Ethical Conduct and Standards of Practice for ...

Ethical Conduct and Standards of Practice for Practitioners of Biofeedback,

Neurofeedback and QEEG

Prepared by

Robert E. Longo, MRC, LPC, NCC, BCN

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Ethical Conduct and Standards of Practice for Practitioners of Biofeedback, Neurofeedback

and QEEG

North Carolina Biofeedback Society

Greensboro, NC

Sunday, October 2011

Robert E. Longo, MRC, LPC, NCC, BCN

Serendipity Healing Arts

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Provide an overview of professional ethics and standards of practice as they apply to the helping professions and specifically those providing peripheral biofeedback and EEG biofeedback.

Address challenges peripheral biofeedback and EEG biofeedback practitioners face in our practice

Create an ongoing forum for discussion of peripheral biofeedback and EEG biofeedback

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History of Ethics

What are Ethics?

What components of professional behavior and conduct are addressed in professional ethics and standards of practice.

Ethical dilemmas

Panel discussion following presentation

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Historically standards of practice and accountability appear to have developed simultaneously with physician’s duties. This occurred in Egypt approximately 2000 B.C.

The Hippocratic Oath was written in approximately 400 B.C.

The Hippocratic Oath upholds and promotes many of the core ethical principles we see in modern codes of ethics.

Continuing Psychology Education Inc. 2011

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The American Psychological Association (APA) began development of a code of ethics following World War II.

The first formal APA code of ethics was adopted in 1953.

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The origin of the phrase is uncertain. The Hippocratic Oath includes the promise "to abstain from doing harm.―

Primum non nocere is a Latin phrase that means "First, do no harm". The original text of the Hippocratic Oath is usually interpreted as one of the first statements of a moral of conduct to be used by physicians, assuming the respect for all human life.

http://en.wikipedia.org/wiki/Hippocratic_Oath

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Uphold two ethical principles:

1) beneficence, which is attempting to do only good for the client

2) nonmaleficence, which is never doing harm.

Effective practice requires intellectual and emotional competence.

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Intellectual: Attaining a knowledge base, assessing and planning effective treatments, and recognizing one’s limitations.

Emotional: Managing clinical information, personal biases, and self-care.

A professional’s license does not specify the types of clients, issues, or interventions he or she may address, nor competency to treat all people for all issues.

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A relationship in which one party places special trust, confidence, and reliance in and is influenced by another who has a fiduciary duty to act for the benefit of the party called also confidential relationship fiduciary relation .

NOTE: A fiduciary relationship may be created by express agreement of the parties, or it may be imposed by law where established by the conduct of the parties. Typical fiduciary relationships exist between agents and principals, attorneys and clients, executors or administrators and legatees or heirs, trustees and beneficiaries, corporate directors or officers and stockholders, receivers or trustees in bankruptcy and creditors, guardians and wards, and confidential advisors and those advised.

http://dictionary.reference.com/browse/fiduciary+relationship

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Where one person places complete confidence in another in regard to a particular transaction or one's general affairs or business. The relationship is not necessarily formally or legally established as in a declaration of trust, but can be one of moral or personal responsibility, due to the superior knowledge and training of the fiduciary as compared to the one whose affairs the fiduciary is handling.

http://legal-dictionary.thefreedictionary.com/fiduciary+relationship

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A fiduciary relationship comes about as a result of an undertaking wherein one person places trust and confidence in another which is accepted by both parties.

This results in a dependency of one party on the influence of the other.

An undertaking sufficient for a court to construe such a relationship exists may be little more than the giving of professional advice.

A fiduciary must act with utmost good faith for the benefit of the other.

The fiduciary owes duties of loyalty, confidentiality, abstinence,

neutrality, and competence.

Competence is a professional duty.

* Dr. Hashem Bahary, Professor of Psychiatry, Al-Azhar University. www.mentalhealthegypt.com/Fiduciary%20Relationship.ppt

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For the psychiatrist, it means to act as would an ordinary and reasonable prudent psychiatrist under the same or similar circumstances.

A breach of a fiduciary or professional duty creates an unreasonable risk of foreseeable harm. If the harm occurs, a malpractice suit may follow.

The psychiatrist-patient relationship is both fiduciary and professional as well as legal.

It comes into existence when a reasonable patient would think it did.

Only then do legal duties attach.

