems (Goldberger, 1999).Despite this complexity, the analysis ofheart rate patterns yields fascinating insightsinto the state of the autonomic nervous sys-tem (ANS), based on the analysis of beat-to-beat variations in heart rate. Heart rate

variability (HRV) patterns provide themeans for assessing nervous system imbal-ances, and for developing strategies forimproved ANS function. As a high schoolbiology teacher, I utilize demonstrations ofheart rate variability to raise student aware-ness of the factors that enhance health andwell-being, as well as performance in classes,sports and activities (Ackerly, 2001).

Heart Rate VariabilityThe heart is sensitive to a variety of phys-

iological conditions, including blood CO2levels, arterial pressure, and hormonal andneural excitation or inhibition. In a healthy,unstressed individual, heart rate rises andfalls with each inhalation and exhalation ofthe breath, a phenomenon related to pres-sure changes within the chest cavity, theheart and the circulatory vessels (Figures 2and 3). Researchers at the Institute ofHeartMath have coined the term“coherence” to represent this orderly patternof heart rate variability (www.heartmath.org;McCraty et al., 2001; Childre & Martin,1999). Coherent heart rate patterns, alsoknown as respiratory sinus arrhythmia(RSA), represent balanced autonomic nerv-ous system functions (McCraty et al., 1996;McCraty et al., 2001). Interestingly, veryfew of my students (14 and 15 year olds)exhibit coherent HRV patterns, suggestingthat ANS imbalances are fairly common.

Heart rate variability analysis allows us tomonitor, in real time, the physiologicalintegrity of our autonomic nervous systems.HRV patterns reflect inputs from both thesympathetic nervous system (SNS), a car-dio-accelerator, and the parasympatheticnervous system (PNS), a cardio-inhibitor.HRV software programs assess the relativecontributions of these two ANS compo-

Figure 1. Heart rate patterns exhibit variability at many scales. The variability is roughly scale-invariant,a property of fractal systems, resulting from the interaction of nonlinear functions. (Reproduced from: A.

Goldberger, Chaos theory and creativity: The biological basis of innovation, Journal of InnovativeManagement, Spring, 1999, p.18. Permission requested: 18Feb02).

Heart Rate Variability and EnhancedStudent PerformanceSpafford C. Ackerly, PhD i

Spafford C. Ackerly, PhD


nents by performing spectral analyses of theHRV data, decomposing the complex HRVpatterns into component frequencies. In acoherent HRV pattern (Figure 2), for exam-ple, the predominant frequency is about 6

cycles per minute, equivalent to 1 cycle per10 seconds (0.1 Hz). The 0.1 Hz frequencyreflects a complex resonance patternbetween the sympathetic and parasympa-thetic nervous systems, and vascular con-

trols on heart rate (Sleight and Casadei,1995, McCraty & Watkins, 1996).Coherent heart rate patterns represent bal-anced autonomic nervous system functions(McCraty et al., 1996; McCraty et al.,2001).

Complex HRV patterns reflect the com-bined inputs of the sympathetic andparasympathetic nervous systems, as well asfeedback from the respiratory and vascularsystems. Figure 4 shows my HRV patternwhile working on the computer after eatinga heavy meal. The high frequency variationshave a cycling frequency of about 0.27 to0.3 Hz (16 to 18 cycles per minute) prima-rily representing inputs from the parasym-pathetic nervous system. The PNS, while acardio-inhibitor, exhibits rapid responsetimes (less than the duration of one heartbeat) associated with respiration-relatedfeedback in the cardio-pulmonary system(Sleight and Casadei, 1995; McCraty &Williams, 1996). The lower frequency vari-ations of about 0.02 Hz (1.2 cycles perminute) represent inputs of the sympatheticnervous system. The SNS, while a cardio-accelerator, exhibits slower response times(3 to 5 seconds) associated with visceral,hormonal, and thermo-regulatory functions(McCraty and Williams, 1996). A human’sresponse to a narrowly averted traffic acci-dent provides a good example of slow SNSresponse time; heart rate sky-rockets a shorttime after the incident has occurred.

The Heart and HumanPerformance

The heart is one of the most powerfuland rapidly developing organ in the humanbody, taking its first beat on about the 22ndday of life (Larsen, 1999). The first beatarises within the heart tissues, not withinthe nervous system, although the autogenic(self-generating) pulse is later modified bythe pacemaker activities of the sympatheticand parasympathetic nervous systems viathe sinoatrial node. The intrinsic rate ofheart contraction is about 100 to 120 beatsper minute (Hainsworth, 1995, McCraty etal., 2001), similar to the beat of manymusical compositions. The similarity intempos is probably not a coincidence asmusic is, at heart, a projection of thehuman spirit (Childre & Martin, 1999;www.heartbeat2000.com).

Figure 2. Heart rate (top) measured from the beat-to-beat interval between successive heart beats. Spectralanalysis (bottom) shows that the predominant frequency in the heart rate data occurs at about 0.1 Hz

(cycles / s) equivalent to 6 cycles per minute, characteristic of balanced ANS function. Data obtained usingthe FreezeFramer pulse monitor and software, www.freezeframer.com.

Figure 3. Heart rate (top) and respiration as measured by chest expansion and contraction (bottom), arecoupled. These data were obtained using Vernier sensors; www.vernier.com. Heart rate values are averagedover two second intervals and are therefore less precise than the FreezeFramer calculations which representactual beat-to-beat intervals (see Figure 1). A sine wave fit to the heart rate data shows the one-to-one cor-

respondence between heart rate and respiration.

The detection of electrical (ECG) signalsat distal points on the body attests to theelectrical power of the heart muscle. Theheart generates an electrical field within andaround the body, approximating the shapeof a donut or torus (Figure 5). Recentresearch suggests that the heart’s pulsatingelectrical field may entrain with the electri-cal fields of the brain or the heart of anoth-er individual (Childre and Martin, 1999;Pearce, 1992; Barrett, 1999). The possiblesensitivity of one person’s nervous system tothe electromagnetic field of another person’sheart may help explain the affinities that wefeel for other people, the so-called “chem-istry” between us.

Personal Experimentswith HRV

The heart exhibits strong psychophysio-logical correlates with our emotional state. Imonitored my heart while writing an emailabout a stressful situation with a student,and an incoherent, heart rate pattern reflect-ed my anxiety (Figure 6, 0-8 minute inter-val). After resuming some less stressfulwork, my HRV pattern became more set-tled, although a brief thought about theaforementioned situation caused a momen-tary spike in my heart rate (Figure 6, 8-12minute interval). I was able to create a sem-

blance of cardiovascular coherence by shift-ing my attention to my breath (Figure 6,12-15 minute interval). The incoherencethat I experienced was associated with anaroused sympathetic nervous system.

HRV in the ClassroomI use HRV biofeedback systems in my

classroom to bring students’ awareness tothe function and conditions of their auto-nomic nervous systems. Computer-basedinstrumentation is available from a varietyof sources at prices from about $400 perunit (Ackerly, 2000). The instrumentationfacilitates the awareness of the actual condi-tions that disrupt ANS balance, for examplestressful emotions. We learn to inhibit dys-functional emotional reactions by recogniz-ing the signs of ANS incoherence andtaking a “time out”. We practice breathinginto the abdomen, enlarging the capacity ofthe lungs and saturating the blood supplywith oxygen (Zi, 1997) and exhaling toremove residual, carbon dioxide-laden air(www.carlstough.org). Mental visualizationsare often effective in establishing ANS bal-ance, for example, “breathing into theheart” with a feeling of deep appreciation,thereby instilling positive thoughts in thebody/mind (Childre & Martin, 1999).Developing awareness of bodily sensations

(somatic awareness) may also help balancethe autonomic nervous system. The mentalactivity of school may disconnect us fromour physical body and the intricate feed-back mechanisms that maintain balance andstability. HRV data provides a metric forthe effectiveness of a given technique inestablishing ANS balance.

I noted earlier that cardiac coherence inthe form of orderly 0.1 Hz patterns of heartrate variability (Figure 2) is rare amongstmy students (14 and 15 year olds). To allaystudents’ concerns about their health (in thecase of incoherent heart rate patterns), Ipoint out that healthy hearts exhibit vari-ability at many scales, representing on-going, dynamic interactions between thebody’s biophysical and biochemical systemsand the external environment (Goldberger,1999; Giardino et al., 2000). The some-times chaotic-appearing oscillations in heartrate are healthy signs of dynamically adjust-ing physiological systems, responding toboth internal and external stimuli. Highvariability represents a flexible autonomicnervous system, responsive to the needs ofthe body at any given moment. Low heartrate variability, on the other hand, generallyrepresents a less transient, less flexible auto-nomic nervous system, unable to shift gearsand respond to dynamically changing stim-uli. Low heart rate variability has been iden-tified as a significant risk factor for disease(Dardik, 1996). Regardless, for enhancedhealth and performance, what is importantis not the existing condition of the ANS,but the possibilities for improvement. Heart


Figure 4. An incoherent HRV pattern showing both very low frequency (VLF), low frequency (LF), andhigh frequency (HF) components of the power spectrum, corresponding to sympathetic (SNS) and parasym-

pathetic nervous system (PNS) activity respectively (see text).

Figure 5. The heart’s electrical field. The ribbonsshow current density in and around the heart.

(from: www.ncsa.uiuc.edu/Pubs/access/95.1/Mapping.html).

rate variability analysis provides this oppor-tunity.

HRV patterns are the result of a long his-tory of ANS response and may representstrongly myelinated (in-grained) neuralpathways. One cannot necessarily change

the ANS response overnight. Nevertheless, avariety of techniques are available for bal-ancing the autonomic nervous system and Ibelieve that the effort to do so is warranted,given the potential benefits for health, cre-ativity, and enhanced performance.

