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BCIA Professional Standards

Updated: Apr 8, 2023


Professional, ethical standards help educators, researchers, and practitioners anticipate and identify ethical dilemmas, make choices that maintain professional integrity, and protect our clients and profession (Striefel, 2003).


BCIA has accredited this post for three ethics continuing education hours for recertification. You can earn ethics credit in three easy steps: (1) purchase our $50 PSEP certificate of completion, (2) read this post, and (3) score at least 70% on a single exam on ClassMarker. When you pass the exam, ClassMarker will issue a downloadable certificate.












Donald Moss, PhD, contributed extensively to chapter content from his AAPB webinar, Professional Ethics and Practice Standards in Biofeedback and Neurofeedback.


Dr. Donald Moss



AAPB Book Recommendation


The text is partly adapted from Moss and Shaffer's (2022) A Primer of Biofeedback, which you

can purchase from AAPB in its member or non-member stores. The authors have donated their royalties to AAPB.


A Primer of Biofeedback


Click on our narrator icon to listen to this post.

Tony narrator




The Purpose of Ethics


Ethical standards are intended to protect the public, biofeedback, the professions that deliver biofeedback services, and the providers themselves.



Ethical Standards and the Reputation of the Profession of Biofeedback


Biofeedback providers recognize that their effectiveness and success as professionals, and the credibility of the biofeedback field, depend on their professional conduct.
Each time a biofeedback or behavioral health professional is charged with serious violations of ethical behavior, the field is also tarnished, and potential patients and their family members lose their readiness to trust in professional care (Moss, 2020).

Ethical codes express our stakeholders' core values. Listen to a mini-lecture on Core Values © BioSource Software LLC. Graphic © New Africa/Shutterstock.com.


core values


Professional Ethics Reflect Personal Integrity


Ethical practices are in the first place aspirational; they reflect the kind of professional one aspires to become. Responsible behavior in professional life should express personal, social, and religious values. Compassion and empathy for one’s fellow humans, who come for help with suffering, draws individuals to professional practice. Professionals with diminished empathy due to "burnout" and "compassion fatigue" are at greater risk for ethical transgressions.
Burnout is a widespread problem in the helping professions. Compassion fatigue is one product of using up or depleting our capacities for caring. Maintaining healthy self-care practices is critical in avoiding compassion fatigue. Difficulties in establishing rapport and mutual empathy in treatment relationships are also a challenge for professionals. When patients do not feel strong rapport and trust in their provider, they are more likely to file complaints (Moss, 2020).

Beneficence in Biofeedback Practice


"Providers strive to protect their clients’ welfare by appreciating their impact on the clients’ lives, and by recognizing and avoiding the potential for conflicts of interest" (Moss, 2020).


The ethical responsibilities of biofeedback providers and their staff are collectively defined by the licensing act under which they (or their supervisors) operate, their profession, and the BCIA’s Professional Standards and Ethical Principles of Biofeedback (9th rev.). The BCIA's PSEP represents the minimum ethical standards expected of its applicants and certificants. Physicians who provide biofeedback must also follow medical ethical guidelines. Psychologists must adhere to the Ethical Standards of the APA (Moss, 2013).


Providers deliver biofeedback services within a context of legal statutes, cultural norms, professional standards, and ethical codes that may vary across nations, cultures, and communities. These expectancies may conflict with each other. For example, the American Psychological Association (APA) proscription against dual relationships with clients would prevent a Psychologist from following a community expectation that "healers" visit the client's family and share their religious rituals (Moss & Shaffer, 2016).


Since ethical guidelines can never anticipate all of the contingencies that providers may encounter, they should always consult with their licensing body, professional association, and colleagues as they reach a choice point and are uncertain about future conduct. Unfortunately, the most severe ethical infractions, like sexual relationships with clients, often involve intentional violations of black-and-white rules.


When a licensing body or a court substantiates a charge of ethical misconduct, BCIA may take disciplinary action against a certificant. BCIA does not have the legal authority to compel testimony or the submission of documents. For this reason, it must often wait for a licensing body or court to investigate and reach a decision. When a licensing body or a court substantiates a charge of ethical misconduct, BCIA may take disciplinary action against a certificant. Applicants who have lost or surrendered their license may not be certified until their license is restored. BCIA has no enforcement role when an individual charged with an ethical violation is neither a certificant nor an applicant.


Diversity and Cultural Awareness


Since professionals provide biofeedback services across diverse communities, cultures, nations, and geographic regions, they must respect the norms of the cultures they serve and recognize the diversity in legal codes, professional standards, and ethical principles.


Dr. Moss discusses Diversity and Cultural Awareness © Association for Applied Psychophysiology and Biofeedback.




They may have to resolve conflicts between the ethical standards of their professional society and community norms. For example, while the American Psychological Association proscribes "dual relationships," like friendship with a client, community norms may require family visits and participation in religious rituals intended to heal the client (Moss, 2013). Graphic © Rawpixel.com/Shutterstock.com.


diversity


Responsibility


One of the most severe challenges to biofeedback is its credibility. A field is judged by the competence and actions of each provider. They should acquire entry-level competence in biofeedback and then progressively expand their expertise through activities like continuing education. They must adhere to the ethical principles that govern their professional practice and accept personal responsibility for the consequences of their actions. Graphic © Boris15a/Shutterstock.com.


responsibility


Dr. Moss discusses responsibility © Association for Applied Psychophysiology and Biofeedback.



As practitioners, they should provide cost-effective services consistent with the highest professional standards. They should educate their clients, referring health professionals, and third-party payers about the rationale for assessment and training procedures, the strength of empirical support for treatment, and its risks, costs, and benefits. They should always explain when treatment is experimental since this is crucial to informed consent and is a frequent source of ethical complaints in biofeedback. Ideally, they should obtain written informed consent for their proposed treatment. They never recommend experimental treatments when an untried well-supported treatment is already available. Providers should only suggest less-documented interventions after informing clients of the available treatment options and the empirical support for each. Then, they should obtain written informed consent for the experimental procedure (Moss, 2013).


They strive to protect their clients’ welfare by appreciating their impact on their clients’ lives and recognizing and avoiding potential conflicts of interest. They candidly communicate with their clients about their progress and modify or discontinue training if clients fail to make progress. When their clients require services outside their expertise, they refer them to qualified professionals and never abandon them. Graphic © Rido/Shutterstock.com.


abandonment


When clients do not improve and require an intervention that a clinician is not qualified to provide, options include referral to a qualified provider or consultation with or supervision by a qualified professional.


As educators, they help advance knowledge through research and encourage students to value knowledge, think critically and from an interdisciplinary perspective, be reflective thinkers, appreciate the strengths and limitations of competing perspectives, and objectively investigate the questions that concern them. Educators recognize their potential impact on their students, strive to provide accurate, complete, and objective information, and encourage free inquiry. Where there are scientific controversies, educators help students understand opposing positions and encourage them to evaluate each side’s scientific support.



Competence


Applicants first gain entry-level competence in biofeedback through didactic education, mentoring, and practice. Dr. Moss explains competence © Association for Applied Psychophysiology and Biofeedback.





Entry-Level Competence

New biofeedback practitioners should acquire entry-level competence in biofeedback and expand their expertise through activities like continuing education. BCIA certification ensures that the provider has completed training and mastered the skills and knowledge for entry-level competence and that the certificant also receives continuing education for Recertification (Moss, 2020)

Competence

Knowing a biofeedback technique is not sufficient when beginning to treat a new patient group. A professional who wishes to treat dissociative disorders, seizure disorders, or major mood disorders must also gain knowledge and experience, through appropriate education and supervision, of the condition and its management. Even expert application of biofeedback therapies for delicate conditions may trigger an emotional or medical crisis, and the therapist must know how to manage such events (Moss, 2020).