These duties terminate when they are discharged, upon proper non-emergent notice, referral to another psychiatrist, or when the patient fires the doctor.

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From a Rogerian perspective, ethics are not normative… Rather, the focus in studying Rogerian ethics is on understanding the deeper nature of intrinsic values that serve as a foundation for the science of unitary human beings.

http://rogeriannursingscience.wikispaces.com/Chapter+3++Rogerian+Cosmology+and+Philosophy

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Personal problems overflow ito professional activity.

Drug or substance abuse.

Depression

Loneliness

Burnout

Can lead to unethical behavior.

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We are unaware or misinformed about ethical standards. i.e., we don’t read articles attend training or belong to organizations.

We offer treatments outside the scope of our practice, i.e., treating head injury with no experience

We display insensitivity to the needs of others, i.e., ignoring what others tell us

We exploit clients by putting our own needs first, i.e., trying experimental

procedures that we try to convince a client to agree to.

We act irresponsibly due to stress, laziness, non-awareness, or inattention, i.e., not checking protocols before we begin treatment.


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We react with vengeance against clients for perceived harm, make unnecessary threats instead of offering ways to resolve a problem

We experience burnout or other emotional impairment, i.e., not practicing what we preach.

We experience/reveal interpersonal boundary issues* (we will come back to this item)

Our actions are self-serving, i.e., not thinking about the needs of or benefits to a patient.

Generally we are ethical but occasionally blunder resulting from oversight or distraction.


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If regulated, our professions have regulatory codes of ethics and standards of practice. In addition, our organizations may have codes of ethics or codes of conduct or both. The underlying ethical premise is that the professional service being provided will ―do good‖ and not do harm. However, each of us may interpret the phrase ―not do harm‖ in our own way, based on our own predispositions and values.

http://www.ncaassociates.com/pdf/RCCM%20Spr05%20Newman.pdf

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In part, a code of ethics is there to prevent us from bringing our personal values or bias into our ethical decision-making process. Why? Because as soon as our bias enters our decision-making process, our personal views and needs begin to govern or shape the therapeutic intervention. Subsequently, our client’s needs become secondary in the relationship, and as a result, we begin to work from a point of self-gratification.

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Consider the following dilemma as an example:

Your client lets slip that she is driving despite the fact that her license has been suspended. Many assumptions can be made about this situation. Being human, we may jump to a conclusion based on our own work context. Cognitive impairments or drunk driving are frequent conjectures. Therefore, there is a danger to self and others.

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Boundaries are how the self knows who it is and who it isn’t.

Interpersonal boundaries are frequently at the root of relationship difficulties – between parents and children, spouses, partners, friends, and professional colleagues.

Boundaries are key to how we deal with intimacy, loneliness, conflict, anxiety, stress and challenge at every stage of life. They are integral to how our identity is constructed; because they are so central to the development of our personalities, to how we think and feel about ourselves and how others experience us – our inner, as well as our shared reality – they provide a special lens through which we can perceive not only what and who but also why we are.

http://www.4therapy.com/life-topics/family-relationships/boundary-issues-2682

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When we talk about interpersonal or workplace boundaries, it can sometimes be a difficult concept to grasp because it isn’t something that we can see.

Professional boundaries are important because they define the limits and responsibilities of the people with whom you interact in the workplace.

http://ucsfhr.ucsf.edu/index.php/assist/article/setting-healthy-workplace-boundaries/

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Protect patients

Protect professions

Quality of services

Defining professional expectations

Practical and ethical guidelines

Address problems when they occur

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Some say that “Ethics” are the Golden Rule.

The golden rule (GR) requires that we treat others only as we consent to being treated in the same situation. GR is [an] important principle …and perhaps the most important rule of life.

However…this may not always work when we

have significant individual bias or differences. http://www.jcu.edu/philosophy/gensler/et/et-08-00.htm

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We believe it is important to become familiar with the basic ethical guidelines that therapists should follow before beginning psychotherapy, and we encourage you to do so.

Although all the therapists and counselors listed in GoodTherapy.org certify that the therapy they provide accords in orientation and attitude to the Elements of Good Therapy, GoodTherapy.org does not provide a set of specific Code of Ethics for therapists to follow. However, Ethical Codes have been developed by mental health associations for the purpose of setting professional standards for appropriate behavior, defining professional expectations, and preventing harm to consumers. Mental health professionals have an obligation to be familiar with their professional Code of Ethics and its application to their professional services.

http://www.goodtherapy.org/ethics-therapy.html

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We provide links to Ethical Codes below because we feel it is very important for consumers of psychotherapy to know the difference between ethical and unethical behavior. Most therapists intend to “do no harm” and strictly follow ethical guidelines.