Research suggests that sustained levels ofsympathetic arousal may underlie a varietyof health problems (Sapolsky, 1998) andmay undermine learning (Caines & Caines,1994). Balanced autonomic system func-tion, on the other hand, promotesenhanced health, creativity and human per-formance (Caines & Caines, 1994; Childre& Martin, 1999; McCraty et al., 1996).Heart rate variability analysis is a useful andpowerful tool for working with a wide vari-ety of stress- and performance-related prob-lems encountered in schools, includingemotional depression, testing anxiety, stagefright, interpersonal conflicts, and thestresses of multiple and conflicting demandsfrom teachers, parents, and peers.

ReferencesAckerly, S. C. (2000). Psychophysiology and

biofeedback resources for teachers; website:www.crms.org/spaff/edtools.htm.

Ackerly, S. C. (2001). Learning by heart:Students use heart rate patterns to identify nervoussystem imbalances. The Science Teacher, 68(6):53-57.

Barrett, J. (2000). Welcome to heartbeat 2000.www.heartbeat2000.com.

Caines, R.N., & Caines, G. (1994). Makingconnections: Teaching and the human brain. MenloPark, CA: Addison-Wesley.

Childre, D., & Martin, H. (1999). TheHeartMath solution. San Francissco:HarperSanFrancisco.

Dardik, I. (1996). The origin of disease and health: Heart waves, the single solution to heart rate variability and ischemic preconditioning. Cycles, 46 (3), 67-77. On-line at:www.heartbeat2000.com/dardik.htm.

Giardino, N., Lehrer, P. M., & Feldman, J.(2000). The role of oscillations in self-regulation:Their contribution to homeostasis. In D. Kenney,& F.J. McGuigan (Eds.), Stress and health: Researchand clinical applications (pp. 27-52).Amsterdam:Harwood.

Goldberger, A. (1999, Spring). Chaos theory andcreativity: The biological basis of innovation.Journal of Innovative Management, 15-23.

Hainsworth, R. (1995). The control and physio-logical importance of heart rate. In M. Malik, &A.J. Camm (Eds). Heart rate variability (pp. 3-19).Armonk, NY: Futura.

Larsen, B. (1999). Human embryology and devel-opmental biology. St. Louis: Mosby.

McCraty, R., Atkinson, M., & Tiller, W. A.(1995). The effect of emotions on short-termpower spectrum analysis of heart rate variability.The American Journal of Cardiology, 76 (14): 1089-1093. On-line at: http://www.heartmath.org/RP.html.

McCraty, R., Atkinson, M., & Tomasino, D.


Figure 6. Heart rate patterns, while writing an e-mail about a stressful situation with a student, are inco-herent (0-8 minute interval). After resuming less stressful work, the HRV pattern is more settled, althougha brief thought about the stressful situation causes a momentary spike in heart rate (8-12 minute inter-val). Attention to the breath brought the HRV pattern into coherence at the end of the recording session

(12-15 minute interval). The HRV recording demonstrates the sensitivity of the heart to stress.

Internet Resources for Educatorswww.heartmath.org is the website for the Institute of HeartMath, whose goal is to“conduct research on the human heart and its role in establishing mental, physiolog-ical and emotional coherence.”

www.carlstough.org is the website of the Carl Stough Institute of BreathingCoordination, with information on respiratory science and a short breathing video.Also see www.authentic-breathing.com.

www.pbs.org/wgbh/nova/heart and www.pbs.org/wgbh/nova/eheart are informative web-sites on the heart, heart surgery and heart transplants, produced in conjunction withthe NOVA videos “Cut to the Heart” and “Electric Heart”.

http://www.howstuffworks.com/heart.htm and http://www.howstuffworks.com/lung.htmare good, basic information on heart and lungs, with good diagrams. Part of theHow Stuff Works website.

http://sln.fi.edu/biosci/ is an exploration of the heart by The Franklin InstituteOnline.

www.sci.utah.edu/sci_images/images8.html andwww.sci.utah.edu/sci_images/images9.html are collections of fascinating images thatmodel the heart’s electro-magnetic field; produced at the Center for ScientificComputing and Imaging, University of Utah. Also seewww.ncsa.uiuc.edu/Pubs/access/95.1/Mapping.html .



Active sEMG Training Strategies forChronic Musculoskeletal Pain – Part 1Randy Neblett, MA, LPC

Randy Neblett, MA, LPC

Abstract: Specific surface EMG assessmentand training strategies are presented, whichthe author has found useful in teaching mus-cular self-regulation to injured workers withchronic musculoskeletal pain. Part one of thisarticle compares an active sEMG approachwith a traditional general relaxation approachto biofeedback treatment. An sEMG assess-ment and training model is offered foraddressing recovery problems following con-tractions and for promoting generalization ofskills outside of treatment. Part 2 of this arti-cle will present an assessment and trainingmodel for addressing postural imbalance andwill offer specific training tips to help patients’gain independence in self-regulating muscletension.

IntroductionI have been using surface EMG in a

physical rehabilitation setting for about 12years with an emphasis on chronic painmanagement. I currently provide biofeed-back services within a multidisciplinarychronic pain program focused almost exclu-sively on injured workers. Between 300 and400 chronic pain patients complete ourprogram each year, which has allowedample practice for my staff and I to mastereffective biofeedback training strategies forthis population. Though I am trained in themental health side of treatment, the oppor-tunity to work closely with physical andoccupational therapists has strongly shapedmy approach to biofeedback. In this articleI will offer some specific sEMG trainingtechniques that I find useful for teachingmuscular self-regulation. I realize that thesestrategies will seem very basic to sEMG vet-erans. It has been my experience, though,that the active use of sEMG is relatively for-eign to many biofeedback providers, espe-cially those of us who are trained in mental

health. I hope to challenge those of youwho work within a traditional general relax-ation model of biofeedback to expand howyou use sEMG.

General RelaxationTraining vs. Active sEMGTraining

I am using the term “active sEMG train-ing” to describe the treatment approachthat I utilize in our clinic and to distinguishthis approach from a general relaxationtraining model that is often used in chronicpain treatment. The primary goal of generalrelaxation training is to facilitate low psy-chophysiological arousal (Schwartz &Associates, 1995). The patient is often posi-tioned in a soft reclining chair, and much ofthe training may occur with eyes closed.Training procedure usually involves the useof progressive tensing and relaxing of vari-ous muscle groups or a cognitive strategysuch as mental imagery, autogenic phrases,or breathing meditation. Along with othermeasures of autonomic arousal, such ashand temperature, sEMG is commonlyused to provide muscle feedback and tomonitor progress with the training strategybeing used (Arena & Blanchard, 1996;Schwartz & Associates, 1995). Thebifrontal sEMG placement is commonlyutilized in general relaxation training,despite evidence that it does not representgeneral levels of tension in the body, or gen-eralize to other muscle groups (Alexander &Smith, 1979; Suarez, Kohlenberg, &Pagano, 1979; Schwartz & Associates,1995). Home practice of general relaxationtechniques involves sustained focus on achosen technique for a dedicated period oftime (Ettare & Ettare, 1990).

With active sEMG training, on the other

hand, the patient is taught to self-regulatemuscle activity during his or her normaldaily routine. The patient is most often notin a recliner, but is trained in postures thatone uses often, like sitting up in a straightchair, sitting at a keyboard, standing, oreven walking. Training is done most oftenwith eyes open. The therapist and patientare usually in open dialogue as they evaluatethe sEMG feedback and effectiveness of dif-ferent strategies for controlling the targetmuscles. The goal is not to facilitate lowpsychophysiological arousal, but to learnincreased awareness and control over a spe-cific muscle or muscle group. In the physi-cal therapy world, sEMG training of thisdescription is called neuromuscular re-edu-cation (Cram, Kasman, & Holtz, 1998).

A basic assumption in active sEMG train-ing is that sustained muscle bracing cancause or contribute to pain. For many indi-viduals with chronic pain, muscle bracinghas become a habitual pattern, often occur-ring outside of awareness. The general treat-ment goal therefore, is to identify problemswith muscle bracing that may be contribut-ing to pain, to teach the patient how to cor-rect the problems within treatment sessions,and to encourage the patient to independ-ently monitor and correct the problemsduring the day.

I don’t wish to imply that a general relax-ation approach to treatment is inferior orless useful than active sEMG approaches.Relaxation and imagery training have beenshown to be effective for a variety of chron-ic pain conditions (Syrjala, Donaldson,Davis, Kippes, & Carr, 1995; Turner &Jenson, 1993; Fernandez & Turk, 1989).Relaxation training is a vital part of ourbiofeedback program. I spend a good dealof session time teaching relaxation and

imagery techniques, and I encourage use ofrelaxation tapes and other independentpractice to my patients. But when donetogether, an active sEMG approach, com-bined with general relaxation training, canprovide a complimentary and comprehen-sive biofeedback treatment package fortreating chronic pain.

Many important and useful active anddynamic approaches to sEMG evaluationand training have been described, such asDonaldson and Donaldson’s (1990) move-ment analysis and symmetry training,Taylor’s (1990) shoulder rotation training,and Kasman, Cram, Wolf, and Barton’s(1998) uptraining procedures for activatinginhibited muscles during movement. Thesetypes of dynamic sEMG approaches mayseem intimidating and may be beyond thelevel of expertise and scope of practice formany biofeedback providers, especiallythose in the mental health field. In thistwo-part article, I wish to present some sim-ple concepts and techniques that I havefound useful in our treatment facility. Mostof these techniques are not new, and havebeen described elsewhere (Ettare & Ettare,1990; Middaugh, Kee, & Nicholson, 1994;Cram, Kasman, & Holtz, 1998; Kasman,Cram, Wolf, & Barton, 1998). I believethat most biofeedback practitioners whohave been trained in the use of surfaceEMG can learn to use many of these strate-gies relatively quickly, easily, and effectively.

