Donald C.E. Ferguson, Ph.D., MPH
Research Professor, Department of Psychiatry
Uniformed Services University
Bethesda, Maryland
Health Care and/or Medical Interventions

HYPERLINK "mailto:dferguson@usuhs.mil"
dferguson@usuhs.mil

When any action is undertaken to modify or improve a health problem, what is termed a health or medical intervention has been made. Clinical medicine classifies such interventions as surgical, medical, pharmacologic, medical, rehabilitative, palliative, physiological or electrical, to name a few such classifications. 

A health or medical intervention may have one, or a spectrum of effects on the individual receiving it. The same intervention may result in non-identical effects and outcomes when applied to different individuals. Individuals differ. A health intervention for a particular problem may prove effective, partially effective, ineffective, or perhaps even harmful insofar as an individual's response to that particular treatment is concerned. Different patients often respond differently to the same treatment. Individual differences, and biochemical individuality of patients play a role in response to most treatments. We are not all the same.

Health interventions may have unintended side effects. Unintended side effects may be beneficial, but can also be unpleasant, intolerable, unwanted, and in some cases may be adverse. Even the beliefs of a patient about a treatment, or about the skill of a particular physician or health care provider have been demonstrated to result in unintentional side effects, good and bad. 

Not only what a treatment consists of, but who administers it, can and often does make a difference in outcome. Most of us do better with those we feel understand us and our situation, all other things being equal. While the science of medicine is important, the "art" of medicine plays a role in outcome as well. Knowledge on a practitioner's part, not only of "what to do" but "when to do it", and when not to attempt an intervention all form part of his or her clinical judgment, something not easily taught. Clinical judgment develops as a result of learning by example, as well as through clinical experience, and as a result of that often uncommon attribute termed "common sense". Many of these skills cannot be learned through book learning alone.  

"The Placebo Effect"

A continuing puzzle and often heated debate within medicine involves the placebo effect. The placebo effect is a result obtained from using substances, techniques or interventions which in terms of present objective knowledge has no documented or theoretical known relation to the condition being treated. Often powerful, patient's placebo responses may result in unplanned positive and unpredicted improvements in a condition when the placebo itself has no known scientific relation to the condition under study.

Such patient responses are real, not imagined, even though they may not logically have been caused by the action of the medication or treatment. They are not easily explained since it not often known or understood, by either patient or physician, how the observed change or improvement was achieved.  Although denied by many physicians, some portion of every successful treatment involves some degree of placebo response by patients. This is not to say that a treatment itself may not have an objective effect, but the subjective response of the patient augments the favorable or unfavorable treatment outcome.

To pragmatists, this presents no problem. Their response is "Go with what works for the patient. Figure out why later, if needs be." Most patients agree. They argue that what works for them should not be discounted or discontinued, if there are no significant associated downsides. 

From a patient's perspective if a treatment helps, it is immaterial whether scientific medicine understands the mechanism by which that result has been achieved. Even present day routine, conventional, clinical, evidence based medicine offers many treatments whose underlying physiologic or biochemical mechanisms are not fully understood, and will not be understood for many years in the future. Despite the discomfort of those who believe "science must reign", this has been true and will remain true as long as medicine exists. Any unbiased reading of the history of medicine from ancient times through the present is replete with undeniable evidence of this truth.

Risks and Benefits 

It is widely accepted within medical and clinical science that any particular intervention used in an attempt to improve a health condition within any group of patients having that condition has a risk/benefit ratio (or risk ratio) associated with it with respect to treatment outcome. What does this mean? Sometimes called an “odds ratio” this conceptual notion yields a number that tell us that for a particular treatment, a probability exists that amongst those individuals receiving it will obtain varying degrees of benefit, a proportion will experience no discernible effect, and a proportion will experience negative outcomes which may range from mild unpleasantness through mortal danger (for some types of treatment interventions).

Put another way, every treatment intervention undertaken for a health condition has some possibility of negative outcome as well as some probability of benefit. The risk however varies with the treatment or medication. Some treatments are high risk, some are low risk, only a few are essentially no-risk. 