Overall, mental health professionals are a good bunch. However, not only do good therapists make mistakes, there are some providers who, unfortunately, are careless and unaware of the importance and purpose of some ethical guidelines. We believe it is in everyone’s best interest to become familiar with basic ethical guidelines before beginning psychotherapy.


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A professional code of ethics prescribes how a professional pursues his/her common ideal so that each may do the best she/he can at a minimal cost to one’s self and those receiving professional services. The code is to protect each professional from certain pressures (for example, the pressure to cut corners to save money) by making it reasonably likely (and more likely then otherwise) that most other members of the profession will not take advantage of one’s good conduct.

http://ethics.iit.edu/index1.php/Programs/Ethics%20Across%20the%20Curricul

um/Professional%20Ethics Retrieved 4/15/2011 Illinois Institute of Technology

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The Code of Ethics and/or Ethical Principles of organizations may include the following:

1) Purpose and Scope of Ethical Principles

a) Who should follow the Standards & Ethics?

Certificants,

Applicants

Trainees

Those providing services

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b) How ethics are measured:

Licensing boards

Membership in professional organizations

Certification Institutes

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c) What happens if ethics are violated?

• May lead to disciplinary action

• May lead to decertification

• May lead to a complaint to the appropriate state licensing/certifying agent

• or the individual's professional association

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2) Professional responsibility to uphold and follow ethics by: a) Adhering to the ethical principles of one’s profession local, state and national laws relevant to one’s professional activities, and representation of professionalism

b) Advancement of the field through learning and education and ongoing skills development.

c) Not misusing one’s personal or professional influence

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3) Professional Competence

a) Recognize and understand the limitations of

biofeedback

b) Use of informed consent

c) Maintain basic knowledge of the research

d) Recognize one’s competence boundaries

e) Accurately describe their qualifications, training, experience, degrees, and/or specialty.

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Professional Competence Continued

f) Recognize, understand and respect one’s scope of practice .

It is illegal to treat medical or psychological conditions without appropriate supervision if one is not licensed or credentialed to do so. One must acquire appropriate supervision according to applicable state and national laws and professional codes/regulations

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Professional Competence Continued

One must operate within applicable local, state, and national laws as well as in accordance with the ethical principles of their profession (for example, BCIA certification is not a license to practice independently).

g) Ongoing training CEUs

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4) Billing practices a) Professionals will only charge for services actually

provided by them or by those under their legal supervision.

b) In billing third party payers, practitioners will comply with the rules and regulations of the third-party payer clearly specify which services the practitioner provided directly clearly specify which services were supervised providing information regarding the supervisee’s qualifications (e.g., degree, license, and certification).

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5) Conflict of interest

A conflict of interest arises when an individual or organization is involved in multiple interests, one of which could possibly corrupt the motivation for an act in the other.

Conducting training or research, or when engaged in any other professional activity (such as a workshop in which applicant/ certificants/presenter(s) recommend their own product).

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6) Informed Consent Components of Informed consent Purpose of the treatment What the treatment consists of Benefits of treatment Risks and/or side effects Alternatives to treatment/other treatments Confidentiality Frequency and associated costs Voluntary May withdraw at any time without consequence Read and Understand Signature and date

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7) Public Information, Advertising, and Promotional Activities a) Announcements and listing of services and training

o Service directory listings oLetterheads oBusiness cards oMarketing brochures oWebsites

Should be accurate and designed in a professional manner.

Should adhere to the guidelines of their

professional associations.

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Unrealistic claims… Cure Guarantees Promises

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8) Confidentiality a) The Health Insurance Portability and Accountability Act of 1996

(HIPAA) Privacy and Security Rules b) Protect client’s confidentiality and privacy c) Legal limits of confidentiality to clients d) Collection of past due fees e) Compliance with mandated reporting laws that concern abuse or neglect. f) Confidentiality applies to clients in treatment, students in training, and research participants. g) Client records are stored and destroyed in ways that maintain confidentiality h) Keep records for the time required by applicable national and state laws.