Maintaining Competence


Certificants progressively expand their expertise through continuing education, including teleseminars, massive open online courses (MOOCs), workshops, conference presentations, classes, reading journal articles and texts, mentoring, and their scholarship (Striefel, 2004). Providers consult experienced practitioners and obtain clinical supervision when expanding their practice into new applications, equipment, software, and protocols (Moss, 2013). This ensures they practice within the scope of their expertise (Moss & Shaffer, 2016). Graphic © Eti Ammos/Shutterstock.com.


competence


Competent providers critically evaluate biofeedback outcome studies, guide their practice using peer-reviewed findings, and strive to use the best practices in the field. They maintain a current understanding of the efficacy of biofeedback interventions and recognize where it is indicated and contraindicated (Moss, 2013).


AAPB's Evidence-Based Practice in Biofeedback and Neurofeedback provides an authoritative evaluation of the efficacy of biofeedback applications. Listen to a mini-lecture on Evidence-Based Practice © BioSource Software LLC.


Evidence-Based Practice in Biofeedback and Neurofeedback (4th ed.) rates the application of biofeedback for 37 general medical and mental health disorders and many subcategories, such as adult vs. pediatric headache and the various types of anxiety disorders.


Evidence-Based Practice

Professionals comply with applicable laws and the ethical standards of their profession and certifying organization. Providers require a government license or credential to independently treat a medical or psychological disorder. Those without a license or credential must obtain appropriate supervision to treat these disorders. "Supervision" is legally defined by states within their practice acts. A supervisor oversees the unlicensed individual's delivery of services and assumes legal responsibility for provided care. Supervision should not be confused with consultation, where the licensed individual has no legal responsibility for the unlicensed provider's actions.


They accurately disclose their regionally-accredited degrees, training, specialty areas, experience, and their license or credential and certification status. Ethical providers recognize that participation in a membership organization does not imply competence and that certification is not a license for independent practice.


BCIA professionals who treat medical or psychological conditions must demonstrate professional competence as defined by applicable local, state, and national licensing/credentialing laws. BCIA certification becomes invalid when a license is suspended, revoked, or not renewed due to an investigation of a complaint, and the individual is not allowed to provide services under supervision. A professional may only apply for recertification after the license has been reinstated.

It is illegal to treat medical or psychological conditions without appropriate supervision if you are not licensed or credentialed to do so. BCIA certification becomes invalid when a certificant loses and cannot replace appropriate supervision. An individual may only apply for recertification after documenting that appropriate supervision has been reestablished. (BCIA, 2016).


Scope of Practice and Competence


Listen to Dr. Donald Moss explain the scope of practice and competence © Association for Applied Psychophysiology and Biofeedback.





Scope of Practice


The scope of practice is defined by state and provincial licensure laws and the practice standards established by professional associations. Scope of practice defines which forms of assessment and treatment a clinical professional may deliver. Biofeedback is typically within the scope of practice for psychologists, social workers, physical and occupational therapists, counselors, nurses, dentists, and physicians.

The scope of practice varies in some specifics from state to state and from one health discipline to another. Diagnosing a mental health disorder is within the scope of practice of psychologists, but diagnosing a medical disorder is typically not. Most licensed health and mental health professionals are permitted to provide treatment, including biofeedback, for patients with diagnosed medical and mental health disorders.

BCIA certifies technicians who must practice under a licensed and certified professional. Technicians may only treat diagnosed disorders under supervision. The technician’s scope of practice is defined by the supervisor’s license and scope of practice. Thus, a technician supervised by a dentist may provide biofeedback treatment for dental phobias but not for chronic back pain or panic disorder.

Scope of practice is often the “elephant in the room.” Until they face complaints, licensed practitioners rarely read the statutes that regulate their scope of practice and professional responsibilities (Hopkins, 2013). Unlicensed certificants may not understand how the scope of practice applies to their activities and may be unaware of any limitations in their supervisor's scope of practice. Graphic © Aleksandr_Kuzmin/Shutterstock.com.

Elephant in the room


Health and wellness coaches and sports trainers may utilize biofeedback training in their practice but typically cannot treat or advertise the treatment of diagnosed medical or mental health disorders. For example, coaches may provide relaxation training, stress management, or optimal performance training, even to patients with diagnosed disorders. Still, they cannot specifically treat a generalized anxiety disorder or major depression. Nor should they advertise treatment for diagnosed disorders.


Individual states vary greatly in how the scope of practice is defined and limited. In some states, for example, a psychologist may not provide any advice on dietary change or the use of nutritional supplements. Biofeedback practitioners are advised to read the licensing acts for their home professions in the states where they practice and to consult with the relevant licensing boards with any questions.


In some states, to give another example, a professional who is a licensed mental health professional and also a certified nutritional specialist may combine counseling, biofeedback, and nutritional advising in a single session; in others, the counseling or biofeedback practice must be delivered in a discrete and separate session from any nutritional services.



Mentoring Versus Supervision


BCIA requires mentoring as an educational process for individuals seeking BCIA certification. BCIA requires clinical supervision for individuals certified as technicians and for BCIA-certified practitioners who wish to treat diagnosed disorders yet are not licensed in healthcare. Peer consultation with colleagues and with area experts is recommended as a lifelong strategy to assure the quality of care and protect against potential patient complaints. BCIA publishes mentoring handbooks, which include Essential Skills Lists for Biofeedback, HRV Biofeedback, and Neurofeedback mentors (BCIA, 2021, 2022, 2023). Graphic © fizkes/Shutterstock.com.


mentoring


BCIA requires legal clinical supervision for individuals certified as technicians. Peer consultation with colleagues and consultation with area experts are recommended as lifelong strategies to assure the quality of care and to protect against potential patient complaints (Moss, 2020).

Dr. Moss explains the difference between mentoring and supervision © Association for Applied Psychophysiology and Biofeedback.





Mentoring Defined


Mentoring is the "process of transmitting knowledge and skills from the trained to the untrained or the experienced to the inexperienced practitioner. Mentoring involves a relationship between a mentor and candidate that promotes the development of skill, knowledge, responsibility, and ethical standards in the practice of biofeedback" (BCIA, 2022, p. 3).


mentorship

Typically, the mentor does not assume legal responsibility for the patients receiving treatment or training from the mentee. A mentor focuses on the planning and delivery of biofeedback services, not on the entirety of the client's care. The mentor may be blinded to the patient's name/identity since the focus is on the treatment process.



Selecting a Mentor


Who is an appropriate mentor for an individual preparing for certification?


First, the mentor must be Board Certified in Biofeedback (BCB). Occasionally, because of location or other special circumstances, a candidate cannot be mentored by a professional who is Board certified. If there is a professional available who, by exceptional merit and experience, would be able to provide appropriate mentoring, a special review of his/her credentials is requested before starting training.


Second, the mentor must have at least 2 years of experience in the practice of biofeedback and with a similar client base as the candidate. For example, a dental practitioner cannot mentor an applicant specializing in the pelvic floor or post-traumatic stress disorder (PTSD). A psychologist or psychiatrist whose scope of practice allows them to treat the disorder in question would be suitable. Biofeedback must also be a significant portion of the person's professional work.


