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




      



This unit covers Professional conduct (A-E).

Students completing this unit will be able to discuss BCIA ethical principles concerning:
  1. Responsibility and competence
  2. Client rights
  3. Supervision and consultation
  4. Professional relationships
  5. Record keeping

We strongly recommend that you purchase Sebastian Striefel' s seminal ethics document, the Practice guidelines and standards for providers of biofeedback and applied psychophysiological services (2004) from your vendor or the AAPB Bookstore.

This unit reproduces the 2005 Biofeedback Certification Institute of America's Ethical Principles of Biofeedback with our annotations in blue text.





Because the Biofeedback Certification Institute of America (BCIA) and its certificants are committed to the protection of human rights, its certificants strive to maintain the dignity and worth of the individual while rendering service, conducting research, and training others. All certificants are expected to belong to and operate within the principles of ethics governing their own discipline and those outlined herein. The certificants strive to provide optimum quality services, and to differentiate for those served whether procedures provided have been proven effective clinically, or if such procedures are experimental. Certificants accept responsibility for their actions and make every effort to protect the welfare of those they serve. They limit their services to those areas in which they have skills and expertise and recognize their needs for competence, objectivity, freedom of inquiry, and honest communication.

This statement of Ethical Principles of Biofeedback is intended for use by all BCIA certificants. Licensure and certification laws and regulations should reflect and support these Principles, and acceptance as a BCIA certificant commits the certificant to adhere to these Principles.

A copy of these Principles will be sent to all applicants for BCIA certification. The Principles are intended to be preventive, educational, guiding, and action oriented, and are to be applied with professional maturity. Certificants are required to cooperate with the Ethics Committee of BCIA by responding promptly and completely, in writing, to inquiries from the Ethics Committee. Lack of response may be a basis for reprimand and decertification. Individuals who are not BCIA certificants, but who practice biofeedback, are encouraged to adhere to these ethical standards to help maintain and improve the image of biofeedback providers. In addition, certificants are subject to the principles of ethics of their own professional disciplines.


The Ethical Principles of Biofeedback (EPOB or Principles) consist of a set of guidelines agreed to by the BCIA which outline the moral duty, obligation, or custom on how certificants should behave professionally. The Principles that follow are not all-inclusive and should not be viewed as limiting the scope of ethical responsibility of BCIA certificants. Rather, the EPOB point out and underscore particular areas in which there is concern.
  1. The EPOB are to be followed by BCIA certificants in the provision of biofeedback and related services. Certificants must assure that the Principles are also adhered to by their employees engaged in biofeedback and biofeedback related activities, and by individuals receiving training in
    the use of biofeedback under their supervision. BCIA certificants will inform their employers of the EPOB and will make every effort to urge their employers to cooperate with them in adhering to these Principles.
     
  2. The EPOB constitute the guidelines against which the ethical conduct of a BCIA certificant is measured.
     
  3. A violation of the EPOB may lead to disciplinary action, decertification, and/or a letter to the appropriate state licensing/certifying agent or the state or national association of the individual's professional discipline concerning the charges or actions.
     


In utilizing biofeedback, BCIA certificants adhere to the highest standards of their profession. They behave responsibly; accept responsibility for their behavior and the consequences of their behavior; ensure that biofeedback is used appropriately; and strive to educate the public concerning responsible use of biofeedback in treatment, research, and training.

  1. Each BCIA certificant is responsible for adhering to the ethical principles of their profession; the local, state and federal laws relevant to their professional activities; and the EPOB. Additional related documents include those of the Association for Applied Psychophysiology and Biofeedback.1, 2, 3
     
  2. As practitioners, BCIA certificants recognize their obligation to help clients acquire knowledge and skill within the confines of the highest professional standards and in the most cost efficient/effective manner possible.
     
  3. As teachers, BCIA certificants encourage the free pursuit of learning by their students, consistent with the best interest of their obligation to help others acquire knowledge and skill, and present information objectively, accurately and fully. They are guided by a conviction of the worth of advancement of knowledge.
     
  4. All BCIA certificants are responsible to be alert to and report to the BCIA Ethics Committee false claims and misrepresentative statements about biofeedback.
     
  5. All practitioners realize that their professional activities with clients may result in changes in the lives of those clients and others. As such, practitioners guard against misuse of their influence and actions.
     
  6. Biofeedback services are continued only as long as it is reasonably clear that clients are benefiting from the relationship. If another type of intervention is needed for which the practitioner is not qualified, the practitioner assists the person in obtaining the appropriate therapeutic services. Clients are never to be abandoned.  