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9) Protection of Client Rights and Welfare a) Sexual intimacy with current clients, trainees, supervisees, and research subjects is prohibited.

b) Use of touch. In attaching biofeedback sensors, professionals assure that the privacy and rights of the client are protected and

respect the feelings and sensitivities of their clients c) Any physical contact requires the permission of the client d) Touching of sensitive body parts, such as breasts or genitals, is not acceptable in biofeedback practice Do not discriminate against or refuse services to anyone on the basis of

sex, sexual orientation, sexual identity, race, religion, disability, or national origin.

Only treat medical disorders if clients have first received a medical

evaluation and/or are under the care of a physician.

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10) Relationships Professional Relationships Strive to be objective in the professional judgment of colleagues

and to maintain good professional relationships even when opinions differ.

Avoid dual relationships with their clients that could impair their professional judgment or increase the risk of exploitation and

must never exploit clients, students, supervisees, employees, research participants, or third party payers.

Personal Problems and Conflicts Supervisory Relationships Client Relationships Multiple Relationships

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11) Research with Humans and Animals a) Research should be conducted to advance understanding of human behavior, to improve human health and welfare, and to advance science. Researchers should carefully consider alternative research methods and assure that in the conduct of research the welfare of research participants (human and

animal) is protected.

b) Research and Publications: Research results are released in a manner which accurately reflects research results and only when the findings have satisfied widely-accepted scientific criteria.

Limitations regarding factors such as long-term effects and population samples will be

explicitly stated.

All descriptive materials distributed regarding clinical practice will be factual and straightforward.

The investigator is responsible for the ethical treatment of research participants by collaborators, assistants, students, and employees, all of whom also incur similar obligations

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Information obtained about research participants during the course of an investigation is confidential.

The investigator inform participants of all features of the

research that might be reasonably expected to influence their willingness to participate and to explain all other aspects of the research about which the participant inquires.

Protect participants from physical and psychological discomfort, harm, and danger. If the risk of such consequences exists, investigators are required to inform the participant of that fact, secure informed consent before proceeding, and take all possible measures to minimize distress.

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A research procedure may not be used if it is likely to cause

serious and lasting harm to participants.

Written informed consent or a verbal and written summary of the research is customary for most kinds of non-survey research (including a signature by the research participant in both cases).

The investigator must respect an individual’s freedom to decline to participate in research or to discontinue participation at any time.

After research data are collected, the investigator must fully debrief participants about the nature of the study. When scientific or human values justify delaying or withholding information, the investigator acquires a special responsibility to assure that the participant is not harmed.

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12) Adherence to Professional Standards

a) Professionals should be knowledgeable about efficacious interventions and adhere to the professional standards associated with these techniques.

b) Professionals who hold a state or national license should adhere to the guidelines of one’s professional licensing act.

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13) Ethics Complaint Procedures a) A process is established as to how a complaint about the ethical conduct of a

member will be recorded and who within the organization will write a letter to the complainant that will describe the organization’s role in ethics cases. b) A process is established as to who will directly discuss the complaint with the member, and if necessary, advise the complainant of state and/or national regulatory agencies with jurisdiction over biofeedback practice. c) The organization’s Board of Directors will periodically review and update the

organizations Ethical Principles. Once revised, Organization members shall be required to adhere to the revised Ethical Principles.

d) Comment from the membership is invited. e) A process is established whereby individuals desiring more information about the

organization’s Ethical Principles or wishing to register a complaint may contact the organization.

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The Philosophical Foundation (this may also be included in the Preamble of the Ethical Principles).

Definitions When an organization deals in a service or profession that may involve a

unique service or professional practices, definitions of terms might be in order as a part of the Ethical Principles. For example, the definition of Biofeedback adopted by BCIA, AAPB and ISNR May 18, 2008 states:

“Biofeedback is a non-invasive form of treatment. The therapist attaches sensors

or electrodes to the body and these sensors provide a variety of readings –feedback - which is displayed on the equipment for the patient to see. The signals typically measure skin temperature, muscle tension and/or brainwave function. With this information, patients can learn to make changes so subtle that at first they cannot be consciously perceived. With practice, however, the new responses and behaviors can help to bring relief and improvement to a variety of disorders.”

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For the purposes of this document, the term BCIA professionals refers to BCIA certificants and those who have filed a formal application for BCIA certification.