Third, remember the concept of avoiding potentially destructive dual relationships (Nagy, 2005). A practitioner's mother, brother, spouse, lover, or child will lack the objectivity to provide mentoring.



Supervision Defined


Supervision is the provision of ongoing guidance for clinical practice for qualified health professionals by a more experienced health professional (Scaife, 2019).


supervision

BCIA defines supervision as "the legal oversight and responsibility for the work of an unlicensed person" (BCIA, 2022, p. 3). In supervision, the supervisor assumes legal responsibility (and liability) for the quality of care and the patient's well-being in the treatment process. A supervisor is responsible for reviewing and assuring the quality of care for the supervisee's caseload, client assessment, treatment planning, and treatment delivery. For this reason, the supervisory schedule must include adequate time for a regular review of all new cases and continuing cases. In addition, patients should be informed of the supervisory process.


In clinical biofeedback practice, two typical situations call for supervision:

First, a technician is an individual who lacks a health care license and applied for technician status with BCIA. The technician is then certified to practice biofeedback under supervision.

The application for technician status includes documenting a supervisor for ongoing clinical practice. When supervisors terminate a supervisory relationship, the technician is required to provide documentation for BCIA of a new supervisory relationship. BCIA may suspend a technician's certification until the individual documents a new supervisor.

Second, individuals with full certification in biofeedback but no healthcare license must utilize supervision if they wish to treat diagnosed healthcare or mental health problems. Such practitioners are also responsible for informing BCIA of any loss of a supervisor or change in supervisors. Treatment of diagnosed disorders should not continue until a new supervisory relationship is established.


Unlicensed practitioners can apply biofeedback for stress management, relaxation training, and optimal performance work without supervision. An unlicensed practitioner may provide stress management or relaxation training for an individual with a diagnosed disorder, such as generalized anxiety disorder, but may not treat the disorder itself. Similarly, an unlicensed practitioner may not advertise the treatment of diagnosed disorders unless a licensed practitioner supervises the treatment.


Since supervisors assume legal responsibility for client care, they must be physically present at the site where a technician or non-licensed practitioner works. BCIA rejects applications from technicians whose supervisors are not licensed, not legally allowed to supervise biofeedback services, or who can only oversee the delivery of services at a distance.

Supervisory sessions should be documented in a supervision log and the patient's chart. The supervision notes provide evidence of conscientious practice by the supervisee and may provide a defense of practice decisions in case of a complaint or lawsuit.



Selecting a Supervisor


Who is an appropriate supervisor for a technician or an unlicensed biofeedback practitioner?


First, the supervisor should be a licensed practitioner with the scope of practice and the competence to treat the patient populations that the technician/unlicensed practitioner is treating. Thus, a dentist cannot supervise a biofeedback practitioner treating anxiety disorders (except dental phobias) or PTSD.


Second, a supervisor should be a practitioner who understands biofeedback sufficiently to guide the treatment. A psychiatrist with no knowledge of biofeedback cannot adequately supervise biofeedback treatment, even in their specialty areas.


Third, the concept of avoiding dual relationships applies to clinical supervision. Practitioners should not use an individual with another significant relationship as their legal supervisor. For example, a practitioner should not receive personal therapy and supervision from the same individual (Nagy, 2005).



Consultation Defined


Consultation is a regular process in professional life. Typically, consultations are short-term and focus on a specific patient or clinical issue. A consultant does not oversee the patient's care or the entire caseload. Nevertheless, a consultant may assume some liability for their advice. The consultant provides expert guidance, may confirm current treatment directions, or may suggest a modification in the treatment plan.


Consultation

Practitioners are well-advised to seek out a consultant whenever (a) they enter a new area of clinical practice, (b) encounter a concerning situation in practice, or (c) sense potential liability in new decisions on current treatment. Consultants do not assume responsibility for the practitioner's entire caseload or even for a case under consultation but guide from their professional perspective. A consultant may be an expert consultant, a recognized authority on a type of biofeedback treatment or a specific disorder, or an attorney with expertise relevant to the situation. A consultant may also be a peer, someone at the practitioner's own level of training, who provides perspective on a current problem.


When commencing the treatment of a new, unfamiliar clinical disorder, it is advisable to seek out a specialist for a brief clinical consultation or ongoing supervision. A biofeedback practitioner who decides to add pelvic floor biofeedback to their practice should seek a consultant who is an expert in the clinical practice of pelvic floor biofeedback.


When the practitioner observes a poor treatment response or a patient reports significant adverse effects, and the practitioner is uncertain about the source of the problem, consultation with a more experienced practitioner is advised.


Consultation with an expert or a peer at the same training level is advised whenever a practitioner recognizes that a treatment situation contains potential liability. Areas of potential liability might involve: (a) providing extensive, expensive treatment with no benefit, (b) release of confidential information without a patient's authorization, or (c) reporting a potential threat of violence by a patient or a threat of self-harm.


When a practitioner receives a subpoena for a release of information or testimony, and the patient refuses to sign a release, legal consultation is in order. Providing treatment for children when a divorce is pending is also a potential area of liability, especially when only one parent signs the consent to treatment, and a legal consultation may be beneficial.


The patient's chart should document all consultations on a specific case. Documentation that the practitioner has discussed the problem with an expert or another licensed practitioner and considered that individual's perspective would be beneficial if a complaint is filed.



Selecting a Consultant


Who is an appropriate consultant for a biofeedback practitioner?


First, if a question arises about poor response to treatment or adverse treatment effects, a recognized specialist with documented years of biofeedback treatment in the specialty and documented teaching or research in the area of the patient's problem is appropriate. For example, suppose a patient with post-traumatic stress disorder responds poorly to biofeedback or neurofeedback treatment. In that case, the best consultant will be a recognized specialist in trauma care with additional expertise in biofeedback treatment for individuals with PTSD.


Second, if the problem involves legal issues such as consent to treatment or release of information, an attorney with a behavioral health practice will be appropriate.


Third, many questions that arise in clinical practice, such as the choices of modalities or protocols for a patient's biofeedback treatment, alternative interpretations of a psychological test, or decisions for a treatment approach based on a QEEG or a physiological baseline, a peer consultation with another licensed biofeedback practitioner with a similar level of training and experience may be beneficial.



Ethical Standards


Biofeedback providers recognize their effectiveness, and the field's credibility depends on their professional conduct. They only bill for the services they or supervised staff provide. When billing third-party payers, they conscientiously follow the payers’ rules and regulations. This includes conservatively using billing codes, obtaining written agreements in advance to use specific codes, differentiating the services they provide from those provided by their supervisees, and accurately describing staff credentials.


Providers have fiduciary responsibility. Listen to a mini-lecture on Fiduciary Responsibility © BioSource Software LLC. Graphic © WIN12_ET/Shutterstock.com.


fiduciary responsibility


They understand that the appearance of a conflict of interest can be as damaging to their reputation as an actual conflict. Whenever possible, they proactively identify potential conflicts and avoid them. For example, workshop presenters should refrain from promoting their products. When a conflict of interest cannot be avoided, they quickly resolve it. For example, providers who serve on boards often recuse themselves from decisions that involve their financial interests.


Client education should include detailed information about assessment and treatment procedures, billing and fee collection, protection of confidentiality, and the limits of confidentiality. Providers should provide clients with a copy of these policies to read as they are carefully explained and only accept written consent when clients indicate they understand them. Informed consent is essential for experimental treatment procedures, which may have a higher risk of failure and client dissatisfaction.