Clinicians should seek consultation or supervision, or refer the client to another professional when there is no established procedure to treat the client's symptoms, the client fails to improve despite the provider’s determined efforts, the treatment protocol is nonvalidated, the provider is inexperienced with the procedure, the provider is inexperienced in treating a type of client (e.g., age, ethnicity), or the provider cannot deal objectively with the client (Striefel, 2004, pp. 28-29).



BCIA certificants recognize the boundaries of their competence and operate within their level of competence, using only those biofeedback techniques in which they are trained and experienced. They also recognize the proper limitations of biofeedback and inform all concerned parties about the clinical utility of particular procedures, possible negative effects, and whether the procedures are experimental or clinically verified. BCIA certificants remain current on knowledge concerned with scientific and professional
applications of biofeedback in those areas in which they practice.

  1. BCIA certificants should operate within applicable local, state, and federal laws as well as in accordance with the ethical principles of their profession/occupation. BCIA Certification is not a license to practice.
     
  2. The treatment of medical or psychological conditions requires the demonstration of professional competence as defined by applicable local, state, and federal licensing/credentialing laws.
     
  3. It is unethical to treat medical or psychological conditions without supervision if you are not legally licensed or credentialed to do so.
     
  4. It is the responsibility of certificants who are not licensed or credentialed to treat medical or psychological conditions to seek appropriate supervision according to applicable state laws and professional codes/regulations.

  5. Misrepresentation of one’s qualifications, training, experience, degrees, and/or specialty is a violation of BCIA ethics. 

Providers maintain and enhance their areas of competence through continuing education activities. These can include attending short courses, workshops, conferences, and classes, reading and self-study, and receiving supervised practice and discussion (Striefel, 2004, p. 29).

A licensed professional with competence in supervision and the biofeedback services provided should supervise biofeedback assistants and technicians who are not professionally licensed or certified to provide these services (Striefel, 2004, pp. 31-37).

If biofeedback training reduces the need for a prescription medication (e.g., insulin), a clinician should instruct the patient to immediately discuss this problem with the physician who prescribed the drug to avoid the potential problem of a functional overdose. The clinician should strongly discourage the client from unilaterally reducing drug dosage or discontinuing the drug entirely.



BCIA certificants are sensitive to prevailing community moral and ethical standards and to the possible negative impact that deviating from those standards may have upon the quality of their performance in applying biofeedback, in fulfilling their professional responsibilities, and in maintaining public trust in
biofeedback.

  1. No certificant may resign his or her BCIA certificate while an ethical investigation of behavior relating to biofeedback is in progress.

  2. BCIA certificants are obligated to report alleged ethical violations concerning biofeedback and its application to the ethics committee of the alleged violator's professional discipline and/or to the Ethics Committee of BCIA.

  3. Certificants will charge only for services actually provided by them or those provided by others under their direct supervision. In billing third party payers, practitioners abide by the rules and regulations of the third-party payer, including clearly specifying which services the practitioner provided directly and which were supervised, as well as providing information regarding qualifications (degree, license, certification, etc.).

  4. Certificants clarify any potential or actual conflict of interest that exists when serving clients, conducting training or research, or when engaged in any other professional activity (such as a workshop in which a certificant as trainer recommends a specific product).

  5. Informed consent shall be obtained from clients for all assessment procedures, treatment procedures, billings and fee collections, and procedures to protect confidentiality, as well as conditions that limit confidentiality. Clients shall be informed of FDA approval status of biofeedback devices.

  6. Written informed consent shall be obtained from clients for all experimental treatment procedures. (To distinguish experimental and clinically reliable procedures is difficult and requires familiarity with related documents.3, 4, 5)
     


BCIA certificants recognize that all public statements, announcements of services and products, advertising, and promotional activities concerned with biofeedback should be conducted in such a manner as to help the public make informed choices. Statements about biofeedback will be based on scientifically verifiable information, including recognition of the limits and uncertainties of such data. BCIA certificants
accurately represent their qualifications, affiliations, and functions and do not mislead the public.

  1. Biofeedback providers shall accurately represent the efficacy of biofeedback procedures for all disorders or conditions being treated.

  2. In providing services, publishing and marketing a product, and in all other professional activities, BCIA certificants use truthful and not misleading information in both direct and indirect statements about biofeedback. BCIA certificants consider the context and source requesting information when making a public statement and guard against misrepresentation.

  3. BCIA certificants recognize that they have financial or career interests in the promotion of biofeedback activities and agree that these interests must be superseded by professional objectivity, humanistic concern, and the EPOB and the other professional societies of which they are members. When a question arises as to their objectivity, certificants seek professional guidance from
    appropriate professional sources such as BCIA, the Association for Applied Psychophysiology and
    Biofeedback, the professional association of the discipline in which they are credentialed, or other qualified sources.