Because the Biofeedback Certification International Alliance (BCIA) and its

professionals are committed to the protection of human rights, they strive to maintain the dignity and worth of the individual while rendering service, conducting research, and teaching others. They operate within the BCIA Professional Standards and Ethical Principles (PSEP). They strive to provide the highest quality of service and carefully differentiate between empirically validated and experimental procedures. They hold themselves responsible for their actions and make every effort to protect their clients’ welfare. Finally, they limit their services to those areas in which they have expertise and exemplify the values of competence, objectivity, freedom of inquiry, and honest communication.

The PSEP is intended to guide all BCIA professionals, who commit themselves to

adhere to these Principles as well as to the Principles stated in their licensing act. A copy of the PSEP will be provided to all BCIA certification applicants and will be available on the BCIA website. The PSEP are intended to educate and guide professionals to prevent ethical misconduct and should be applied with professional maturity.

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The term biofeedback refers to all modalities for which we provide certification including, but not limited to, BVP, EEG or neurofeedback, electrodermal, EMG, HRV, respiration, and thermal.

Biofeedback is a process that enables an individual to learn how to change physiological activity for the purposes of improving health and performance. Precise instruments measure physiological activity such as brainwaves, heart function, breathing, muscle activity, and skin temperature. These instruments rapidly and accurately "feed back" information to the user. The presentation of this information — often in conjunction with changes in thinking, emotions, and behavior — supports desired physiological changes. Over time, these changes can endure without continued use of an instrument.

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Organizations often base their ethics and standards based upon incidents and issues that have challenged its members. The examples that follow are from different organizations.

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1.Definitions 2. Purpose and Responsibility of the Ethics Committee 3. Procedural Steps Involved in Filing an Ethical Complaint and Investigation

by the Committee 4. Confidentiality 5. Records 6. Recommendation Development 7. Types of Recommendations for Sanctions Corrective Actions and Directives 8. Membership 9. Procedures for Commencing an Investigation on the Committee’s Own

Motion 10. General Considerations 11. Special Advocate 12. Evaluation of Complaints 13. Legal Representation

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Ethical Principles The Philosophical Foundation 1. Definitions 2. Professional Conduct 3. Payment for Services 4. Members’ Training and Expertise 5. Personal Problems and Conflicts 6. Supervisory Relationships 7. Client Relationships 8. Multiple Relationships 9. Confidentiality 10. Professional Relationships 11. Research and Publications 12. Public Information and Advertising

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Preamble Purpose and Scope A. Responsibility B. Competence C. Ethical Standards D. Public Statements E. Confidentiality F. Protection of Client Rights and Welfare G. Professional Relationships H. Research with Humans and Animals Adherence to Professional Standards Additional Standards Ethics Complaint Procedures

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I. Preamble Revision II. Purpose and Scope Responsibility Competence Standards Public Statements Confidentiality Protections of Client Rights and Welfare Professional Relationships Research with Human and Animals III. Complaints and Concerns IV. Ethics Committee Procedures V. History of Document

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I. AUTHORITY AND JURISDICTION

II. ETHICAL PRINCIPLES

III. ETHICS COMMITTEE

A. Purpose and Mission:

B. Objectives:

C. Membership and Meetings:

D. Duties:

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E. Administrative Procedures: General: Complaint Clarification: Fact Finding: Question Clarification: Dispute Resolution: Disciplinary Options: Final Resolution Report-The Committee's Acceptance of Preliminary

Findings and Joint Resolution: When Dispute Resolution Fails: Formal Hearings: Appeals: IV. CODE OF CONDUCT V. ALLEGATIONS THAT MERIT DISCIPLINARY PROCEEDINGS Procedural Revisions Date of Adoption /Revision

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Components of Informed consent Purpose of the treatment What the treatment consists of Benefits of treatment Risks and/or side effects Alternatives to treatment/other treatments Confidentiality Frequency and associated costs Voluntary May withdraw at any time without consequence Read and Understand Signature and date

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For some organizations, professional conduct may be such that it must be defined by the organization for its members in order to specify what is expected.