Public Statements


Providers understand that all public statements, ranging from educational talks to the description of services on their website, should be accurate, comprehensive, and conservative to facilitate informed consumer choices. They confine statements about biofeedback to scientifically supported information and communicate the limitations, uncertainties, and strengths of these findings. "Discussion of treatment options in marketing materials and professional publications should be evidence-based and current" (Moss, 2020). Graphic © Redaktion93/Shutterstock.com.


public statements


Dr. Moss discusses public statements © Association for Applied Psychophysiology and Biofeedback.





Professional Credentials and Transparency in Marketing and Promotion

Biofeedback providers must accurately disclose their degrees, training, specialty areas, experience, and the status of license or credential and certification. Advertisements for clinical practice should include only treatment or practice-relevant and regionally accredited academic degrees. Example: A PhD in French literature or mathematics should not be included on a business card or in an advertisement. It would mislead the potential client to assume the provider has doctoral-level clinical education. Example: Current controversy over nurses with PhD or DPN advertising their practices under the title, “Dr. Frances Schmidt.” Unless the practitioner uses a further heading to clarify, this seems to mislead the patient to believe Dr. Schmidt is an MD. The appropriate title would be Dr. Frances Schmidt, Clinical Nurse Specialist. Participation in a membership organization such as AAPB or ISNR does not imply competence. Advertisement of one’s professional association membership misleads the health consumer to assume that membership assures training and competence. Advertising BCIA and other forms of certification are legitimate ways to show competence (Moss, 2020).


Dr. Moss discusses marketing © Association for Applied Psychophysiology and Biofeedback.





Since professional standards are the foundation of clinical practice, BCIA Board voted to apply the American Psychological Association’s standard on listing professional credentials to its Board Certified Practitioner and Mentor Directory. Certificants may only list the degrees earned in a BCIA-approved healthcare field from regionally-accredited academic institutions (Crawford & Shaffer, 2014).


They carefully explain the efficacy of biofeedback procedures and the costs, benefits, and limitations of commercial services and products. They cautiously endorse the services and products of others, disclose potential conflicts of interest, and ensure that their statements are not misused.


Their professional communications, including business cards, directory listings, letterheads, marketing brochures, and websites, are accurate and consistent with the standards of their professional associations. They seek guidance from colleagues, BCIA, and their professional associations whenever they are uncertain about ethical issues or their objectivity.



Confidentiality


While professionals strive to protect the confidentiality of client, student, and research participant information, confidentiality is never absolute. For this reason, they explain their procedures for safeguarding the confidentiality of data and the legal limits of confidentiality during orientation when they obtain informed consent. While they generally may only release information with the individual or her representative's written consent, exceptions include fee collection, compliance with mandated reporting laws that deal with abuse or neglect, and protecting the client or others from harm.


Dr. Moss explains confidentiality © Association for Applied Psychophysiology and Biofeedback.



Providers should consider consulting with their legal counsel if they receive a subpoena since this does not automatically shield them from their responsibility to maintain confidentiality (Moss, 2013).


Providers use secure procedures to store and destroy records and preserve records for the time required by applicable laws. Graphic © Hafiez Razali/Shutterstock.com.


confidentiality


They must take many precautions to protect digitized client files. These include encrypting files, storing them on portable media and locking them up when they are not in use, locking computers when they are unattended, using a complex password or biometric security systems to prevent unauthorized access, and preventing unauthorized individuals from viewing displays of the client's confidential information (Striefel, 2004, p. 58).


When electronically transmitting confidential client information, encryption and assigning the client a number instead of using the client's name or national identification number protects confidentiality and reduces the risk of identity theft. The provider should include a cover page warning the recipient that the transmitted information is confidential and must be protected, destroyed, or returned. The sender should notify the sender if mistakenly received. The provider should request confirmation that the client's information was received and provide automatic acknowledgment after receiving e-mail or fax messages (Striefel, 2004, pp. 71-72).


Protection of Client Rights and Welfare


Providers protect the welfare of the individuals they serve. Respect for clients requires that providers listen carefully to their clients to understand their goals and concerns. Successful collaboration and training are only possible when your clients believe you are focused on their priorities. Graphic © ANDREI ASKIRKA/Shutterstock.com.


listen to clients



Informed Consent


Respect for the patient’s autonomy requires that the practitioner fully include a patient in treatment planning. The patient should be informed of the rationale for assessment and training procedures, the strength of empirical support for treatments, and the risks, costs, and potential benefits of treatment. Full understanding of all treatment options is essential to informed consent. Optimally, that informed consent will be written. A practitioner may provide less-documented biofeedback and behavioral therapies if the client is first fully informed of the available therapies for their problem, the evidence for each, and the scope of the evidence for the treatment that one is advocating. Many patients have failed to benefit from mainstream treatments and are open to innovative new treatments (Moss, 2020).

Dr. Moss explains informed consent © Association for Applied Psychophysiology and Biofeedback.


As practitioners, they carefully inform their clients about their rights during orientation and provide this information in written form. They explain the nature and purpose of all procedures and obtain permission from clients or their legal guardians before implementing them.


Sexual intimacy with current clients, trainees, supervisees, and research participants is prohibited. Following the termination of a professional relationship, providers should follow applicable statutes and the rules of their professional associations regarding when sexual intimacy is permissible.



Touch, Privacy, and Respect


In general, mental health professionals are discouraged from touching their clients. Many behavioral therapists engage only in handshakes with clients; others carefully engage in a cautious side-hug at moments that call for contact. Yet, biofeedback professionals must touch their clients frequently, applying and removing sensors. Skin conductance sensor graphic © BioSource Software.


Skin conductance sensor

This calls for clear guidelines and procedures to avoid actual or apparent violations of the client's modesty. Listen to Dr. Moss explain touch © Association for Applied Psychophysiology and Biofeedback.





Attaching Biofeedback Sensors


Providers take special precautions when attaching biofeedback sensors to clients since it invades personal space, often involves physical contact, and risks misinterpretation. It is helpful to explain the function of the sensors and how they are attached and ask permission to place them on the client's body. Practitioners can encourage clients to attach sensors to their own bodies whenever feasible. For example, when attaching a respiratory band for respiratory biofeedback, the practitioner can ask clients to place the band around the abdomen or chest, guide them verbally in the placement, and stand behind the patient to secure the band as it is handed back to the practitioner. This strategy minimizes physical contact with vulnerable body areas, treats the client as a respected partner, and can strengthen the therapeutic alliance.

It is wise to remember the high percentage of individuals in the general population, especially women, who have been molested, raped, or otherwise violated, often by a person of trust. One multi-state and territory study showed that 18.5% of women report a history of attempted or completed nonconsensual sex during their lifetime (Smith & Breiding, 2011). Further, women with histories of sexual violation experience higher rates of chronic illnesses and health risk factors such as smoking, excessive alcohol use, and elevated cholesterol and blood pressure (Santaularia et al., 2014; Smith & Breiding, 2011). This research suggests that biofeedback practitioners will also see a disproportionate number of women with histories of sexual violation.

Accordingly, biofeedback practitioners are responsible for conducting all procedures involving even seemingly trivial touches with caution and respect. Explaining the procedure and asking permission to place the sensor are good guidelines. In many cases, the client can position the sensor, reducing any sense of being passively violated.

Biofeedback practitioners do not touch sensitive body parts like breasts or genitals during biofeedback practice except as part of a medical examination or medical treatment essential for the patient's complaint and performed by a licensed medical practitioner.



