Dr. Donald Moss on the Scope of Practice and Competence

Clinical practitioners always operate under practice standards developed by their home profession and under their state or provincial licensure acts. Two primary concepts governing what practitioners can and should do are the scope of practice and competence. Both of these concepts will be introduced here.

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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.

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, among others.

The scope of practice varies in some specifics from state to state and from one health discipline to another. The diagnosis of a mental health disorder is within the scope of practice of psychologists, but the diagnosis of a medical disorder is typically not. Most licensed health and mental health professionals are permitted in their scope of practice 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 scope of practice applies to their activities and may not be informed of any limitations in their supervisor's scope of practice. Graphic © Aleksandr_Kuzmin/Shutterstock.com.

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.

Competence

The scope of practice determines which professions can utilize biofeedback. Competence determines whether an individual provider has adequate training and experience to use a specific biofeedback intervention or protocol, and adequate clinical experience and training to work with a specific population. For example, a practitioner trained and certified in neurofeedback has the scope of practice to deliver neurofeedback. But if the individual practitioner has no training and experience in the clinical management of seizure disorders, the practitioner lacks the competence to provide neurofeedback to patients with seizures.

The practitioner may know how to apply EEG electrodes to specific 10-20 sites or a 19-channel cap to the entire scalp. They may know how to uptrain or down-train cortical activity in a specific frequency range. But does the practitioner know how to recognize the onset of a seizure prodrome or how to assist the patient experiencing a grand mal seizure in the clinic?

One useful guideline is that one should not deliver biofeedback or neurofeedback treatment to a patient with a disorder unless one is already trained to treat that disorder by other means. Whenever a practitioner wishes to embark on treating new disorders or new patient groups, that practitioner should seek out additional training or ongoing clinical consultations, thus expanding competence.

Competent providers are critical consumers of biofeedback research and stay informed on relevant findings. They recognize where biofeedback is indicated and contraindicated, and critically evaluate the efficacy of biofeedback applications. Providers strive to utilize the best practices in the biofeedback field. Wherever possible, they use evidence-based protocols and maintain current knowledge about treatment efficacy.

Resources are available to assist the biofeedback practitioner in assessing the efficacy of any biofeedback treatment. In 2000 and 2001, AAPB and ISNR collaborated to establish standards for assessing the clinical efficacy of biofeedback and neurofeedback treatment (LaVaque et al., 2002; Moss & Gunkelman, 2002).

A publication approved and published by AAPB regularly reviews the application of biofeedback and neurofeedback for a wide range of medical and emotional disorders and rates the efficacy of each application area in accordance with the 2002 efficacy standards (Khazan et al., in press; Tan et al., 2016; Yucha & Gilbert, 2004; Yucha & Montgomery, 2008).

The 2023 edition of this publication will rate the application of biofeedback for 37 general medical and mental health disorders and a number of subcategories, such as adult vs. pediatric headache and the various types of anxiety disorders.

Responsible biofeedback professionals recognize the limits of their expertise, provide only those services they are competent to deliver, and obtain additional training and supervision when they wish to offer services outside their current areas of proficiency.

Providers should achieve an entry-level competence in biofeedback before commencing the delivery of any clinical biofeedback services or biofeedback training. Entry-level competence is achieved through biofeedback training, reading, attendance at conferences, practice with biofeedback instruments, and supervised or mentored delivery of biofeedback sessions. Standards for entry-level competence have been established by BCIA. BCIA has published Blueprints of Knowledge defining entry-level knowledge and skills for general biofeedback, neurofeedback, pelvic floor muscle biofeedback, and heart rate variability biofeedback (BCIA, 2011, 2015a, 2015b, & 2015c). Certification by BCIA in one or more practice areas provides objective verification that a professional has attained entry-level competence.

Providers are responsible for maintaining and enhancing their competence areas through continuing education activities. These can include attending workshops, training, conferences, and classes, reading and self-study, and receiving supervised practice and discussion (Striefel, 2004, p. 29).

Professionals are advised to seek supervision or peer consultation from resources such as colleagues, BCIA, and their professional associations whenever they lack experience with a patient’s problems or the choice of intervention. Supervision and peer consultations are valuable whenever practitioners are concerned or uncertain about ethical issues involved in a patient’s care, or whenever they question their own judgment. Supervision and consultation should be recorded in progress notes in the relevant patient record, to document the effort to address any ethical issue. Such documentation is helpful in constructing a defense of one’s actions, in event of any complaint or litigation.

Summary

Whether practitioners are licensed or unlicensed, they must comply with relevant state statutes or risk prosecution. The scope of practice determines which professions can utilize biofeedback. Competence determines whether an individual provider has adequate training and experience to use a specific biofeedback intervention or protocol, and adequate clinical experience and training to work with a specific population.

Glossary

BCIA: the Biofeedback Certification International Alliance. certificant: an individual who has been certified by BCIA.

competence: level of proficiency.

scope of practice: the assessments and treatments a clinical professional may deliver.

References

Biofeedback Certification International Alliance (2011). Blueprint of knowledge statements for pelvic muscle dysfunction biofeedback certification.

Biofeedback Certification International Alliance (2015a). Blueprint of knowledge statements for board certification in biofeedback.

Biofeedback Certification International Alliance (2015b). Blueprint of knowledge statements for board certification in neurofeedback.

Biofeedback Certification International Alliance (2015c). Blueprint of knowledge statements for a BCIA certificate in heart rate variability biofeedback.

Hopkins, S. L. (2013). How effective are ethics codes and programs? Financial Executive, 29, 42-45.

Khazan, I., Shaffer, F., Moss, D., Lyle, R., & Rosenthal, S. (Eds). (in press). Evidence-based practice in biofeedback and neurofeedback. Association for Applied Psychophysiology and Biofeedback.

LaVaque, T. J., Hammond, D. C., Trudeau, D., Monastra, V., Perry, J., Lehrer, P., Matheson, D., & Sherman, R. (2002). Template for developing guidelines for the evaluation of the clinical efficacy of psychophysiological evaluations. Applied Psychophysiology and Biofeedback, 27(4), 273–281.

Moss, D., & Gunkelman, J. (2002). Task force report on methodology and empirically supported treatments: Introduction. Applied Psychophysiology and Biofeedback, 27(4), 261–262.

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

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

Tan, G., Shaffer, F., Lyle, R., & Teo, I. (Eds.) (2016). Evidence-based treatment in biofeedback and neurofeedback (3rd ed.). Association for Applied Psychophysiology and Biofeedback.

Yucha, C., & Gilbert, C. (2004). Evidence-based practice in biofeedback and neurofeedback (1st ed.). Association for Applied Psychophysiology and Biofeedback.

Yucha, C., & Montgomery, D. (2008). Evidence-based practice in biofeedback and neurofeedback (2nd ed.). Association for Applied Psychophysiology and Biofeedback.