Practice Standards Conduct Rules and Procedures Proceedings Relating to Unethical Conduct Ethical Conduct - Rules and Procedures Purpose and Responsibility of the Ethics Committee Procedural Steps Involved in Filing an Ethical Complaint and Investigation by the Committee Confidentiality Records

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Recommendation Development

Types of Recommendations for Sanctions,

Corrective Actions and Directives

Membership

Procedures for Commencing an Investigation on the Committee’s Own Motion

General Considerations

Special Advocate

Evaluation of Complaints

Legal Representation

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The following comes from various sources/persons on several listserves:

Treatment ―Neurotherapists would have questionable ethics to

evaluate and see a patient who has head injury from sports, and wants to participate in NFB while continuing in the same injurious sport. Unfortunately we can't mandate all of the behavior of parents or our patients. Personally, I'd consider it unethical not to inform them strongly that continued head injuries could do further damage and undo progress. But I don't refuse to continue seeing them, but I keep telling them stories as we're working about cases where people have continued risky behavior and we've seen the results.‖

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Scope of practice ―You can find the state laws specific to your license(s) by

going online to your state board's website and reading the scope of practice outlined. This assumes that your profession has a "practice act" in your state which outlines the legal scope of practice for whatever license you have (psychologist, social worker, professional counselor, physician, chiropractor, physical therapist, etc.) - as opposed to a "title act" which simply says that nobody can call them self a "psychologist" (or whatever) unless they have a psychology (or whatever) license in that state. There are also board rules for each profession that usually have additional info. You can also contact your board with specific questions. Most state boards and state associations provide free legal counsel for such questions.‖

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Billing “Inappropriate billing of biofeedback/

neurofeedback or QEEG services to insurance, Medicare or Medicaid as being psychotherapy or psychological testing, rather than using the appropriate codes that have been created already for these services. (i.e,. BC/BS will not pay for NFB and only 14 sessions of BFB).

Under the discussion of CPT codes, some interesting

points are made, such as the laws governing services from licensed/unlicensed professionals, and mentoring, vary from state to state.”

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Treatment Techniques “As I hear from various members, I am made keenly

aware, some practices have been considered "proper" until studied further. As they are studied, it becomes clear, some practices considered acceptable in the past, do not actually pass a careful examination. We all, just want to do well, "right thing for our clients," and be paid for our services. In our exuberance to practice and be paid, it is wise and prudent to re-examine what has been considered, "OK."

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Use of Equipment

―We could also add to this the sale, rental or lease of home training units without ongoing supervision of the use of those units, including structuring things so that there is assurance that the home training units are not being used by parents on people other than their own children. ‖

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Use of Technicians

―I would also add to the list the use of technicians with inadequate training, and who are not fully supervised by licensed people.‖

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Insurance Billing “In reference to ___'s previous post, billing insurance

for 90806, psychotherapy, when 90876, biofeedback (EEG biofeedback), is what is being done, would appear to be "a manipulation for monetary benefit," or an unethical, and thus illegal practice. Compounding the coding practice occurs when the service is carried out by a unlicensed technician not on the insurance panel. Such practices would not pass an insurance audit. Dealing with these ethical concerns can insure or torpedo the future success of biofeedback.”

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Scope of Practice

“I'll suggest another ethical concern. I'm seeing people coming in who have had brain maps done by questionably qualified people. In one case a technician (uncertified) gathering QEEG data under the license of an osteopath, which is being analyzed by an individual running a service, and then the results are being used by a technician (no advanced degrees) who administers the therapy suggested.”

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Selling of Equipment “In my estimation, we're seeing people all too willing

to make money selling equipment, QEEG analysis software, and their QEEG analysis services to unqualified people. All of this eventually leads to the public ending up with a negative impression of the field as more people don't get well or in some cases get harmed, not to mention how professionals such as neurologists are going to begin reacting when they see this. Many neurologists would have a hard enough time with mental health professionals getting certified and doing QEEG's, without what I'm describing coming to their attention.”

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―A _________ who is similarly having data gathered, sent to an individual running a service to analyze the QEEG, often on patients with mental health problems (ADD/ADHD, but also things such as OCD, depression---areas not within the scope of practice of the chiropractor), and then they are delivering services. I just went over a map gathered by these people. The report from one of our members did not reflect that the young man was drowsy during the gathering of the QEEG (which I would anticipate was responsible for the excess in 14-16 Hz frontal activity centering on Fz). The deficit in alpha may well have been accounted for or influenced by the fact that he was on Zoloft (not reflected in the report). No head injury discriminant was run because the unqualified people gathering the data did not do a thorough enough history to even find out that he had experienced two head injuries. When members are analyzing data and making treatment recommendations for unqualified people or people operating outside their legal scope of practice, is this unethical (as well as involving them risking liability)?”