Treatment Applications With More Intrusive Procedures


Biofeedback practitioners whose clinical specialization requires the use of more personally intrusive sensors and procedures have a special responsibility to protect the privacy and dignity of their clients. Practitioners utilizing pelvic floor muscle biofeedback may utilize sensors that require insertion in the vagina or anus. The graphic below is a TensCare Vaginal Sensor.

Vaginal muscle sensor

It is important to develop educational materials to inform clients about such sensors' purpose and to develop office procedures/routines supporting professionalism in pelvic floor practice. Many pelvic floor therapists educate clients to insert the sensor themselves, and frequently a same-sex nurse or technician is included in the patient orientation session to assure clients of the professionalism of this treatment.



Obtaining Assent from Children


They respect children's rights and seek their assent before receiving biofeedback training or participating in research.


Consent means that the consenting person understands what they are getting into and its implications and that they are making a choice that they control and have authority over. Assent more means that the person is willing to participate in something without necessarily understanding the essential details of what they are getting into or all its consequences. If a child or person with cognitive impairments cannot provide consent, then someone with authority over the child or person provides consent. However, the child or mentally impaired person is still asked for their assent. This is not mere politeness but is also practically useful because it helps to engage the child’s active participation in the experiment.



Respect for Dignity and Rights


They respect the dignity and rights of all individuals and never discriminate against or refuse services to clients because of their sex, sexual orientation, sexual identity, race, religion, disability, or national origin.


Biofeedback Equipment Selection

Wherever possible, purchase equipment that is FDA approved. The major equipment manufacturers expend thousands of hours and go to considerable expense to obtain FDA approvals and to meet ISO 13485 medical device certification requirements. 'Quality first: all our products are designed and developed according to ISO 13485 and FDA requirements of quality systems' [Mind Media]. However, many small companies producing inexpensive devices do not follow these procedures. Manufacturers may have FDA waivers for some battery-operated devices. Clinical biofeedback devices are regulated by the US Government’s Food and Drug Administration (FDA). You should not use any biofeedback device for clinical applications which is not labeled as safe and effective by the FDA unless you are using it for approved research. If you are outside the US, your own government may have its own system of regulation. Each device approved by the FDA has a 'label' stating those uses which the FDA feels have been sufficiently well demonstrated to be efficacious. You must inform your clients in writing if you use the device off-label, meaning something other than uses listed with the FDA. For a complete discussion of FDA issues, including who can prescribe the use of biofeedback devices, please see the discussion at 'Food and Drug Administration (FDA) Biofeedback Equipment Labeling and Approval Issues' (Moss, 2020).


Strongest Position


Hypothetically, if you treat a patient with a diagnosed disorder using non-FDA equipment, the insurance company could demand re-payment. FDA-registered equipment should only be sold to licensed professionals. No practitioner who is not licensed for independent practice should advertise biofeedback treatment for diagnosed disorders (or provide a diagnosis on statements for submission to insurance companies) unless supervised by a licensed provider (Moss, 2020).



FDA Labeling

The FDA only labels devices for specific uses that have been strongly documented. Most biofeedback and neurofeedback devices, for example, are designated for relaxation or stress management only. Licensed practitioners can utilize equipment off-label but should be careful not to advertise off-label applications (Moss, 2020).


Infection Risk Mitigation

A neurofeedback provider applied reusable EEG sensors to the scalp of a high school wrestler with skin lesions. When questioned, the wrestler explained that the lesions were due to mat abrasion and that all the wrestlers on his team had them. Since the clinician did not disinfect the sensors in between sessions, several of her clients developed MRSA infections and sued him for malpractice. This vignette was adapted from Moss (2013).


wrestlers


Professionals follow the most rigorous standards of infection mitigation to protect clients and staff. Practitioners should learn and implement reasonable disinfection standards for biofeedback instruments, sensors, and office environments (Moss et al., 2019).



During a pandemic, distance training may be necessary due to the risk of community spread. Where the positivity rate is acceptable, practitioners should adopt current Centers for Disease Control (CDC) standards for screening, distancing, masking, and cleaning surfaces. Graphic © Kinga/Shutterstock.com.


COVID precautions


Biofeedback providers may underestimate their risk of transmitting infection to their clients and may lack basic knowledge about risk mitigation strategies. Whereas clinicians may assume that infection risk is low since biofeedback is noninvasive, handshakes, reclining chairs, cables, and sensors can easily transfer infectious organisms to clients. Moreover, over-abrasion in SEMG biofeedback and neurofeedback can expose sensors to client blood (Spaulding semi-critical classification), and inserted pelvic and rectal sensors expose sensors to tissue (Spaulding critical classification). This ubiquitous problem is called common vehicle transmission. Risk mitigation involves three strategies: handwashing and drying, disinfection of surfaces clients will contact, and disinfection or sterilization of sensors and cables. (Hagedorn, 2014).


A comprehensive prevention strategy includes handwashing by both the clinician and client. When the skin is not visibly soiled, alcohol-based products may be superior to antiseptic soap and water in terms of effectiveness, minimizing skin dehydration, and ease of use. However, soap and water are superior to alcohol-based products in removing spores from Clostridium difficile (C. diff; Sullivan & Altman, 2008).


Clinicians should disinfect chair or recliner surfaces using wipes impregnated with biocidal agents that control bacteria and spores like Freshnit or Virusolve instead of ineffective 20% isopropyl alcohol (Hagedorn, 2014).


Freshnit



When equipment like precious metal electrodes and cables can be damaged by heat, liquid chemical sterilization should be used before and after each training session. Low-level disinfectants like Protex Disinfectant Spray can destroy a broad spectrum of bacteria, viruses, and fungi, including herpes, MRSA, and VRE.


protex


The risk of infection transmission can be reduced by using disposable sensors, and in the case of rectal or vaginal sensors, using dedicated sensors that belong to the client (Sullivan & Altman, 2008).

rectal sensor


Best Telehealth Practices


The Covid-19 pandemic has increased the delivery of biofeedback and neurofeedback services via telehealth both within and across state lines. Dr. Moss provides an overview of best telehealth practices © Association for Applied Psychophysiology and Biofeedback.





Professional Relationships


Providers build partnerships with colleagues in diverse professions based on respect for their competencies. These networks allow allied providers to combine their expertise and resources when treating clients, conducting research, and educating the public, legislators, and third-party payers.


Listen to a mini-lecture on Partnerships © BioSource Software LLC. Graphic © fizkes/Shutterstock.com.


partnership


They should only treat medical disorders with biofeedback if their clients have been medically evaluated or are under the care of a physician. They should collaborate with the physicians who treat their clients by explaining their treatment strategy and goals, providing regular progress reports supported by physiological data, and advising physicians on how biofeedback and adjunctive procedures can interact with medication. For example, relaxation training may reduce a diabetic patient's insulin requirement, resulting in a functional overdose that could cause hypoglycemia and coma. This collaborative approach can promote sharing of vital information, physician encouragement of their clients to continue biofeedback and future referrals.


Providers respect the importance of client-physician relationships and avoid the appearance of interfering with medical treatment. If clients express the desire to adjust or eliminate medication as their symptoms improve, providers should withhold their opinion and encourage clients to discuss this issue with their physician.


They maintain good relationships with their colleagues by striving to be objective and compassionate in their judgments of others and showing respect for different perspectives. They collaborate with allied professionals to increase understanding and pursue goals they could not achieve alone.



