Dr. Moss on Mentoring, Supervision, and Consultation

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).

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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.

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).

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' 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).

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 the event 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.

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.

Summary

The overall purpose of mentoring, supervision, and consultation is to improve and assure patients' quality of care. Mentoring is a regular component in learning biofeedback skills, and mentoring hours are required for BCIA certification. Supervision is an ongoing requirement for technicians, who must practice under supervision, and for non-licensed practitioners, who may only treat diagnosed disorders under supervision. Consultation is a recommended part of ongoing professional practice and should take place whenever concerning treatment situations arise.

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References

Biofeedback Certification International Alliance (2021). BCIA HRV certification mentoring

handbook. C:\Users\rkpan\AppData\Local\Temp\mso9FE2.tmp (memberclicks.net)

Biofeedback Certification International Alliance (2022). BCIA biofeedback mentoring handbook. C:\Users\rkpan\AppData\Local\Temp\msoC55B.tmp (memberclicks.net)

Biofeedback Certification International Alliance (2022). BCIA neurofeedback mentoring handbook. C:\Users\rkpan\AppData\Local\Temp\mso9BA7.tmp (memberclicks.net)

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.

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

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