Generalization andRecovery

People aren’t designed to be perfectly stillfor long periods of time. We are constantlymoving and adjusting during the day. StaticsEMG training within a general relaxationmodel may teach your patient some valu-able skills, but you will miss most of themuscular picture if you just evaluate andtrain while lying still in a reclining chair.Studies have shown that muscles training inone postural position don’t necessarily gen-eralize to other postural positions (Cram &Freeman, 1985). For instance, if yourpatient learns to independently relax hershoulders while sitting in a chair, you can’tassume that she will be able to successfullyrelax her shoulders while standing or walk-ing. Second, a painful muscle site that looksrelaxed during a static assessment will often

show muscular dysfunction after use(Middaugh, Kee, & Nicholson, 1994;Cram, Kasman, & Holtz, 1998; Kasman,Cram, Wolf, & Barton, 1998).

Figure A. shows a left and right cervicalto upper trapezius placement (see muscleatlas, Cram, Kasman, & Holtz, 1998) uponinitial evaluation of a patient who suffered aright shoulder injury about one year earlierand has since developed chronic pain,including a preliminary diagnosis of ReflexSympathetic Dystrophy Syndrome (RSDS).The graph shows the patient’s muscle ten-sion values while sitting in a straight-backchair, standing, lifting his arms out to hissides, then bringing his arms down andresting. This is a quick and easy way toassess several aspects of neck and shouldermuscle tension. This person had elevatedreadings in both sitting and standing condi-tions, with the standing levels being clearlyhigher. These readings look relatively sym-metrical, suggesting a general bracing pat-tern. Other patterns that are often seen inour clinic are “splinting,” or asymmetricalelevation on the injury side, and “protectiveguarding,” or asymmetrical elevation on theopposite side of injury (Cram, Kasman, &

Holtz, 1998). It is especially important forthe clinician to notice with this shoulderinjury patient how the muscles didn’t recov-er after the contraction. Muscles aredesigned to work when used and relaxwhen not in use (Middaugh, Kee, &Nicholson 1994; Cram, Kasman, & Holtz,1998; Kasman, Cram, Wolf, and Barton,1998). This patient’s neck and shouldermuscles seem to get “stuck” after the con-traction. If this patient’s muscle bracing andrecovery problems happen habitually overthe course of the day, then it is likely thatthe muscles are not going to get adequaterest breaks and will be over-used, which willlikely contribute to pain.

sEMG training for this patient would ini-tially focus on static relaxation while sittingand standing, then would move to con-tract/recovery training (Middaugh, Kee, &Nicholson 1994). The patient might beasked to shrug his shoulders then release; toreach up with his arm, then bring it backdown and release; to move and adjust andthen release; to alternate between sittingand standing with focus on release aftereach movement, etc. When muscle tensionis especially stubborn, I have found that dis-


Figure A. Left and right cervical to upper trapezius placement measured with a narrow band pass of 100-200 Hz with a patient with chronic right shoulder pain. Thresholds set at 2.0uv and 5.0uv to provide

scale. Initial baseline assessment - sitting, standing, and recovery following contraction.

crimination training (Kasman, Cram, Wolf,& Barton, 1998) can aid the patient’s suc-cess with recovery. The patient is asked toalternate in 5 to 10 second intervalsbetween very slight contractions and com-plete release of the target muscles, whilebeing coached to recognize the difference insensation between tension and relaxation.

A portable sEMG unit can be used tohelp generalize neck and shoulder relaxationto walking. When using a portable unit, Ifind a bi-lateral upper trapezius placementuseful (see muscle atlas, Cram, Kasman, &Holtz, 1998). I begin by focusing on recov-ery (walk, stop, relax; walk, stop, relax; etc)then move towards walking and relaxing atthe same time. The portable unit can alsobe used to practice recovery between func-tional tasks in the physical therapy gym. Aswith most standard biofeedback procedures,feedback is gradually taken away in order tofacilitate independence. Figure B. showsanother baseline measure after two trainingsessions with the shoulder injury patient.Good progress with self-regulation of mus-cle bracing is clearly evident from thegraph.

Figure C. shows a clear example of recov-ery problems in a patient who developedchronic pain after a traumatic injury to hisleft arm when it was caught and mangled insome heavy machinery about one year earli-er. The graph shows a left and right “web”placement, in which one active electrode isplaced on the web of the hand and oneactive electrode is placed on the forearmover the brachioradialis muscle (Peavy,1990). I have found this placement usefulin displaying general hand and arm tensionwhen assessing patients with upper extremi-ty pain including repetitive strain injuries.An alternative placement, which also dis-plays diffuse arm and hand tension, is aforearm flexor to extensor placement (seemuscle atlas, Cram, Kasman, & Holtz,1998). Initially, this patient looked relative-ly relaxed with arms supported on armrests.After holding a fist for about ten seconds,you can see that his right arm and handrecovered normally, while his left arm andhand did not. Figure D. shows anotherbaseline assessment of a fist, and recoveryafter two sessions of contraction/recovertraining. Even though both of the twopatients in these examples progressed rela-

tively quickly, continued practice was need-ed to maximize consistency and independ-ence with muscular self-regulation.

Just as I might miss crucial muscular

information with static assessment only, Imight also miss crucial information bysticking to only one placement. Studies sug-gest that relaxation training of one muscle


Figure C. Left and right “web” placement measured with a wide band pass of 20-500 hz with a patientwho suffered a traumatic injury to his left arm. Thresholds set at 2.0 uv and 5.0 uv. The patient was

asked to rest his arms and hands on armrests, then to make a fist, and again to rest back onto the armrests.A recovery problem is clearly evident in his left arm and hand.

Figure B. Baseline sitting, standing, and recovery following contraction at the beginning of third trainingsession with the same chronic shoulder pain patient.

group does not necessarily generalize toother muscle groups (Alexander & Smith,1979; Suarez, Kohlenberg, & Pagano,1979). I generally find it useful to evaluateseveral sEMG placements around the site ofinjury and pain during the course of treat-ment. I might also miss information, andpossibly be unsuccessful in teaching muscu-lar self-regulation, if I don’t consider pos-ture as a primary contributing factor inmuscle tension and pain. The assessmentand training of postural problems will beaddressed in part 2 of this article.

ProfessionalConsiderations

Obviously, all biofeedback practitionersare obligated to work within the rules oftheir professional practice acts, ethicalguidelines, and biofeedback skill sets.Knowledge of muscle anatomy and trainingin the use of sEMG are essential beforeusing strategies that I have described here.When doing active sEMG training, it isimportant to be consistent with electrodeplacements and to check the electrodesoften during the treatment session for signsof slippage. I have found the two book setcited in this article, by Cram, Kasman, and

Holtz (1998) and Kasman, Cram, Wolf,and Barton (1998), to be a valuableresource for maximizing the clinical use ofsEMG.

ReferencesAlexander, A.B., & Smith, D.D. (1979) Clinical

applications of EMG biofeedback. In R.J. Gatchel& K.R. Price (Eds.), Clinical application of biofeed-back: Appraisal and status. New York: Pergamon.

Arena, J.G., & Blanchard, E.B. (1996).Biofeedback and relaxation therapy for chronic paindisorders. In R.J. Gatchel and D.C. Turk (Ed.),Psychological Approaches to pain management: A prac-titioner’s handbook (pp. 179-230). New York:Guilford Press.

Cram, J.R., & Freeman, C. (1985) Specificity inEMG biofeedback treatment of chronic painpatients. Clinical Biofeedback Health, 8, 106-119.

Cram, J.R., Kasman, G.S., & Holtz, J. (1998)Introduction to surface electromyography.Gaithersburg, Maryland: Aspen Publishers.

Donaldson, S., & Donaldson, M. (1990). Multi-channel EMG assessment and treatment tech-niques. In J.R. Cram (Ed.) Clinical EMG for surfacerecordings, Volume 2 (pp143-174). Nevada City,California: Clinical Resources.

Ettare, D.L. & Ettare, R. (1990). Muscle learn-ing therapy – A treatment protocol. In J.R. Cram(Ed.), Clinical EMG for surface recordings, Volume 2(pp.197-234). Nevada City, California: ClinicalResources.

Fernandez, E., & Turk, D. C. (1989). The utilityof cognitive coping strategies for altering pain per-ception: a meta-analysis. Pain, 38, 123-135.

Kasman, G.S., Cram, J.R., Wolf, S.L., & Barton,L. (1998). Clinical applications in surface electromyo-graphy for chronic musculoskeletal pain.Gaithersburg, Maryland: Aspen Publishers.

Middaugh, S.J., Kee, W.G., & Nicholson, J.A.(1994). Muscle overuse and posture as factors inthe development and maintenance of chronic mus-culoskeletal pain. In R.C. Grzesiak & D.S. Ciccone(Eds.), Psychological vulnerability to chronic pain (pp.55-89). New York: Springer Publishing Co.

Peavey, B. (1990). Personal communication.Schwartz, M.S., & Associates. (1995),

Biofeedback: A practitioner’s guide (Second edition).New York: Guilford Press.

Suarez, A., Kohlenberg, R., & Pagano, R.(1979). Is EMG activity from the frontalis site agood measure of general bodily tension in clinicalpopulations? Biofeedback and Self-Regulation, 4,293-297.

Syrjala, K. L., Donaldson, G. W., Davis, M. W.,Kippes, M. E., & Carr, J. E. (1995). Relaxationand imagery and cognitive-behavioral trainingreduce pain during cancer treatment: a controlledclinical trial. Pain, 63, 189-198.