A startling fact reported by the Institute of Medicine, (the IOM is medical wing of the National Academy of Science) is that each year between 44,000 to 98,000 persons die from side effects of properly prescribed medications in the United States. It is disturbing to realize that the most prevalent approach to medical care places heaviest emphasis on expensive and side effect laden surgical and pharmacological treatments that often devalue prevention, self-care, and rational disease management, and this routinely provided care, even appropriately used, is itself the fourth leading cause of death in the United States.

The IOM also separately reported that 1 in 5 deaths in U.S. hospitals are associated with medical errors of some kind. The element of medical risk is writ large in these reported findings. Until hospitals reduce the policy of having physicians, medical and surgical house staff (residents and interns) do 36 hour stints on duty on call, with 24 hours off, these numbers will remain high. Federal law does not allow truck drivers to drive more than 10 hours for safety reasons. Hopefully we will soon apply the same policy to physicians on hospital duty. Physicians have the same physiology and the same needs for rest as do highway truck drivers in order to reduce the probability of mishaps and errors. Notice the word used was reduce, not eliminate. Many problems are system problems, and are not due to provider fatigue. These present challenges also.

With respect to medication problems, at least 35% of those who take one of the most popularly prescribed modern antidepressant medications experience ill effects from the medication itself. Adverse side effects from a considerable number of prescription pharmaceuticals negatively affect as many as 50% of those taking that medication, despite the tangible benefits others receive from their use. Side effects are a major problem of many pharmaceuticals, for many patients, even when properly taken. 

Many prescription medications in current use have a not insignificant risk of negative side effects. There is, however, no easy way of predicting, in advance, who will, and who will not be troubled by a given medication. Whether or not to use such prescribed medications often presents a Hobson's choice for informed patients. Downside risks are not only significant, but are often not well known by either their doctors or their patients early on. The newest medications often present greatest risks since groups on which they have been tested are necessarily less broad or numerous than those who receive them in general clinical use. We (the U.S.) do not yet have a good system in place for systematically recording adverse events after medications have been approved for use by M.D.'s. Only recently have the beginnings of a system for recording and studying Adverse Events associated with medications been begun to be slowly developed by the FDA.

Pharmaceutical companies, fearing loss of market share, are not eager to see such systems in place. This is why choosing low risk, older medications, or non pharmacological based interventions when possible is often a prudent strategy for patient and physician alike.

Every year we learn, after FDA review, approval, and release, that some medicaments must be completely removed from the market because they are later found to have unacceptable levels of risk, sometimes even deadly ones for a subset of the people who take them. In order to reduce such risks many individuals prefer to employ non-pharmacologic treatment interventions wherever possible.

Some persons will say they just “hate to take pills,” but often many such persons have had "scary" experiences with prescribed medications and have become "wary" from then on. Readers should not draw the conclusion they are being told here that all prescription medicines are bad or dangerous. Far from it. Many medications are truly life-savers, and many are genuinely helpful, when used properly. One reason prescription medications are not available over the counter without a physician's prescription is that care is needed in their use, and guidance and follow up may prove necessary or essential. Physicians are charged with assessing the risk to benefit potential of a drug in each patient's case. The average practitioner however does not have on hand all information on the drugs he prescribes however, and there can be no guarantee that any medicine will be side-effect free with all persons. That being the case, non pharmacologic therapies, and interventions and treatments free from unwanted side effects are options prudent patients need to consider after an accurate diagnosis of their ailment or illness has been confirmed.

Biofeedback Benefits

The foregoing discussion is a prologue to discussing the potential benefits of utilizing neurofeedback or biofeedback as a treatment method. Traditional biofeedback has been employed in clinical use as a treatment intervention for nearly five decades and has proven itself a benign, essentially no-risk intervention.

Though self-evident, it needs be clearly stated that biofeedback is not being advocated as an appropriate treatment for all health and medical problems. As an example, biofeedback has no justifiable use in treating fevers or infections. Also, consider that there are over 25,000 conditions listed in the International Classification of Diseases (ICD-9). Biofeedback and neurofeedback can help, improve, reduce or eliminate problems associated with a number of conditions listed elsewhere in this Web site, and also for other medical conditions when used adjunctively with medication and/or surgical treatment, but are not a panacea. Beware any practitioner who claims otherwise. Seemingly improbably however, these methods can and do help some conditions for which conventional medical approaches have little to offer. Many medications will palliate a condition temporarily, but do not modify the underlying physiological response patterns. Biofeedback and neurofeedback can help "reprogram" these patterns, and restore a more healthful functioning.  In this sense they are rehabilitative.