Dual Relationships or Multiple Relationships


The American Psychological Association (APA) has guided the way on dual or multiple relationships (APA, 2017). The original concept of a dual relationship prohibited developing a romantic or sexual relationship with a current client. Over time, this ethical principle was broadened to include advice against entering into many forms of dual or multiple relationships with current clients and recent clients.

A therapist has an unequal relationship with clients. First, the therapist learns many intimate secrets about the client during therapy, and for the most part, the clients learn relatively little about the therapist as a person. Some therapist disclosure at critical moments is often beneficial in treatment, yet the relationship remains unequal. The therapeutic concept of transference expresses that the therapist becomes a projection screen, onto which the client projects both positive and negative emotions engendered in past relationships, especially parent-child relationships. Clients may adopt a blind trust in the professional, anticipating parent-like selfless support. Conversely, they may project emotions from past abusive relationships, expecting the therapist to harm the client, just as past trusted figures have abused them.

The therapy relationship is also a power relationship. The client enters therapy in a vulnerable state, hoping and expecting assistance in overcoming life problems and burdens. When a therapist uses the client for their own purposes, it exploits that power. Photo 165564906 © Prostockstudio | Dreamstime.com


therapist relationship


This unequal relationship between therapist and client opens the potential for other relationships outside therapy with the client to be exploitative. This does not preclude ever having multiple relationships.


For example, therapists in small-town situations frequently find interacting with clients in other settings unavoidable. A therapist in a small town may consider treating a social acquaintance when the relationship is quite casual and no other professional with comparable expertise is available locally. Nevertheless, however justified, the unequal relationship raises a responsibility for the therapist/practitioner to assess carefully, on an ongoing basis, how this interaction may be or may seem harmful to the client.

Entering into a financial relationship with a client constitutes a dual relationship and can have adverse consequences. Starting a business with a client, hiring a client for services, or bartering to pay for services constitute dual relationships. The American Psychological Association now discourages entering a barter relationship with clients to pay for the therapy with labor. This author has observed past bartering relationships in therapy go sour because the client either did not fulfill the agreement or carry out poor work. Suddenly the therapist is seeking to enforce the work agreement with someone still in a relationship of vulnerable trust with the therapist. In this case, the therapist may also feel exploited, perceiving the client as taking advantage of the therapeutic trust to avoid providing the promised work.

Multiple relationships also apply to behavioral health professionals, not in a treatment relationship with a client. Examples of multiple relationships beyond therapy include developing a sexual relationship with a student in an unequal relationship with an instructor; the instructor can pass or fail the student's work.


In past years, it was commonplace for instructors to engage in sexual relationships with students, yet today this an offense triggering discharge from university employment and opening liability for civil suits for damages. It was also common in past years for instructors in psychology and counseling departments to take on students as therapy clients, yet this puts the instructor in a position to evaluate and grade someone in a vulnerable therapeutic relationship expecting positive support.


Similarly, a biofeedback professional mentoring a potential biofeedback certificant should have second thoughts about accepting the mentee as a therapy client. That therapeutic relationship could create a potentially harmful conflict when the professional must provide an assessment of the mentee for BCIA or other certifying bodies. The administrator or supervisor in a work site has a similar power relationship over subordinates, and the Me-Too movement highlights that exploiting this power relationship is unacceptable.

Biofeedback professionals must recognize that dual or multiple relationships can threaten their therapeutic relationship with those they serve and risk exploiting both parties. Biofeedback professionals are advised to avoid dual relationships with clients whenever possible and avoid exploiting clients, students, supervisees, employees, and research participants. For example, professionals should never treat their spouses, and supervisors should never treat their employees. When providers question their own objectivity, they should seek guidance from colleagues.



Sexual Involvement with Current and Former Clients


Sexual involvement is an especially destructive form of dual relationship. Sexual intimacy with current clients, trainees, supervisees, and research participants is prohibited under professional ethics guidelines; sexual activity with current and recent clients is a criminal offense in many states. Following the termination of a professional relationship, providers should follow applicable statutes and the rules of their professional associations regarding when sexual intimacy is permissible. The American Psychological Association, for example, absolutely prohibits any sexual contact in the first 2 years after termination of treatment (APA, 2017).


Even when it is within the written guidelines of professional codes of conduct, post-treatment sexual involvement removes the patient's option of benefitting from a possible return to treatment with an already trusted provider. It also risks that the unequal treatment relationship makes it difficult for the former patient to make a completely autonomous decision about entering a sexual relationship. Professionals should also remember that although the post-therapy relationship may seem mutually consensual at the beginning, the former client may, over time, feel exploited and file a complaint about abuse of the previous power relationship.

Providers should consider the recommendation of the American Psychological Association that all intimacies are prohibited in the first 2 years post-treatment and that after that, the practitioner bears "the burden of demonstrating that there has been no exploitation, in light of all relevant factors" (Behnke, 2004).



Research with Humans and Animals


Professionals conduct research to increase our understanding of human behavior, improve the human condition, and advance science. They believe that human and animal welfare must be their paramount concern when conducting research and strive to protect them. They adhere to their professions' applicable legal statutes and standards, consider alternative research methods that minimize participant discomfort and deception, and reduce the number of animal subjects. They cooperate completely with institutional review boards and animal care and use committees regulating human and animal research.

Their research reports completely describe their methodology and statistical analysis, accurately summarize experimental findings, and satisfy conventional scientific criteria. Descriptions of clinical procedures are factual and avoid self-promotion. They explicitly describe the limitations of their studies and exercise caution in drawing conclusions from their data. They may supplement probability testing with effect size estimates and confidence intervals to better communicate the research significance of their results. Each researcher is responsible for ensuring that research adheres to legal and professional ethical standards and that collaborators, assistants, students, and employees treat participants ethically. All members of a research team are personally responsible for their ethical conduct. Researchers protect information obtained from participants through procedures that ensure anonymity and confidentiality. They protect anonymity by identifying participant records using codes. They guard confidentiality by securely storing data, only using data as promised to the participants, and only reporting aggregate results. They explain these precautions when they obtain informed consent. They inform prospective subjects about all aspects of a study that might influence their decision to participate, including potential risks and benefits, and encourage questions when they obtain informed consent. Their responsibility to protect participants increases with the risk of harm. If participants are injured by research, they are responsible for providing effective care to make these individuals “whole.” They never employ research procedures that are likely to cause severe and lasting harm to participants. They respect an individual’s right to refuse to participate in research or to end their participation at any time and never coercively use compensation. They are especially vigilant in protecting this freedom when the investigator can affect the participant’s outcomes. When studying minors, investigators should seek their assent whenever possible. When a study involves deception, researchers are responsible for completely debriefing participants about the nature of the study, either immediately after their participation or when data collection is finished. When debriefing must be delayed, researchers redouble their precautions to ensure that participants are not harmed.



Adherence to Professional Standards


Providers strive to utilize the best practices in the biofeedback field. They use evidence-based protocols and maintain current knowledge about treatment efficacy wherever possible. They carefully describe their protocols and objectively document treatment outcomes when utilizing experimental procedures.


Hammond, Bodenhamer-Davis, Gluck, Stokes, Harper, Trudeau, MacDonald, Lunt, and Kirk (2011) authored Standards of practice for neurofeedback and neurotherapy: A position paper of the International Society for Neurofeedback & Research. An ISNR Task Force consisting of Randy Lyle, Cory Hammond, Jerry Gluck, Genie Bodenhamer Davis, Deb Stokes, and John Davis updated these standards in 2019. They represent ISNR's official position on the delivery of neurofeedback (EEG biofeedback).