Taylor, W. (1990). Dynamic EMG biofeedbackin assessment and treatment using a neuromuscularreeducation model. In J.R. Cram (Ed.) ClinicalEMG for surface recordings, Volume 2 (pp. 175-196).Nevada City, California: Clinical Resources.

Turner, J. A., & Jenson, M. P. (1993). Efficacy ofcognitive therapy for chronic low back pain. Pain,52, 169-177.


Figure D. Baseline at the beginning of third training session showing the left arm patient making a fist,then releasing back onto armrests.


The distinction between HealthPsychology and Behavioral Medicine isoftentimes blurred. Indeed, many authorsuse the terms interchangeably. Both fieldsemerged in the 1970s out of the perspectiveof behaviorism to study the role of psychol-ogy in illness (Sarafino, 2002). Based uponthe principles of respondent and operantconditioning, these disciplines utilize psy-chological strategies to promote and main-tain physical health. Researchers in HealthPsychology and Behavioral Medicine studysuch topics as the physiological and psycho-logical bases for nicotine addiction, meth-ods for alleviating chronic pain, personalpreferences regarding utilization of automo-bile seatbelts, and advantages and disadvan-tages of certain eating habits. Based uponthe findings of such investigations, clini-cians within these disciplines develop prac-tical interventions to address from apsychological perspective various health-related concerns (e.g., smoking cessationcourses to reduce cigarette use, psychoedu-cational classes to promote adjustment toknee replacement surgery).

While the two disciplines operate hand-in-hand from a practical standpoint, theyare not entirely synonymous in theory.Behavioral Medicine may be thought of asan interdisciplinary field (Belar &Deardorff, 1995) that includes individualsfrom various professions (e.g., psychology,sociology, medicine, nursing, occupationaltherapy); whereas Health Psychology oper-ates principally within the discipline of psy-chology (Sarafino, 2002). In any case,within the contexts of these fields, the prin-ciples of operant conditioning and behaviormodification maintain a crucial function. It

is upon the bases of these techniques thateffective, replicable, and reimbursable inter-vention strategies are developed and imple-mented.

Although multiple sources exist for pro-viding students and practitioners with thetheoretical foundation for understandingthe principles of operant conditioning, fewimpart the requisite skills for executing suchprinciples in the clinical milieu. The sixthedition of Alan Kazdin’s BehaviorModification in Applied Settings representsan excellent source for bridging the gapbetween behavioral theory and application.Although not written solely for HealthPsychology and Behavioral Medicine profes-sionals, the concepts covered in the textshould serve to provide a solid foundationfor individuals practicing within these disci-plines.

The work is most appropriate for thereader possessing a foundation in learningtheory and the basic principles of behaviormodification, for the historical develop-ments of learning and behaviorism aretouched upon only briefly. While the pri-mary operant techniques for changingbehavior (e.g., reinforcement, punishment,extinction) are sufficiently reviewed, theemphasis of the text, as the title suggests, isthe utilization of these techniques withinapplied settings. Indeed, Kazdin’s work isladen with examples and case discussionsillustrating the application of behaviormodification principles in various environ-ments, including schools, hospitals, nursinghomes, and community mental health cen-ters to address disorders of depression, anxi-ety, sleep, substance use, etc. Throughoutthe text, an emphasis is placed upon clinical

implementation of therapeutic strategiesthat are based on and have been sufficientlyvalidated by empirical research.

An entire chapter is committed to theimportant role of functional analysis inbehavior modification programs. The signif-icance of adequate assessment prior to theinitiation of intervention is stressed, andthis function is consistently emphasizedthroughout subsequent chapters. For thosewith an interest in biofeedback, a section ofChapter 10 is devoted to this topic andincludes a case example in which biofeed-back is utilized to “…train relaxation as ameans of managing stress in a 36-year-oldwoman with insulin-dependent diabetes”(p. 321). In addition to demonstrating useof operant techniques in various appliedsettings, Kazdin discusses the relationshipbetween overt behaviors and cognitions.Indeed, Chapter 11 is dedicated solely tothe therapeutic cognitive approaches ofBeck, Ellis, Cautela, and others. Adequatecoverage is given to issues of response main-tenance and transfer of training. The textconcludes with a pragmatic overview of thesocial, ethical, and legal implications ofclinical interventions and a discussion ofthe current issues in behavior modificationand the future directions for the field thatare relevant to practitioners.

As is the case with most, if not all, ofKazdin’s works, the text is well organizedand comprehensive in nature. While profes-sionally written, it is quite readable for stu-dents. Tables serve to highlight andsummarize many key points of each chap-ter, and an inclusive glossary is provided fordefining fundamental terms presentedthroughout the book. From a didactic

A Review of A. E. Kazdin (2001). BehaviorModification in Applied Settings (6th ed.).Belmont, CA: Wadsworth.Reviewed by Samuel T. Gontkovsky, Psy.D., BCIAC,Lawton, Oklahoma i

BOOK REVIEW


(compilers). (2001). Science of the heart: Exploringthe role of the heart in human performance. BoulderCreek: HeartMath Research. On-line version at:http://www.heartmath.org/RO.html.

McCraty, R., Tiller, W. A., & Atkinson, M. (1996). Cardiac coherence: A new non-invasive measure of autonomic nervous system order. Alternative Therapies in Health and Medicine, 2 (1): 53-65. On-line at:http://www.heartmath.org/RP.html.

McCraty, R., & Watkins, A. (1996). Autonomicassessment report: A comprehensive heart rate variabil-ity analysis. Boulder Creek, CA: HeartMathResearch Center.

Pearce, J.C. (1992). Evolution’s end: Claiming thepotential of our intelligence. San Francisco:HarperSanFrancisco.

Pearsall, P. (1999). The heart’s code: Tapping thewisdom and power of our heart energy. New York:Random House.

Porges, S.W. (1995). Orienting in a defensiveworld: Mammalian modifications of our evolution-ary heritage. A polyvagal theory. Psychophysiology,32, 301-318.

Porges, S.W. (1997). Emotion: An evolutionaryby-product of the neural regulation of the auto-nomic nervous system. Annals of the New YorkAcademy of Sciences, 807, 62-77.

Sapolsky, R.M. (1998). Why zebras don’t getulcers: An updated guide to stress, stress related dis-eases, and coping. NY: Freeman.

Sleight, P., & Casasdei, B. (1995). Relationshipsbetween heart rate, respiration and blood pressurevariabilities. In M. Malik & A.J. Camm (Eds).Heart rate variability (pp. 311-327). Armonk, NY:Futura.

Sylvia, C. (1997). A change of heart: A memoir.NY: Warner.

Zi, N. (1997). The art of breathing. Glendale,CA: Vivi.

iSend all correspondence to Spafford Ackerly,PhD, Colorado Rocky Mountain School, 1493County Road 106, Carbondale, CO 81623, Email:[email protected], Website: www.crms.org/spaff,eFax: 309-215-4746

conditioning and dangerous offenders, III. Journalof Neurotherapy, 1 (2), 44-54.

Robbins, J. (2000). A symphony in the brain.New York: Atlantic Monthly Press.

Scott Kelso, J.A. (1999). Dynamic patterns: Theself-organization of brain and behavior. Cambridge,MA: MIT Press.

Sterman, M.B. (2000). Basic Concepts andClinical Findings in the Treatment of SeizureDisorders with EEG Operant Conditioning,Clinical Encephalography, 31 (1), 45-55.

Suffin, S.C., & Emory, W.H. (1995),Neurometric subgroups in attentional and affectivedisorders and the association with pharmacologicaloutcome. Clinical Encephalography, 26, 76-83.

Tansey, M. (1991). Wechsler (WISC-R) changesfollowing treatment of learning disabilities via EEGbiofeedback training in a private setting, AustralianJournal of Psychology, 43, 147-153

Tucker, D.M., & Williamson, P.A., (1984).Asymmetric neural control system in human self-regulation. Psychological Review, 91, 185-215.

Emerging Trends inNeurofeedback

continued from Page 23

Heart Rate Variability and Enhanced StudentPerformancecontinued from Page 27

standpoint, the text would be most appro-priate for an upper-level undergraduate or agraduate course subsequent to the comple-tion of a prerequisite that provides a funda-mental overview of learning theory. From aclinical standpoint, it should serve as anexcellent reference for individuals practicingwithin applied settings, particularly thoseutilizing behavioral and/or cognitive-behav-ioral interventions within the areas ofHealth Psychology and BehavioralMedicine.

Kazdin’s text is available throughWadsworth Publishing, Thomson Learning,10 Davis Drive, Belmont, CA 94002-3098,1-800-354-9706, www. wadsworth.com, ata cost of $60.26.

ReferencesBelar, C. D., & Deardorff, W. W. (1995).

Clinical health psychology in medical settings: A prac-titioner’s guidebook. Washington, DC: AmericanPsychological Association.

Sarafino, E. P. (2002). Health psychology:Biopsychosocial interactions (4th ed.). New York:John Wiley & Sons.

Letter to the EditorAugust 16, 2002Dear Editor:

In their most interesting article, Palsson & Pope (2002), provide a fascinating pictureof a future for biofeedback. Unfortunately, it also raises an issue of some concern. Asthey describe it, all these new capabilities will be used to serve the most benign purpos-es. But since much of what they envision is intrusive into our most private affairs,another perspective is possible. Providing the kind of feedback they describe would nec-essarily build up a database of life styles, learning styles, cognitive capacities, moodstates, medical conditions and vulnerabilities, etc. Such a database could be used byinsurers, employers, financial backers and others in a way that would be inimical to thepersons’ interests. This problem has already arisen with respect to medical coverage andgenetic information.

Of course, one can always argue that privacy will be respected, but we have seen inthe case of medical records what happens to privacy when it conflicts with corporateinterests. We need to come to grips with this issue as we develop our capabilities. Thereis the danger that those who control this technology, (usually not those who develop it),would use it to further increase the power imbalance with which we all live.

