Biofeedback and Self-Regulation, VoL 13, No. 2, 1988

L e t t e r to the E d i t o r

The questions raised about biofeedback by Furedy and others (Vol. 12, No. 3) are entirely legitimate questions that need to be asked and need to be an- swered. This answer, in part, occurred to me in connection with a recent article in the New York Times (March 1, 1988, p. C6). The article is entitled "Anesthesia Linked to Trembling," and it states: "Post-operative trembling results from the use of anesthetics, not from decreased body temperature, as had been assumed, according to a new study." It goes on to say: "We now know that a very dramatic side effect of surgery has been misinterpreted for more than 35 years . . . . "

I am prepared to bet the proverbial "dollars to donuts" that there won't be a rush to excoriate that profession in medical journals. It might be a les- son to us, biofeedback practitioners, to see how anesthesiology handles this sudden revelation: "But according to Dr. Sessler [whose findings were report- ed at last year's meeting of the International Anesthesia Research Society[, warming the skin with infrared heating lamps or even a hair dryer while the patient is still asleep should prevent the tremors altogether. Infrared heat- ing lamps are used empirically, in some hospitals and have already been shown to work, he said."

Note the word empirically. Parenthetically, no citation of controlled studies were apparently necessary to convince Dr. Sessler. Someone tried it, observed that it worked reliably, and passed on the word. A very practical solution to the problem emerged, with no apology proffered for a scientifi- cally unvalidated conclusion and its possible contamination with uncontrolled variables.

Why are we so baffled because we cannot zero in on the specific-effects model in biofeedback? It doesn't make any sense to be on the defensive with issues regarding placebo control versus our clinical experience with biofeed- back. Instead, we might take some degree of pride in the fact that psycholo- gy is the study of complex, multiple, interacting, nonspecific behavioral effects. That is neither in itself unscientific nor worthless.

On the contrary, psychology is a complex, alinear science, and the sig- nal noise ratio is not invariably in our favor.

Medicine does not reject a treatment shown to work because its mechan- isms are obscure. It is my distinct impression, based on a better than passing

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182 Letter to the Editor

acquaintance with the clinical and research literature on pain control, that the specific mechanisms of anesthesia are still a matter of intensive investi- gation: Main effects, nonspecific effects, and placebo effects are a matter of controversy. But there is a highly respected specialty called anesthesiolo- gy and a body of empirical guidelines for its application. And you would, no doubt, avail yourself of its services with considerable confidence.

And as evidence piles up, life moves on. If there is something that works, it is used even if there is no adequate explanation for how or why it works, so long as it can be shown, "empirically," that it works reliably. We can do the same thing in biofeedback therapy, while testing theories, and be doing right by our clients.

Case in point: When I reported that self-regulation of PETCO2, with biofeedback, could reduce idiopathic seizures refractory to anticonvulsant medication (Psychosomatic Medicine, 1984, 46, pp. 315-331), I was told by a prominent epileptologist that it was "almost certainly placebo." To which I replied, admittedly in a snit, that since he was so sure that placebo reduced seizures, why had he been unwilling to use it to help his clients?

But do you see what is wrong with his statement? I administered no placebo. What he meant was "nonspecific effect." And he was, of course, wrong on both counts because the main treatment was breath control, and (a) there is no way that placebo could be used in this paradigm, and (b) if there were, there is not a seizure sufferer on earth who would ever believe that this has more power than medication!

But psychologists seem to believe that to compete legitimately with other "sciences," they have to be hard-nosed. And their models for hard-nosed are the "natural" sciences, such as physics and chemistry, where things have specif- ic e f f e c t s - o r so it was thought until it was recently hypothesized that they have "charm," among other properties. And contamination with nonspecif- ic placebo effects is so f t -pa in fu l ly soft. In fact, it has become a derogatory term.

The use of pharmacotherapeutics in medicine ushered in the era of place- bo control. The practice of administering a placebo is correctly applied only in connection with studies of medication: An essentially "inert" substance is given to a subset of subjects in a study of the efficacy of a drug treatment. There is nothing comparable in biofeedback. There have been studies that have reported the effects of no feedback, delayed feedback, noncontingent, and even erroneous biofeedback. But no placebo. I cannot imagine what one could use as a placebo in biofeedback.

What about belief in the treatment? That is not placebo. Placebo is a substance-administered to control for the effect of the administration of a substance and the attendant effects on the patient of the "healing ritu- al." That the effects of a treatment may center on beliefs may well be true, but that does not make anything that may affect belief a placebo.

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I think that we confuse the so-called nonspecific effects in biofeedback treatment with placebo because they seem to be of a kind. We are confusing the thing (res) with its putative outcome. If we administer a placebo, and we observe greater than expected results, then something else, perhaps non- specific, must be held responsible.

We also seem to have a tendency to label complex interacting effects "nonspecific" because we are set on the "magic bullet" treatment-model in which one particular molecule destroys a specific pathogen. It is amazing how much we are still influenced by Paul de Kruif (The Microbe Hunters, Harcourt Brace, 1966): We collectively reason that whenever we cannot speci- fy the molecule or technique that yielded an above-chance improvement, we must indict "placebo" in the name of legitimate science.

I propose that we (a) reaffirm the use of the word placebo for use in connection with the administration of an inert substance, where that applies, and nonspecific effects for such things as motivation, hope, faith, and be- lief, and (b) that we pursue the development of an empirically validated tech- nology of self-regulation pending explanations for why things work the way they do.

If they turn out to be largely dependent on "cognitive" nonspecific ef- fects, so much the better, because that can only help to validate us as psy- chologists.

Robert Fried, Ph.D. Professor o f Psychology Hunter College, CUNY,

and Director o f the Biofeedback Clinic

Institute for Rational Emotive Therapy New York, New York