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"Practitioners should know the laws of their individual state in reference to who is and who is not legally allowed to provide biofeedback, psychotherapy, and other health care related services. Laws in some states restrict the provision of some health care services such as biofeedback and psychotherapy to members of specific disciplines and some do, and some do not, allow licensed practitioners to supervise unlicensed personnel in the provision of these restricted services. What do the relevant laws in your state say governing the provision of biofeedback, psychotherapy, and related services? It is critical that you know what the provisions of your state laws are. Colorado has licensing laws governing the practice of specific disciplines like psychology, social work, nursing, and physical therapy, but it allows unlicensed practitioners to register themselves as unlicensed psychotherapists and to provide such services as biofeedback."

http://bio-medical.com/news/2004/04/billing-coding-and-reimbursement-issues-in-clinical-practice/

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Here is a summary of some concerns presented on a professional

listserve:

1) Claims about treatment outcomes

2) Educational requirements for members

3) Equipment without 510Ks

4) Professional responsibility and liability

5) Continuing education requirements

6) Standards of practice

7) "Advertizing"

8) Licensure

9) Mentoring

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With what we know and practice in regard to personal ethics….

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http://en.wikipedia.org/wiki/Hippocratic_Oath

http://dictionary.reference.com/browse/fiduciary+relationship

http://legal-dictionary.thefreedictionary.com/fiduciary+relationship

Dr. Hashem Bahary, Professor of Psychiatry, Al-Azhar University. www.mentalhealthegypt.com/Fiduciary%20Relationship.ppt

http://rogeriannursingscience.wikispaces.com/Chapter+3++Rogerian+Cosmology+and+Philosophy

http://www.ncaassociates.com/pdf/RCCM%20Spr05%20Newman.pdf

http://www.4therapy.com/life-topics/family-relationships/boundary-issues-2682

http://ucsfhr.ucsf.edu/index.php/assist/article/setting-healthy-workplace-boundaries

http://www.jcu.edu/philosophy/gensler/et/et-08-00.htm



http://ethics.iit.edu/index1.php/Programs/Ethics%20Across%20the%20Curriculum/Professional%20

Ethics Retrieved 4/15/2011. Illinois Institute of Technology

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Continuing Education for National Certified Counselors (2011). Continuing Psychology Education Inc.

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Related Documents and Acknowledgments Ethical principles of applied psychophysiology and biofeedback. (1995). Wheat Ridge, CO: AAPB. The International Society for Neurofeedback and Research (2008). Code of ethical principles &

professional conduct. http://www.isnr.org/ISNREthics.cfm#,

Striefel, S. (2004). Practice guidelines and standards in psychophysiological self-regulation. Wheat Ridge, CO: AAPB.

Clinical efficacy and cost effectiveness of biofeedback therapy: Guidelines for third party reimbursement. (1994, 2nd edition). Wheat Ridge, CO: AAPB.

Clinical applications of biofeedback and applied psychophysiology: A series of white papers prepared in the public interest by AAPB. (1995). Wheat Ridge, CO: AAPB.

Regulations for the protection of human research subjects (45 CFR46 and 56 FR 28003) (Federal Regulations).

Humane care and use of animals (A 343401) (Federal Regulations).

Practice in biofeedback and neurofeedback (2nd ed.). Wheat Ridge, CO: Association for Applied Psychophysiology and Biofeedback.

We thank the Association for Applied Psychophysiology & Biofeedback, whose Ethical Principles

were modified and adapted for these Principles.

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Original version adopted by BCIA Board of Directors, August 26, 1990.

1st revision prepared by John G. Carlson, Adopted by the BCIA Board of Directors, October 14, 1999.

2nd revision prepared and adopted by the BCIA Board of Directors, March 24, 2002.

3rd revision prepared and adopted by the BCIA Board of Directors, April 5, 2004. Fourth revision prepared and adopted by the BCIA Board of Directors, April 1, 2005.

Fifth revision prepared and adopted by the BCIA Board of Directors, August 26, 2009.

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Code of Ethical Principles & Professional Conduct International Society for Neurofeedback and Research (ISNR)

The Association for Applied Psychophysiology and Biofeedback (AAPB) Ethical Principles (2003: Fourth Revision)

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