Therefore, each stage in the development of this technology needs to be accompaniedby an encryption system powerful enough to put some teeth into the privacy notion.

Sincerely yours,David W. Jacobs, Ph.D.

ReferencesPalsson, O.S. & Pope, A.T. (2002). Morphing beyond recognition: The future of biofeedback tech-

nologies. Biofeedback, 30, 14-18.


Communication Apprehension by BettyHorwitz is an interesting, well-written andclinically relevant guide to the understand-ing, assessment and treatment of perform-ance anxiety. The book’s title refers toperformance anxiety as “the hidden com-munication disorder” – anxiety “suffered byan individual of either actual or anticipatedcommunication . . .” Dr. Horwitz arguesthat speech and language pathologists areuniquely qualified to address this disorderand presents a wealth of informationdesigned to help clinicians approach theissue with confidence.

Several years ago, I attended a conferenceat a prestigious rehabilitation facility, on thetopic of mild brain injury. Part way throughthe workshop, an experienced clinicianexpressed serious concern that we were ven-turing into areas not specifically related tospeech language pathology and that wemight be denied reimbursement or, worse,be verging on unethical practice outside ourarea of expertise by incorporating thesetechniques into our treatment protocols.

In my own area of practice, rehabilita-tion of mild traumatic brain injury, my col-leagues (psychologists, physicians) oftenspend an inordinate amount of time andenergy trying to isolate the cause of aclient’s complaints – depression, pain, trau-ma or brain injury - to determine whoshould treat the patient at the expense ofimplementing effective treatment by inte-grating aspects of all relevant approaches.

Communication Apprehension: Origins andManagement presents a convincing andimportant argument for the interdiscipli-nary approach to a specific disorder: per-formance anxiety. In so doing, Dr. Horwitzexamines the complex interaction, oftendescribed as the mind-body connection,underlining performance anxiety. Dr.Horwitz renames this issue, “communica-tion apprehension” perhaps to make it moreaccessible and acceptable as a legitimate areaof practice for speech pathologists. This lin-guistic device should encourage practition-ers to think more holistically about ourfield.

Dr. Horwitz gently reminds us that weare trained that speech/language are overlaidfunctions in the basic survival functions ofbreathing, valving and shaping (laryngeal,articulation) – and urges us to explore com-plicating factors of anxiety and hyperarousalwhich may pose obstacles to successfultreatment. Cognition is clearly mediated bylanguage. Dr. Horwitz’s book points out thefact that emotions also have a cognitive/lin-guistic base which must be acknowledgedand understood in order to be treated effec-tively. How one uses language to explainone’s reactions or feelings can be instrumen-tal in how receptive to change a person maybe. Identifying these often subtle factors candetermine whether or not treatment will beeffective. Dr. Horwitz observes that “com-munication apprehension is a pervasive,multifaceted phenomenon that must be

viewed from many perspectives if it is to beunderstood and overcome” (p 23). She laterobserves “unfortunately there is very littlecrossover between the fields of speech lan-guage pathology and applied psychophysiol-ogy” and her book convincingly encouragespractitioners in both fields to expand theirknowledge base in the interest of improvingtreatment outcomes.

On a purely technical level, the book isnicely organized with information aboutdevelopmental, psychological and physio-logical perspectives illustrated with clinicalexamples. Each chapter and question issummarized concisely. Dr. Horwitz statesclearly what she intends to discuss, coversthe material thoroughly and then reviewsthe chapter to focus on important points.

The chapters on psychological and physi-ological perspectives by Don Moss, PhD,and Richard Gervitz, PhD, provide excel-lent information which should be easilyunderstood even by those with little back-ground in biofeedback. The speech lan-guage pathologist will recognize familiarthemes crossing disciplines. For example,Dr. Moss speaks of cognitive self-help pro-cedures used in biofeedback and describesother cognitive strategies for managing andmastering anxiety. Speech language patholo-gists are increasingly familiar with the rolemetacognitive skills play in the remediationof many disorders. Reading about cognitiverestructuring in conjunction with educa-tion, which is emphasized throughout the

Review of Betty Howitz (2002),Communication Apprehension:Origins and Management. Albany, NY:Singular-Thomson Learning.Review by Mary Lou Acimovic, MA, CCC-SP

BOOK REVIEW

Mary Lou Acimovic, MA,CCC-SP

book, underscores the importance of thetransdisciplinary approach to communica-tion apprehension.

Similarly, Dr. Gervitz directs our atten-tion to the role of respiration and breathingretraining in treating anxiety disorders.Speech language pathologists typically focuson breathing with clients who have voiceproblems, neurological disorders and dysflu-ency. Applying this expertise to anxiety dis-orders which affect communication is asmall step.

Finally, chapter 5, ManagementPerspectives, actually presents the treatmentprotocol Dr. Horwitz uses. This chapter isvery valuable clinically taking us throughthe course describing, class by class objec-tives, homework assignments, material to be

presented (with generous references to otherchapters in the book) and suggestions forresources for clinicians who may decide tofurther their education and training inbiofeedback. Dr. Horwitz emphasizes theimportance of support (hence the efficacyof the group approach), and individualizingthe program based on personality issues dis-cussed earlier in the book. In a short para-graph toward the end of chapter 5, Dr.Horwitz makes her most important pointwhen she stresses that therapeutic approach-es which do not “uncover or address thesource of a problem” cannot hope to beeffective and that clients “considered unco-operative or unmanageable” should cause usto reflect on our therapeutic techniques, beflexible and use “failures” to explore alterna-

tive approaches. Principles outlined in Communication

Apprehension are applicable to many otherareas of speech/language treatment: accentreduction (why are some of our clientsmore resistant to changes we ask them tomake); voice therapy (why we may not beas effective when asking our clients tochange lifelong patterns); brain injury (whydoes cognitive rehabilitation sometimes stallwhen alternate approaches are suggested).

As with any good clinical material, Dr.Horwitz’s book encourages us to evaluateour methods and outcomes, expand ourknowledge and in doing so become moreeffective clinicians.


BSC 2002Asilomar Conference CenterNovember 8 through November 10

November 7 — Preconference Institute Heartmath with Roland McCraty

Personal Retreat: Open your Heart with the music of Peter Makena

INVITED SPEAKERS: Gary Schwartz, PhD; Will Evans, MD; Liz Strobel, PhD;

Naras Bhat, MD; Jeffrey R. Cram, PhD

PANELS: Breath & Heart; Neurofeedback

WORKSHOPS: Somatics; Sensori-Motor Psychotherapy For Trauma; Assessment and Treatment of

Dystonias; With Heart & Breath, Coherence Within & Beyond; The Heart of Your Right to Be;

HEG; Hidden Gems for Intake Assessments; How To Perform an Evoked Potential Study On

Lexicor; Advances in qEEG Analysis; Interactive Metronome for ADD; Advances in Energy

Medicine for Biofeedback; Make Health Happen: A 14 Week Program; Social Psychophysiology

of Attachment and Dominance; Neuroscience for the Biofeedback Practitioner

For more information call (800) 272-6966 or visit www.biofeedbackcalifornia.org

Mary Lou Acimovic, MA, CCC-SP, is acertified speech/language pathologist. Shehas been in practice since 1974. Her area ofexpertise is the evaluation and treatment ofmild traumatic brain injury. She is also cer-tified in biofeedback and neurofeedbackand incorporates both in her treatment pro-tocols. Ms. Acimovic has presented region-ally on the subject of traumatic brain injuryand biofeedback applications with the neu-rogenic population. Currently she is in pri-vate practice in Boulder, Colorado andserves on the Colorado Governor’s TaskForce on Brain Injury.

Spafford C. Ackerly, PhD,teachesBiology at the Colorado Rocky MountainSchool (www.crms.org). He is currently on asabbatical leave and leave of absence, enti-tled The Heart of Learning, visiting schoolsand developing curriculum on the biologyof learning and human performance in conjunction with the Association for Applied Psychophysiology andBiofeedback (www.aapb.org and www.coloradobiofeedback.org), the Advanced Learning Foundation(www.advanced-learning.org), the Instituteof HeartMath (www.heartmath.org), and theUniversal Tao Center (www.universal-tao.com). His CurriculumVitae is on-line at www.crms.org/spaff

Frank Andrasik, PhD, is a SeniorResearch Scientist, Institute for Human andMachine Cognition, and a Professor,Psychology, at the University of WestFlorida. He is a Past President (1993-1994)and Program Chair (1992) of AAPB, the1992 recipient of AAPB’s Merit Award forLong-Term Research and/or ClinicalAchievements, the 2002 recipient of AAPB’sDistinguished Scientist Award, a SeniorFellow in BCIA, and the current Editor ofAAPB’s journal, Applied Psychophysiology andBiofeedback. He has published and presentedon a variety of topics, but his work has con-centrated most intensively on assessmentand treatment of recurrent headache. He iscurrently assisting Dr. Mark Schwartz as co-editor for the third edition of Biofeedback: APractitioner’s Guide.

Stuart Donaldson, a psychologist in pri-vate practice in Calgary, Alberta, receivedhis Ph.D. in 1989 at the University ofCalgary. He is the director of a multidisci-plinary pain treatment and rehabilitationcenter (Myosymmetries, Calgary). A pio-neer in the field of sEMG and chronic pain,his more recent work has involved the inte-gration of sEMG, QEEG, psychological sta-tus, and chronic pain. He has publishedextensively on biofeedback, chronic pain,and fibromyalgia.