Biofeedback and neurofeedback have the greatest probability of affording relief with conditions listed elsewhere in this Web site, but also with other conditions not listed in which stress, or a dysfunctional autonomic arousal component plays a role. With a very few persons biofeedback may be ineffective in conditions for which it has shown demonstrated value, but the vast majority of those who utilize biofeedback have found it of benefit. 

When biofeedback is used in combination with medication, it is necessary to remain alert to the fact that often a reduction in dosage levels of medication dosages becomes necessary for prescribed medications as a patient's health improves when a pharmacologic (medication) treatment regimen is augmented with biofeedback. Such medication changes must be coordinated with the treating physician.

It is very common for biofeedback patients to require smaller dosages of their medications as their biofeedback treatment progresses. Since high medication dosage levels are often accompanied by unpleasant and unwanted side-effects reduced medication dosage levels (and reduced side effects) are often much wanted benefits. This is not a risk of biofeedback. It is a benefit. Only inexperienced or inadequately trained therapists or physicians will fail to spot such problems. Most biofeedback clinicians work with patients of, and often receive referrals by the patient's own physicians. Many physicians begin to refer patients for neurofeedback or biofeedback after one or more of their patients shows marked improvement on a combined medication-biofeedback regimen, or when a patient cannot tolerate medication side-effects for a condition they have been attempting to treat.

Compared with risk ratios associated with many prescription medications, biofeedback has proven itself a useful intervention with a miniscule to non-existent side-effects ratio. Amongst groups of biofeedback professionals speaking frankly with each other, few are able to come up with credible examples of negative biofeedback side-effects in patients they have treated, even when hard pressed and guaranteed anonymity.

And what of neurofeedback? Both biofeedback and neuro eedback are frequently turned to as a treatment by many who have experienced, and cannot, or will not tolerate experienced unpleasant side effects associated with medications prescribed for their condition. When compared with many medications, biofeedback and neurofeedback has proven a no risk or low risk intervention with strikingly positive results for many persons unable to tolerate drugs prescribed for their condition. Hypersensitivity (or allergy as most patients call it) to one or more pharmaceuticals by patients is much more frequent than the general public or most readers realize. Patients are often reluctant to discuss their problems with others. It would be a rare event for one or more of those reading this page not to have experienced an "allergy" to one or more substances encountered in their daily lives. Medications are but one class of chemical substances we expose ourselves to.

In most cases the question of using pharmaceutical medication is not an either-or question. Neurofeedback and medications are frequently used simultaneously as treatment methods to achieve maximal benefit. The individual who can tolerate a sub-optimal dose of a drug can often couple this dosage with biofeedback and in many cases achieve a satisfactory management or improvement of their medical condition. As the Chinese might put it "one hand washes the other."

Evidence that neurofeedback can have harmful effects, is scarce and unconvincing. The question of predicting which specific patient will benefit, and which will not is at this point unanswerable. A majority of appropriately selected patients with conditions mentioned elsewhere in these pages do benefit, although a few do not. Many that fail to achieve significant benefit do so because they are unable or unwilling to undertake a treatment series and hope for a "magic one-shot cure."  
 
Neurofeedback requires a series of sessions in order for the brain to physiologically unlearn maladaptive patterns, to relearn more beneficial ones, and to regain a more healthy and adaptive ongoing state.

The best defense against failure to benefit from neurofeedback is to work with experienced, knowledgeable, qualified practitioners. Neurofeedback, as true for surgery, is best done by practitioners skilled in what they do. Surgeons who frequently perform a particular procedure are repeatedly shown to have fewest failures and adverse outcomes. If you want good surgery, find a surgeon who has done as many of the types of surgical procedure you seek as possible. Existing evidence also suggests that likewise, most optimal results in neurofeedback are obtained through utilizing expert practitioners, as is true for surgeons.