Ethics Complaint Procedures


BCIA strives to promote communication between complainants and its certificants.

For example, when a client or a professional raises ethical concerns about a certificant with BCIA's Executive Director, they will encourage the complainant to contact the certificant to resolve the matter directly. "When the violation is more grievous and not appropriate for informal resolution, or the effort at informal resolution fails, then the professional should take action appropriate to the situation (such as referral to state or national ethics committee, licensing board, or institutional authorities" (Moss, 2020). Graphic © fizkes/Shutterstock.com.


complaint


Dr. Moss explains BCIA's educational approach to ethical complaints © Association for Applied Psychophysiology and Biofeedback.




BCIA will not intervene in complaints about manufacturer or vendor products, services, or sales practices as these issues do not concern certification, and corporations are not BCIA professionals.


When BCIA receives a written complaint about the ethical conduct of a BCIA certificant or applicant, BCIA’s Executive Director will record the complaint and will write a letter to the complainant that will describe BCIA's role in ethics cases, direct the complainant to directly discuss the complaint with the provider [certificant or applicant], and if requested by the complainant, identify state and/or national regulatory agencies with jurisdiction. Since BCIA’s approach to ethical issues is educational, BCIA will not recommend that complainants contact these agencies, nor will it represent complainants before these agencies. When BCIA receives a complaint, it will first encourage the complainant to carefully consider whether this is a consumer satisfaction issue or a potentially harmful violation of standard healthcare practice or professional ethics. BCIA will not intervene in complaints regarding consumer satisfaction, since these issues fall outside of its mission and are better resolved by organizations that promote marketplace trust. When BCIA receives consumer satisfaction complaints, it will encourage consumers to directly discuss their concerns with the BCIA professional who provided their services or with organizations, like the Better Business Bureau, that provide voluntary dispute resolution (BCIA, 2016).


Biofeedback Certification International Alliance (BCIA)


BCIA logo









What Is Certification?


Professional certification is not a license to practice. BCIA Board certification does not authorize professionals to provide services they could not legally offer before certification. Certification is a voluntary process in which applicants demonstrate competence, commit themselves to a code of ethics, and pursue continuing education to increase their proficiency.


"Professional certification is the voluntary process by which a non-governmental entity grants a time-limited recognition to an individual after verifying that predetermined and standardized criteria have been met. Because biofeedback is an unregulated field, certification is crucial for providing standards of care. To be viable as a professional service, competence and clinical practice standards must be defined and measured. Since 1981, BCIA has taken on this task.


Through the BCIA recertification program, each certificant is held accountable to a code of ethics, obtains specified continuing education, and maintains proper credentialing appropriate for clinical practice." (BCIA, 2011).


BCIA's Mission

BCIA, formerly the Biofeedback Institute of America, was created in 1981 with the primary mission to certify individuals who meet education and training standards in biofeedback and progressively recertify those who advance their knowledge through continuing education.


In March 2010, the BCIA adopted a new name to reflect its global identity and became the Biofeedback Certification International Alliance. Graphic © Rawpixel.com/Shutterstock.com.



BCIA is an autonomous nonprofit corporation. BCIA policies and procedures are set by an independent board of directors comprised of a rotating group of distinguished biofeedback clinicians, researchers, and educators.


Board certification is the mark of distinction for providers of biofeedback and neurofeedback services. Certification is valid for 4 years for providers who carry the credential in Biofeedback, HRV Biofeedback, Neurofeedback, and Pelvic Muscle Dysfunction Biofeedback. Recertification indicates continuous peer review of ethical practice and the acquisition of advanced knowledge of recent developments in the field through required continuing education. Names of certified practitioners may be found on the BCIA website by using its Find a Practitioner search function.


Board certification establishes that an individual has met entry-level requirements for the clinical practice of biofeedback. However, BCIA certification is not a substitute for a state-issued license or another credential to practice one's profession. Candidates for certification who do not hold a professional license or its equivalent must stipulate they practice under the supervision of a licensed provider when treating a medical or psychological disorder.



Why Choose BCIA Certification?


BCIA certificants reported in a comprehensive survey they initially sought certification for credibility, validation of their skills and knowledge, professional satisfaction, to ensure proper training, and to promote the field. BCIA biofeedback certification is internationally recognized for six reasons.


1. BCIA is a nonprofit institute that effectively advocates for our field. The American Psychological Association (APA) has recognized biofeedback as a proficiency in professional psychology because of the petition that BCIA filed with them. BCIA has been dedicated to a singular mission since 1981:


BCIA certifies individuals who meet education and training standards in biofeedback and progressively recertifies those who advance their knowledge through continuing education.


2. BCIA's biofeedback certification is the only program that is recognized by the three major international membership organizations: the Association for Applied Psychophysiology and Biofeedback (AAPB), the Biofeedback Federation of Europe (BFE), and the International Society for Neurofeedback and Research (ISNR).


3. BCIA's biofeedback certification is based on scientific evidence published in refereed journals. BCIA rejects narrow, unsubstantiated perspectives and the conflict of interest that exists when certification depends on a specific vendor's equipment, databases, and protocols. BCIA certification is based on a reading list, Blueprint of Knowledge, and Professional Standards and Ethical Principles developed following an extensive job analysis and regularly updated by a task force of international authorities in biofeedback. BCIA continually gathers data to validate and revise its exams through the psychometric process to ensure its certification program's relevance, integrity, and value.


4. BCIA's biofeedback certification exam adheres to the highest psychometric standards. We painstakingly evaluate and revise its exam regularly. Several independent experts, who include clinicians and the most experienced educators in our field, regularly review exam items to ensure that they represent key blueprint concepts, are sourced to its suggested reading list, and are psychometrically sound. BCIA regularly replaces outdated exam questions with new ones that are contributed by biofeedback authorities and then validated by our certificants.


5. BCIA requires that its certificants adhere to one of the strongest ethical codes in our field. In addition, we require that its certificants complete 3 hours of ethics continuing education when they renew their certification. BCIA's rigorous ethical standards are one of the many reasons its international colleagues chose BCIA biofeedback certification.


6. BCIA's Board of Directors consists of clinicians, educators, and researchers who have guided the development of biofeedback. BCIA's Board includes leaders of the three major international membership organizations who have contributed decades of service to our field (Why Choose BCIA Biofeedback Certification?).



BCIA Certification Programs


BCIA has four certification programs:

  1. Biofeedback Certification

  2. HRV Biofeedback

  3. Neurofeedback Certification

  4. Pelvic Muscle Dysfunction Biofeedback Certification


Individuals certified in Biofeedback have demonstrated entry-level competence in biofeedback modalities, including EMG, HRV, respiration, skin conductance, and temperature.


Individuals certified in HRV Biofeedback have demonstrated entry-level competence in ECG, EMG, PPG, and respiration modalities.


Individuals exclusively certified in Neurofeedback, commonly called EEG Biofeedback, can utilize only that specialty modality.


The Pelvic Muscle Dysfunction Biofeedback Certification is only for licensed providers wishing to use biofeedback and behavioral interventions to treat elimination disorders and pelvic pain within their scope of practice.


All certification programs require strict adherence to the Professional Standards and Ethical Principles of Biofeedback.