Samuel T. Gontkovsky, Psy.D., BCIA-C,earned his doctorate in Clinical Psychologyfrom Nova Southeastern University. Hecompleted his internship training with spe-cializations in Neuropsychology and HealthPsychology at the Department of VeteransAffairs Medical Center in Little Rock,Arkansas. Subsequently, he completed atwo-year postdoctoral fellowship in ClinicalNeuropsychology at the University ofOklahoma Health Sciences Center. Dr.Gontkovsky presently is employed in clini-cal research at the INTEGRIS Jim ThorpeRehabilitation Center in Oklahoma City,Oklahoma and holds a faculty appointmentat Cameron University in Lawton,Oklahoma. He maintains certifications inbiofeedback, cognitive-behavioral therapy,and addictions counseling.

Jay Gunkelman, QEEG-T, started in thebiofeedback field in 1972, co-authoring agrant that started the first biofeedback labin a state hospital. Specializing in EEG, hetaught at the Biofeedback Institute of SF’sprofessional training program for 12 years,and working in the busiest EEG lab in thenation. He has been involved in over500,000 EEGs. He is currently one of theowners of Q-Metrx.com, an internet basedquantitative EEG service and in-house sleeplab in Burbank. Though a recent AAPBnew member, Jay has been actively involvedin SNR, is their immediate past president,and has been conference program chairfrom 1997-2003.

D.Corydon Hammond, PhD, is thePresident-Elect of the Society for NeuronalRegulation, the Past President and a Fellow

of the American Society of ClinicalHypnosis, and a full Professor of PhysicalMedicine and Rehabilitation at theUniversity of Utah School of Medicine. Hehas published 47 journal articles or reviews,40 chapters, and 8 books, his latest beingThe Art of Artifacting (with Jay Gunkelman)on artifacting qEEG data). He has receivedthree best book of the year awards fromprofessional societies. He is an AssociateEditor of the Journal of Neurotherapy,Associate Editor of the American Journal ofClinical Hypnosis, and an Editorial BoardMember of the Journal of Alternative andComplementary Medicine. He holdsDiplomate’s in Hypnosis, Marital Therapy,Sex Therapy, and Neurotherapy. He hasrecently been a Consultant for the FederalBureau of Prisons on instituting a neuro-feedback program.

Theodore J. La Vaque, PhD, has gradu-ate and postgraduate education in bothphysiological psychology and clinical psy-chology. He received a B.S. in Psychology atthe University of Wisconsin (1963), anM.S. in Psychology from New MexicoHighlands University (1965), and his PhDin Psychology from Iowa State University.He was a V.A. Research Associate in behav-ioral neuroendocrinology at the West SideV.A. Hospital, Chicago and AssistantProfessor in the Department of Psychiatry,Abraham Lincoln School of Medicine,University of Illinois from 1972 to 1976.He was Director of the ClinicalPsychophysiology Center at RogersMemorial Hospital from 1995 to 2000. Hehas been in private practice since 1975. Hehas published papers concerning the historyof EEG, the technical requirements for clin-ical research in EEG biofeedback, co-authored papers comparing clinicaloutcomes of EEG biofeedback with psy-chostimulants, concerning the ethical con-straints on the use of placebo controls inclinical psychophysiology research, andquestioning the validity of the placebo con-dition in medical/behavioral research ingeneral. Ted currently serves on the BCIABoard, is an Associate Editor for the Journal


ABOUT THE AUTHORS

of Neurotherapy and an assistant editor forBiofeedback. He is a BCIA Senior Fellow,and is the 2002 recipient of the ShielaM.Adler award from AAPB. Ted hasworked with EEG biofeedback and ADHDfor the past 8 years.

Douglas W. Matheson, PhD is aProfessor of Psychology at the University ofthe Pacific Stockton, CA. His research andteaching interests include Research Methodsand Statistics, stress management, behav-ioral medicine, clinical applications ofbiofeedback technology in BehavioralMedicine(especially the application of EEGbiofeedback in the treatment of ADHD),Sports Psychology, and the Psychology ofTeaching. His current research involvesexamination of respiratory sinus arrythmiain the treatment of depression followingmyocardial infarction. He is the author orco-author of many useful texts, includingIntroductory Psychology: The Modern View(Harlan Davidson, 1982) and ExperimentalDesign and Analysis (Holt, inehart, &Winston, 1978). He writes a biweekly com-puter column for his local paper (TheRecord) with archives available athttp://www.uop.edu/cop/psychology/archives/archive.html.

Donald Moss, PhD, is a partner inWestern Michigan Behavioral Health inGrand Rapids and Grand Haven, Michigan.He directs their Chronic Pain Services andPrimary Care Outreach Services. He isEditor of the Biofeedback Newsmagazine andConsulting Editor for the Journal ofNeurotherapy. He is adjunct graduate facultyof the Saybrook Graduate School andResearch Center in San Francisco. His pri-mary interests are the application of clinicalpsychophysiological knowledge and inter-ventions to the anxiety disorders, and to thefunctional problems of primary care medi-cine. His current book in progress isHandbook of Mind/Body Medicine forPrimary Care (Sage).

Randy Neblett, MA, LPC, is a LicensedProfessional Counselor with a master’sdegree in psychology from SouthernMethodist University. He has providedcounseling and biofeedback services in theDallas area for 12 years, specializing inphysical rehabilitation. Though his experi-ence has included spinal cord, head injury,

stroke, and chronic pulmonary rehabilita-tion, his primary interest is in chronic pain.He currently manages a biofeedback depart-ment at PRIDE - Productive RehabilitationInstitute of Dallas for Ergonomics, a multi-disciplinary chronic pain management pro-gram for chronically disabled workers. Hehas recently accepted an adjunct facultyposition at the University of TexasSouthwestern Medical School.

Siegfried Othmer, PhD, is a physicistwho has been involved with neurofeedbackalong with his wife Susan Othmer sinceEEG training benefited their epileptic sonBrian in 1985. After developing a neuro-feedback instrument optimized for thehigher-frequency (“SMR-beta”) training,the Othmers started EEG Spectrum in1988 to offer EEG biofeedback services.Since 1990, the Othmers have trained some2,500 neurofeedback professionals in theirmethods. They also established a worldwideneurofeedback practitioner network that isnow in some thirty countries.

Thomas R. Rossiter, PhD, is a licensedpsychologist in private practice in De Pere,WI. He specializes in EEG biofeedback,neuropsychological assessment, and thediagnosis and treatment of AD/HD. (Hecan be reached via [email protected])

Sebastian “Seb” Striefel, PhD, became aProfessor Emeritus in the Department ofPsychology at Utah State University inSeptember 2000. For twenty six years hetaught graduate level courses in ethics andprofessional conduct, clinical applications ofbiofeedback, clinical applications of relax-ation training and behavior therapy. He wasalso the Director of the Division of Servicesat the Center for Persons with Disabilitiesat Utah State University. In that role hemanaged a variety of programs, includingan outpatient clinic, a biofeedback lab andan early intervention program. He is a pastpresident of the Association of AppliedPsychophysiology and Biofeedback (AAPB),current president of the NeurofeedbackDivision of AAPB, Secretary/Treasurer ofthe International Section of AAPB and reg-ularly writes an ongoing ethics column andconducts workshops on ethics, standards,and professional conduct.

David L. Trudeau, MD, is the editor ofthe Journal of Neurotherapy. He directed

the Neurofeedback Lab in the Departmentof Psychiatry at Minneapolis VeteransAffairs Medical Center for ten years, priorto his retirement in 2000. He has served asAssistant Professor in the Department ofFamily Practice and Community Health inthe Academic Health Center at theUniversity of Minnesota and in theDepartment of Psychiatry at the Universityof Kansas-Wichita. He is a career addiction-ist and has been the recipient of grants fromthe Center for Addiction and AlternativeMedicine Research under the Office ofAlternative Medicine, NIH. He has beenactive in the teaching of medical students,psychiatry and family practice residents andaddiction fellows in addiction medicine andbrain wave biofeedback. He has authoredtwenty-four scientific articles in the fields ofneurofeedback, QEEG, and addiction med-icine. He has co-chaired annual nationalscientific meetings of the Society forNeuronal Regulation (SNR), and serves onthe board of SNR. He is a member of theEEG section of the Association for AppliedPsychophysiology and Biofeedback (AAPB)and is a member of the EEG and ClinicalNeuroscience Society (ECNS).



SNR 2002 CONFERENCEScottsdale, ArizonaSEPTEMBER 12 — 15, 2002

La Posada Double Tree Hotel and Resort

602-952-0420

A sampling of the excellent science SNR has scheduled: (SNR general conference sessions will be accepted by BCIA for up to 25 hours of elective continuing education credit.)

Keynote addresses:Michael E. Brandt . . . . . . . . . . . . . . . . . . . . .The Chaotic, Complex Path to Understanding NeurodynamicsM. Doppelmayr & W. Klimesch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .EEG and IntelligenceJohn Hughes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .The Mozart EffectJuri Kropotov . . . . . . . . . . . . . . . . . . . . . . . . .QEEG/ERP/ERD Evaluation in NF of Executive DysfunctionRoberto Pascual-Marqui . . . . . . . . . . . . . .Frequency Structure and Neuronal Generators of Eyes-Closed EEGKarl Pribram . . . . . . . . . . . . . . . . . . . . . . .The Double Neuromythology of Emotions and the Limbic SystemsI. Jon Russell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Fibromyalgia

Invited speakers:Tom Budzynski . . . . . . . . . . . . . . . . . . . . . . . . ..QEEG, LORETA, and SKIL Analyses: One Twin with CFSStuart and Mary Donaldson . . . . . . . . . . . . . . . . .QEEG, Psych. Status and EMG Activity in FibromyalgiaCory Hammond . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Neurofeedback and Obsessive Compulsive DisorderWilliam Hudspeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .The Single-Band Asymmetry ProfileJack Johnstone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Bispectral Analysis: An UpdateJ. Peter Rosenfeld . . . . . . . . . . . . . . . . . . . . . .ERP-Based Lie Detection, Psychopathy and Signs of DeceptionAlan W. Scheflin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .The New Legal Standard for ScienceM. Barry Sterman . . . . . . . . . . . . . . ... Pathologies of Regional EEG Comodulation: Issues and InterpretationRicardo Weinstein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..QEEG in Death Penalty EvaluationsV. "Sue" Wilson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .QEEG/BF in Assessment and Training of Executives

Examples of SNR workshops: (SNR is approved by The American Psychological Association to offer continuing education for psy-chologists enrolling in our workshops. SNR maintains responsibility for the program.)