Summing Up

This page has underscored the problem of medication hypersensitivity (or allergy to medication) side effects, and risks. Pharmaceuticals, though often life-savers, have risks. We have emphasized this problem because legions of persons have such problems but know of nowhere to turn as an alternative to pharmaceutical treatment. Many persons do not have such problems. To them we say "live well and prosper." Each of us must take responsibility for our well being and choose the path of treatment that serves us best. Some however cannot take paths others do. For those who cannot take, or prefer not to take well worn, familiar paths to management of their illness, or to wellness, if your medical condition is one of those known to benefit from biofeedback or neurofeedback we encourage you to learn as much as possible about these approaches, and then seek out a capable and qualified biofeedback specialist for a consultation. 

Though perhaps not as well known to the general public, biofeedback and neurofeedback are based on conventional medical science, on research, and on studies carried out in medical schools, universities, hospitals and clinics for more than six decades. These procedures are not talking therapy or psychotherapy, but physiologically based treatment approaches. They can however be used in conjunction with counseling, psychotherapy or coaching by qualified practitioners. They are also widely used by Olympic athletes (without medical problems) and some corporate executives to achieve peak performance in their chosen careers. Those interested in such uses are encouraged to do a Web search using Peak Performance and Biofeedback as search terms. 

Are there risks at all inherent in using neurofeedback or biofeedback? If so, they are minuscule. Are the risks significant? No. Will neurofeedback or biofeedback have beneficial effects? This will be evident to the patient in the first four to six sessions. Patients themselves are the best barometer or judges as to whether they are receiving benefit from biofeedback or neurofeedback. Few are disappointed.

How does neurofeedback compare with risks inherent in using physician prescribed medications? They are far fewer. Is the question one of choosing one or the other? No. For some patients both medication and neurofeedback or biofeedback are the optimal answer. The individual answer to this question is an individual one in each case.

In a universe in which few perfect solutions exist for medical problems, patients are best advised to choose treatment options which afford them the fewest risks. This suggests that each individual learn as much about the conditions they have and the feasible treatment options applicable.

Strikingly large proportions of those who seek out neurofeedback treatment are remarkably well educated persons who have done a good deal of homework and reading before they seek out a neurofeedback or biofeedback specialist. Most are familiar with questions and issues discussed in this section, and after answering them to their satisfaction, and only then, have sought out this treatment modality. Informed patients or clients have realistic expectations about this treatment and what it entails. We encourage you to learn as much as you can about it. 

Use of neurofeedback to treat ADD, and ADHD has been a godsend to parents with children with these problems. Only those who deal with ADHD children truly understand the heartbreak this condition brings to the lives of the children, the self concept damage and self esteem problems its brings, and the difficulties for parents who must raise and live with them. Seek out someone who has received benefit from this treatment approach. No claims will be made in this page for neurofeedback treatment of ADHD. Treated persons will prove more than convincing if they are willing to share their experience with you. 

As is also true for most physicians, biofeedback therapists rarely advertise, as we generally understand the term. Ethical strictures and legal requirements which govern practice and licensure for licensed psychologists, licensed physicians, certified biofeedback therapists and other licensed health professionals who offer these services all are designed to protect those who seek services through discouraging unwarranted claims or "hype." Though never perfect, such measures afford protections to patients. MASBBM as a professional organization, committed to raising public awareness of the utility and benefits offered by biofeedback and neurofeedback, endorses all such efforts to maintain the highest possible standards of ethical behavior by its members and those who offer such services.

MASBBM encourages those interested to learn as much as possible about these methods. There is a large scientific literature dealing with them and their use. The World Wide Web has many resources for further learning about biofeedback. University, medical schools, and good public libraries all have information of use, and reference librarians can be very helpful in assisting those who wish more information to locate it.  Since "contrarians" literature and authors exist for nearly every type of treatment, including biofeedback, readers should never rely on a single source for the final word. Read widely and wisely, and you may well find you have discovered a treatment resource of value to you for health conditions which medication or surgery may have been of little or limited value, or have unacceptable side effects. With clothing, seldom will "one size fit all" this is true for the treatment of many medical conditions as well.