All certification programs are based on the following:

  1. prerequisite educational degrees, except for the Technician certification

  2. proof of human anatomy/physiology and human biology coursework

  3. didactic course work that is based on the Blueprint of Knowledge statements that cover the fundamental science, history, and theory of biofeedback specific to that certification program

  4. clinical training or mentoring to learn the application of skills

  5. certification exam

Certification is no substitute for a state-sanctioned license. BCIA's certificants must carry an appropriate license/credential valid in the state of practice in a BCIA-approved healthcare field when treating a medical or psychological disorder. If unlicensed, the certificant must work under appropriate supervision (Shaffer et al., 2012). Your biofeedback or neurofeedback provider's licensing body or supervisor has legal jurisdiction over their clinical practice (Crawford, 2013).


Certifications are valid for a set period: 4 years for Biofeedback, HRV Biofeedback, Neurofeedback, and Pelvic Muscle Dysfunction Biofeedback. Recertification is granted upon application, payment of fees, documentation of accredited continuing education specific to the Blueprint, and adherence to the Professional Standards and Ethical Principles of Biofeedback.


In 2012, BCIA created a Certificate of Completion in Heart Rate Variability (HRV) Biofeedback requiring 15 hours of didactic HRV biofeedback instruction, 3 hours over professional conduct, and a passing score on a nationally standardized exam (Crawford, 2013). A certificate of completion is not a certification. This credential attests to completing an approved didactic workshop based on BCIA's Blueprint and passing an exam over its content.




How does certification differ from licensure?


Certification means that a non-governmental organization like BCIA has recognized that an individual has satisfied its requirements and demonstrated at least entry-level competence in a field like biofeedback. Certification is not a license to practice and does not authorize professionals to provide services they could not legally offer before certification (Shaffer, Crawford, & Moss, 2012). Licensure means that a state agency has authorized an individual to use a professional designation, like a Psychologist, and provide services specified by the state's practice act for a fee.


Individuals who diagnose or treat disorders outside their legal scope of practice may face state prosecution.



Graphical Summary


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Earning Your Certificate of Exam Completion


Go to ClassMarker. Enter the username and password we provided, score at least 70% on the PSEP exam, and click on the download link to print a certificate for your records.

ClassMarker


Glossary


anonymity: protection of a client's identity.


BCIA: the Biofeedback Certification International Alliance.


certificant: an individual who has been certified by BCIA.


certificate of completion: recognition by BCIA that an applicant has completed an approved didactic workshop based on BCIA's blueprint and passed an exam over its content.


certification: BCIA recognition that an applicant has met its requirements for entry-level competence in providing biofeedback services.


client: a recipient of biofeedback services.


common vehicle transmission: the transfer of infectious organisms by equipment, including cables and sensors


competence: level of proficiency.


confidentiality: a client's right to keep personal information private.


continuing education: organized learning experiences undertaken after a credential has been earned to ensure up-to-date knowledge.


dual relationships (also called multiple relationships): a situation where a healthcare provider and patient share multiple roles. For example, when a client is also an employee.


efficacy: effectiveness.


ethics: the branch of philosophy that deals with moral issues.


functional overdose: a drug overdose that can occur when biofeedback training reduces a patient's requirement for a drug. For example, biofeedback training may lower a patient's blood pressure to the extent that the prescribed dose may produce hypotension and fainting.


informed consent: a written and signed statement in which participants voluntarily confirm their willingness to participate in a research study following disclosure of all study aspects relevant to their decision to participate.


licensure: legal permission granted to a professional to practice a profession.


mentorship: a relationship between a mentor and candidate that promotes the development of skill, knowledge, responsibility, and ethical standards in the practice of biofeedback


provider: the professional who supervises biofeedback training.


scope of practice: the services an individual may legally provide under their license or supervisor's license under state law.


supervision: providing guidance for clinical practice for qualified health professionals by a more experienced health professional who assumes legal responsibility and liability for the quality of the services provided.



References


Association for Applied Psychophysiology and Biofeedback (1994). Clinical efficacy and cost effectiveness of biofeedback therapy: Guidelines for third party reimbursement (2nd ed.). Author.


Association for Applied Psychophysiology and Biofeedback (1995). Clinical applications of biofeedback and applied psychophysiology: A series of white papers prepared in the public interest by AAPB. Author.


Association for Applied Psychophysiology and Biofeedback (2003). Ethical principles of applied psychophysiology and biofeedback (4th revision). Author.


Biofeedback Certification International Alliance (2016). Professional standards and ethical principles (9th rev.).


Biofeedback Certification International Alliance (2011). What is certification?


Biofeedback Certification International Alliance (2015). Why choose BCIA biofeedback certification?


Crawford, J. (2013). What's new with BCIA? Biofeedback, 41(3), 85-87. https://doi.org/10.5298/1081-5937-41.3.07


Crawford, J., & Shaffer, F. (2014). What BCIA learned from Bob Dylan. Biofeedback, 42(1), 9-11. https://doi.org/10.5298/1081-5937-42.1.05


Hagedorn, D. (2014). Infection risk mitigation for biofeedback providers. Biofeedback, 42(3), 93-95. https://doi.org/10.5298/1081-5937-42.3.06


Hammond, D. C., Bodenhamer-Davis, G., Gluck, G., Stokes, D., Harper, S. H., Trudeau, D., MacDonald, M., Lunt, J., & Kirk, L. (2011). Standards of practice for neurofeedback and neurotherapy: A position paper of the International Society for Neurofeedback & Research. Journal of Neurotherapy, 15(1), 54-64. https://doi.org/10.1080/10874208.2010.545760


Hopkins, B. (2013). Legal aspects of counseling: What you don't know might hurt you. Workshop presented at the Biofeedback Society of Texas conference, Austin, Texas.


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


Moss, D. (2013). Professional conduct in biofeedback and neurofeedback. Workshop presented at the International Society for Neurofeedback and Research conference, Dallas, Texas.


Moss, D. (2020). Professional conduct in biofeedback and neurofeedback. BCIA Webinar. presented to BCIA.


Moss, D., Hagedorn, D., Combatalade, D., & Neblett, R. (2019). “A guide to normal values for biofeedback.” In D. Moss & F. Shaffer (eds)., Physiological recording technology and applications in biofeedback and neurofeedback. Association for Applied Psychophysiology and Biofeedback.


Moss, D., & Shaffer, F. (2022). A primer of biofeedback. Association for Applied Psychophysiology and Biofeedback.


Nagy, T. F. (2005). Ethics in plain English: An illustrative casebook for psychologists (2nd ed.). American Psychological Association.


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


Scaife, J. (2019). Supervision in clinical practice: A practitioner's guide. Routledge.

Shaffer, F., Crawford, J., & Moss, D. (2012). What is BCIA really? Biofeedback, 40(4), 133-136.


Shaffer, F., & Schwartz, M. S. (2016). Entering the field and assuring competence. In M. S. Schwartz and F. Andrasik, Biofeedback: A practitioner's guide (4th ed.). The Guildford Press.


Striefel, S. (1999). Practice guidelines and standards in psychophysiological self-regulation. Association for Applied Psychophysiology and Biofeedback.


Striefel, S. (2003). Professional ethics and practice standards in mind-body medicine. In D. Moss, A. McGrady, T. Davies, and I. Wickramasekera (Eds.), Handbook of mind-body medicine for primary care. Sage Publications, Inc.


Striefel, S. (2004). Practice guidelines and standards for providers of biofeedback and applied psychophysiological services. Association for Applied Psychophysiology and Biofeedback.


Sullivan, L. R., & Altman, C. L. (2008). Infection control: 2008 review and update for electroneurodiagnostic technologists. American Journal of Electroneurodiagnostic Technology, 48, 140-165. PMID: 18998475



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