Congedo, Lubar, Pascual-Marqui, & Sherlin . . . . . . . . . . . . . . .Combining Enhanced QEEG & LORETA Analysis Bob Gurnee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..QEEG Neurofeedback Protocol DesignJohn Hughes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .The EEG From Infancy to AdulthoodPaul Lehrer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...Cardiovascular Resonant Frequency BiofeedbackKarl Pribram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .The Limbic Forebrain and EmotionI. Jon Russell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Recognition and Management of the Fibromyalgia SyndromeLynda & Michael Thompson . . . . . . . . . . . . . . . .EEG Fundamentals: A Review in Preparation for the BCIA Exam

See our web site, www.snr-jnt.org,for details of the general conference scheduleand workshops. Contact the SNR office at [email protected] or call 800-488-3867.

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THE AAPB 2002 ProfessionalPractice Workshops

THE AAPB 2002 ProfessionalPractice Workshops

Washington, DCSeptember 27-29, 2002Friday, September 27“Introduction to QEEG BasedNeurofeedback ProtocolDesign”

Saturday, September 28“The Psychophysiology ofRespiration”“Quantitative EEG Analysis andNeurofeedback ProtocolDesign”

Sunday, September 29“Cardiovascular ResonantFrequency Biofeedback”

Long Beach,California, October 8-12, 2002October 8-12“Fundamentals ofEEG/Neurofeedback”*

October 9-12“Fundamentals of GeneralBiofeedback”*

Friday, October 11“Anxiety Disorders:Identification and Treatment”

Saturday, October 12“Migraines and IBS – Are TheyBoth Brain Disorders?”

Raleigh-Durham,North Carolina,October 18-19, 2002Friday, October 18“Cognitive Therapy andBiofeedback for AnxietyDisorders”

Saturday, October 19“Respiratory Training andHeart Rate VariabilityBiofeedback for AnxietyDisorders”

October 18-19“SEMG Investigation ofMuscular Dysfunctions andSEMG/BFB Treatment” Parts 1 and 2

Washington, DCSeptember 27-29, 2002Friday, September 27“Introduction to QEEG BasedNeurofeedback ProtocolDesign”

Saturday, September 28“The Psychophysiology ofRespiration”“Quantitative EEG Analysis andNeurofeedback ProtocolDesign”

Sunday, September 29“Cardiovascular ResonantFrequency Biofeedback”

Long Beach,California, October 8-12, 2002October 8-12“Fundamentals ofEEG/Neurofeedback”*

October 9-12“Fundamentals of GeneralBiofeedback”*

Friday, October 11“Anxiety Disorders:Identification and Treatment”

Saturday, October 12“Migraines and IBS – Are TheyBoth Brain Disorders?”

Raleigh-Durham,North Carolina,October 18-19, 2002Friday, October 18“Cognitive Therapy andBiofeedback for AnxietyDisorders”

Saturday, October 19“Respiratory Training andHeart Rate VariabilityBiofeedback for AnxietyDisorders”

October 18-19“SEMG Investigation ofMuscular Dysfunctions andSEMG/BFB Treatment” Parts 1 and 2

Summer 2002 1ABiofeedback

aapb News& Events

From the President –AdvocacyPaul Lehrer, PhD

This issue of “advo-cacy” has been trou-blesome for AAPBsince biofeedbackbecame a viable clini-cal intervention, andparticularly since anincreasing share ofhealth care expensesbecame borne by

insurance companies and governmenthealth programs. More than any other, thisissue has the potential to weaken our organ-ization, and thereby our field as a whole.

Quite rightly, AAPB has been criticizedby its membership for being ineffective asan advocate. We can claim few if any leg-islative victories, and have made few inroadswith private third party payers. Indeed, vir-tually all third party payers view biofeed-back as a “Pandora’s box” for new costs,rather than as a way to save on medicalcosts, as many of us believe would be thecase. Further complicating the issue is thetendency for many Americans to changetheir health plans every few years. Thusmost insurance companies tend to seeinvestments and innovations in preventivehealth care as more beneficial to other com-panies, who will insure their customers infuture years, rather than to themselves; sothey are reluctant to pay the up-front costsfor effective and ultimately cost-effectivetreatments for the people they cover.

Adding to this is the complication from

within our own organization, of decidingwhich issues we should advocate. There islittle debate over whether we should pro-mote reimbursement for biofeedback servic-es generically. However, some of ourmembers would prefer that this be limitedto disorders for which there are clearresearch data proving clinical effectiveness.(This is a rather small list, unfortunately.Using criteria of Phase III drug trials forclinical effectiveness, we can count only avery few problems, if any, that meet this cri-terion. Biofeedback does not have the eco-nomic power of the pharmaceuticalindustry to sponsor such expensive research.An AAPB committee under the directorshipof Donald Moss and Theodore LaVaque iscurrently preparing an updated set of “whitepapers” that describe the level of proofavailable for various applications.) Otherswould want AAPB to advocate for reim-bursing any clinical activity that is practicedby a segment of our membership.

Here are the facts and options, as Iunderstand and evaluate them. I invitereplies and debate in this forum fromAAPB members, and urge that they workthrough relevant AAPB sections, divisions,and committees to bring their views effec-tively to the attention of the AAPB board.

First, AAPB simply does not have theresources to be an effective advocate.Advocacy is extraordinarily expensive. Itstrains the resources even of very large andwell-funded organizations like the American

Psychological Association and the AmericanMedical Association. Additionally, there aresome legal limits on what an organizationlike ours can do without jeopardizing ourtax-exempt status, although this objectionusually can be overcome by strategic reor-ganization into several independent corpo-rations, some of which are purelyeducational and oriented to public service,while others unabashedly promote theinterests of biofeedback practitioners bypromoting legislative changes. If AAPBmembers feel that such advocacy is animportant reason for joining and remainingmembers of our society, then we must findmodels of providing it, other than, as now,by doing it (relatively ineffectively) by our-selves, mostly as volunteers, each of us over-worked and overcommitted in our variousprofessional, family, and community activi-ties.

One such model has been proposed bythe Biofeedback and Behavioral HealthPractitioners Guild. The Guild is affiliatedwith the AFL-CIO, and can draw upon theorganizational and financial power andadvocacy expertise of the American labormovement to advocate much more effec-tively and cost-effectively than can be doneby AAPB alone. In this way, the Guild (or asimilar organization) could function side byside with AAPB, in collaboration with it, asan independent advocacy organization,

continued on Page 2A

Summer 20022A Biofeedback

much as BCIA now functions as an inde-pendent certification organization. I wouldlike to hear how members feel about thisoption. To bring it about would requirenontrivial additional expenses from each ofus, and may require a major rethinking ofAAPB’s structure.

Then, how do we decide what to advo-cate. Certainly the first priority should befor adequate reimbursement for biofeedback(and other applied psychophysiology andmind-body) services, where these have beenfound to be clinically effective. In my opin-ion, this should be the first fight. It is theone that has the greatest chance of success.

We can pick the one or two disorders withthe highest level of empirical support, andstart there.

The best way to solve the problem ofadvocacy is to get involved in this debate.Join the Legislation and Insurance commit-tee. We need members from every state, aseyes, ears, and arms for issues and actionson the state level, where most “bread andbutter” issues occur. Most of all, let’s stayunited. Rather than grumble about whatAAPB has not been able to accomplish foryou, join the ranks of active members whowill help make us more effective.

AAPB Year in Reviewcontinued from Page 1A A Personal

NoteTed La Vaque

This year at the annual meeting ofAAPB I was given the very highhonor of being the recipient of theSheila M. Adler Service Award for“contributions to the Association forApplied Psychophysiology andBiofeedback”. In previous years, peo-ple who were recognized at theawards breakfast went to the podiumto receive the award and recognition,but did not address the audience.This year, I was the first to be calledfor recognition, and following what Ithought was correct protocol,acknowledged the award with a smileand wave to the assembly. Of course,everyone who came after me spoke inappreciation of their particular recog-nition.

I want to take this opportunity,then, to express my appreciation tothe Awards Committee and (then)President Don Moss for this award. Iam humbled by the fact that myname will appear in company withsuch notables as Charles Adler,Sebastian Striefel, RobertShellenberger, Edward Blancher,Mary Cook, Joe Kamiya, JohannStoyva, Kenneth Russ, RobertWhitehouse, Mark Schwartz andJohn Perry. I also want to encourageeach of you to actively participate inthe organization. I have found thatthe people who make the organiza-tion work on a day-to-day basis aregenerous with their time and assis-tance, and go to great lengths tomake our tasks easier to perform.Certainly Don Moss, FrancineButler, and a person most of yourarely hear about, MichaelThompson have always been there toease the way and “make thingswork”.

Please accept my thanks for thisrecognition.

Call for Nominations for 2003Board Positions

The AAPB Nominations Committee has the responsibility for presenting a slate of indi-viduals to serve as officers and board members. The Nominating Committee seeks yoursuggestions for the following positions: President-elect and one opening on the Board ofDirectors. Board positions are for a term of three years.

Criteria for board positions include: current membership in AAPB; committee, chapter,or section service; contributions to biofeedback and the field; and past association gover-nance experience. Board members are required to attend two meetings per year, and abideby AAPB ethical principles, including signing a conflict of interest statement.

In the event that an individual’s name is not on the official ballot, AAPB has a mecha-nism whereby a member, by using a petition process, may have his/her name placed on theballot in addition to the Nominating Committee’s slate. Members who wish to use thepetition process to place their name on the ballot must use the official petition form, avail-able from the AAPB office. Only the official form will be accepted by the NominatingCommittee. Deadline for submission of petitions to the nominating committee isOctober 1, 2002.

Award Nominations SoughtThe AAPB membership is encouraged to submit nominations for the AAPB

Distinguished Scientist Award and the Sheila Adler Distinguished Service Award. Theseawards recognize outstanding contributions to research in applied psychophysiology andbiofeedback and service by a biofeedback professional.

Nominating letters should include the name and address of the nominee(s), name andaddress of the nominator and a brief statement describing why the person is being nomi-nated for the award. Letters should be addressed to the Awards Committee, and received atthe offices of AAPB no later than September 30, 2002, to permit time for the committeeto consider the nominations and determine the recipients.

The awards will be presented at the 2003 Annual Meeting.

Summer 2002 3ABiofeedback

Arnon Rolnick Remembers:It is with heartfelt sorrow that I write

about Dr. Paul Bindler. Actually, Paul wasthe one who very often helped me write inEnglish.

I met Paul at one of the AAPB conven-tions in the early 90’s. I was waiting to havea word with Joel Lubar, when Paul rushedin and posed his questions without askingpermission from the others who were therebefore him. I was about to “educate” him,when he smiled warmly and introducedhimself with a wonderful sense of humor.We talked, and I found an extremely openminded man with many wide-ranging inter-ests: not just Biofeedback, but alsoPsychotherapy, Psychoanalysis, religion andphilosophy.

However, our main common interest wasour love of gadgets. Paul was fully updatedabout new software or hardware. I stillremember how he enjoyed his first Palm III:He opened the metal cover of this deviceand said with pleasure: “Kirk to enterprise”.We had real fun, and an adventure, whenwe tried together (for the first time inbiofeedback history) to conduct a “remotebiofeedback session.” This was some 5 yearsago. Paul sat in his clinic in NYC, while Iwas in my office in the outskirts of Tel-Aviv.After a few futile attempts, I suddenly sawPaul’s GSR reading on my screen. We wereexcited and Paul summarized the experiencesaying: “Now I know how AlexanderGraham Bell felt.”

Paul believed that psychology and tech-nology must not be regarded as separateentities. His dream was of helping manymore people, if we could harness the powerof computers and the internet as tools forclinicians.

Paul visited us in Israel a few times andwas always very supportive. He conductedseveral successful workshops about hypnosisand biofeedback; I was fortunate to be ableto work with him and to learn from him.

Paul was, first and foremost, a “mentch” -a true man, very generous and very friendly.

Let me close with this story: every time I

came to the USA and flew back to Israel, hegave me a dollar. “Why do you that,” Iasked. “I want you to donate it to poor peo-ple” he said. And he explained that if Iwould carry this dollar with me to give it tothe poor no harm would happen to mebecause God protects those who are mes-sengers of good will. Paul left us in a sud-den and unexpected manner, but I am surehe did not have to take a dollar with him.

May he live forever in our memory.

Paul Lehrer Remembers:Paul Bindler was one of the most infec-

tiously enthusiastic people in the field ofapplied psychophysiology. Speaking withhim about biofeedback or hypnosis couldalternately make me feel recharged orexhausted, depending on my own capacityat the time to absorb new perspectives “onthe spot.” Many AAPB members willremember him for his expertise on hypnosisand hypnotic phenomena, and the spiritedsymposia he organized on the topic atAAPB meetings during the past few years.

Most of us will also remember him as adeeply religious man. Wherever he went, hewore his kippa, as sign of respect beforeGod. He managed to adhere faithfully tothe rigorous laws and customs of Orthodox

Judaism, while fully immersing himself inthe secular world of applied psychophysiol-ogy, foremost as a clinician, but also as ascientist, teacher, innovator, and a long-term active contributor to AAPB. In thisyear when AAPB explores the “circle of thesoul” in its annual meeting, we might paytribute to him by studying one of his earlybut classic articles:

Bindler, P. Meditative prayer and rabbinic per-spectives on the psychology of consciousness:Environmental, physiological, and attentional vari-ables. Journal of Psychology and Judaism, 41, 228-248.

In it he describes specific attentional,meditative, and psychophysiological aspectsof Jewish prayer, and describes both theirroots in the rabbinic literature and theirconnections to modern psychophysiologicaland psychological research. The paperreminds us that spiritual practices of all reli-gions have major psychophysiologicaleffects. These effects both enhance the reli-gious experience and may contribute tosome of the health-promoting effects thatseem to accrue to those with a satisfyingspiritual life.

In Memoriam:Two Friends Remember Paul Bindler

We Encourage SubmissionsSend chapter meeting announcements, section and division meeting

reports, and any non-commercial information regarding meetings, pre-

sentations or publications which may be of interest to AAPB members.

Articles should generally not exceed 750 words. Remember to send

information on dated events well in advance (we may be able to publi-

cize your event more than once if you get your calendar to us early

enough).

Send Word (.doc) or text files by e-mail to the News and Events

Editor: Ted LaVaque, PhD [email protected] by September 1 for

the Winter Issue.

Summer 20024A Biofeedback

Planning for the 2003 meeting is in fullswing. We need your submissions to pro-duce a great meeting. Please submit databased symposia, paper presentations,posters, short-courses, and workshops. Weare giving you plenty of time to plan aheadso you can get your material in great shapefor submission. This year's program willavoid having too many events going on atthe same time. Thus, there will be fewerslots than in previous years for all categoriesof submissions except posters. Feel free to e-mail me with ideas and questions.

Students please note that there is a newaward for the best graduate student presen-tation - a Thought Technology system!

Theme of Meeting: Beyond thebounds of biofeedback

Submissions (symposia, paper presenta-tions, posters, short-courses, and work-shops) from all areas of appliedpsychophysiology are very welcome andencouraged in addition to biofeedbackrelated material. We are especially interestedin data based presentations on various self-regulation methods, including relaxationtraining, hypnosis, Eastern and Westernenergy therapies, and other methods, oftencategorized as "complementary" or "alterna-tive," that have empirically demonstrableeffects on human psychophysiology.

Meeting Starts: Tuesday 25March 2003Meeting Ends: Sunday 30 March2003Scientific Presentations: FridayAM - Noon on Sunday.

Workshops: Most of the full and half dayworkshops are on Tuesday, Wednesday,Thursday, and Sunday (afternoon only).

Short-courses: The short courses are onFriday and Saturday mornings.

Symposia and Talks: These are onFriday, Saturday, and Sunday.

Posters: Posters will be set up and pre-sented on Saturday.

Where: Jacksonville FloridaSubmission deadline: 30September, 2002How to submit

All submissions are done by filling in aweb based form. Go to www.aapb.org andclick on the link there.

Who to contact with questionsE-mail Rich Sherman (program chair) at

[email protected].

What has been scheduled forthe meeting so far?

Keynote speakers: Herta Flor (new typesof biofeedback for pain based on trainingtwo point discrimination ability), DavidShapiro (effects of Mood, Social Stress, andCoping Styles on Blood Pressure inEveryday Life: Implications for Risk andTreatment of Hypertension), RichardGevirtz (conditioning trigger point activityto decrease pain), Adam Clarke (QEEGstudies with ADHD patients), Kaufman(behavioral clinical trials and alternativemedicine), Sharon Lewis (psychoneuroim-munology), Susan Middaugh (relationshipsbetween posture, muscle tension andheadache), and Jeanete Tries (norms for uri-nary incontinence data). Dr.Yuji Sasaki hasbeen invited to speak on audogenics butarrangements have not yet been finalized.

Symposia include: Howard Hall(Alternative healing), Wes Sime (optimalperformance), and Psychophysiological

enhancement of musical performance.Speakers confirmed so far include: Herta Flor--A new type of biofeedback

for pain based on training two point dis-crimination ability.

David Shapiro--Effects of Mood, SocialStress, and Coping Styles on Blood Pressurein Everyday Life: Implications for Risk andTreatment of Hypertension

Dick Gevirtz -- conditioning triggerpoint activity to decrease pain.

Adam Clarke -- QEEG studies withADHD patients.

Peter Kaufman-- behavioral clinical trialsand alternative medicine

Sharon Lewis -- psychoneuroimmunologySusan Middaugh -- headacheJeanette Tries-- urinary incontinence dataYuji Sasaki-- autogenicsJames Gordon-- alternative medicinePlease consider participation in the 2003

Annual Meeting by submitting a proposalfor a workshop, short course, symposium,oral paper, or poster. Just click on theappropriate link below to begin your sub-mission. We look forward to seeing you inJacksonville!

Submision Deadline Monday,September 30, 2002

See you in Jacksonville in March 2003!

2003 Annual Meeting ProgramCommittee

Richard Sherman, PhD, ChairVince MontastraPaul Lehrer PhDNoland WhiteFred ShafferDenise OliveCarolyn YuchaAdam Burke

AAPB’s 34th Annual Meeting Jacksonville, Florida, March 27-30, 2003

Preview of the 2003 Annual MeetingBeyond the Bounds of BiofeedbackRichard Sherman, PhD Program Chair

Richard Sherman, PhD

Documents

Volume 30, Number 2 Summer, 2002died – Maria Eugenia Carmagnani and Paul Bindler. Proposals and Abstracts are invited for special issues on: Applied Psychophysiology and the Performing