  4. Announcements and listing of services and training offered by BCIA certificants, such as telephone directory listings, letterheads, business cards, and descriptive brochures should be made in a professional manner and must adhere to the guidelines of the profession to which the certificant belongs. Only factual and accurate claims are to be made.
BCIA certificants maintain confidentiality of information obtained from persons in the course of their biofeedback activities. Release of information requires the written consent of the client, the client's legal representative, or the existence of a situation in which not to do so could result in danger to the client or others.

  1. BCIA certificants specify in advance the legal limits of confidentiality to clients/patients, particularly as it pertains to collection of fees and laws requiring reporting (such as abuse or neglect). Confidentiality applies to clients in treatment, students in training and to research participants. BCIA certificants are responsible for meeting HIPAA standards for the protection of individually identifiable health information.

  2. Client records are stored or disposed of in ways that maintain confidentiality. Records will be kept for a minimum of 7 years and will be retained longer if required by state law.

When clinicians receive a request to release records obtained from other agencies or providers that is accompanied by the client's written informed consent, they should refer the request to the source of the information unless the release of these documents is required by law (Striefel, 2004, p. 58).

Clinicians must take many precautions to protect computerized client files. These include encrypting files, storing them on portable media like CDs and DVDs and locking them up when they are not in use, locking the computer when it is unattended, using 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, use of encryption and assigning the client a number instead of using the client's name or Social Security number protects confidentiality and reduces the risk of identity theft. The provider should include a cover page that warns the recipient that the transmitted information is confidential and must be protected, and should be destroyed or returned and the sender notified if mistakenly received. The provider should request confirmation that the client information was received and should provide automatic acknowledgement after receipt of e-mail or fax messages (Striefel, 2004, pp. 71-72).

HIPAA requires that most health care providers give clients a “Notice of Privacy Practices” no later than the first day that services are received. Clinicians should obtain written acknowledgement that the client has received a written copy of this document (Striefel, 2004, p. 74).



BCIA certificants protect the welfare of clients, students, research participants, and other groups with whom they work. They inform all consumers of their rights, provide them with a written statement of these rights, fully inform them as to the purpose and nature of procedures to be implemented, and assure that client's rights are not abridged.

  1. Sexual intimacies, with patients/clients during therapy and for two years following therapy, and with trainees, supervisees, and research subjects are prohibited.

  2. In attaching biofeedback electrodes or other sensors, BCIA certificants assure that the privacy and rights of the client are protected. Certificants respect the feelings and sensitivities of the client.

  3. Special care will be taken to protect the rights and consent of children receiving service, training, or when involved as research subjects.

  4. Caution and common sense are required whenever a BCIA certificant has physical contact with clients, for example, in attaching electrodes. In addition, touching and massage require client permission and are restricted to those body areas considered appropriate for touch or massage within the realm of "common practice” for one's professional discipline. Touching of sensitive body parts, such as breasts or genitals is not acceptable in biofeedback practice, with the exception of a medical exam or medical treatment provided by a licensed medical practitioner. Clients can be instructed in electrode placement using visual and auditory aids (such as diagrams of the body).

  5. BCIA certificants do not discriminate against or refuse services to anyone on the basis of sex, race, religion, disability, or national origin.
BCIA certificants recognize the interdisciplinary nature of biofeedback and respect the competencies of colleagues in all professions. They strive to act in accordance with the obligations of the organizations with which they and their colleagues are associated.

  1. BCIA certificants are responsible for assuring that all patients/clients referred for treatment of a medical disorder or in whom a medical disorder is later identified are treated only in conjunction with medical consultation, as necessary, to best serve the welfare of the client.

  2. Certificants should strive to be objective in their professional judgment of colleagues and should strive to maintain good professional relationships even when opinions differ.

  3. BCIA certificants avoid dual relationships with their patients/clients that could impair their professional
    judgment or increase the risk of exploitation. Because a patient/client may reenter treatment either for the same symptom or another problem, the dictum, “Once a patient, always a patient,” should be adhered to. If, in the professional judgment of the biofeedback practitioner, ethical, moral, or other considerations render reentry into treatment unwise, these issues must be discussed fully with the patient, and a satisfactory resolution found. Certificants do not exploit clients, students, supervisees, employees, research participants or third party payers.
     


BCIA certificants conduct research to advance understanding of basic behavioral principles, to improve human health and welfare, and to advance science. As such, certificants carefully consider alternative research directions and assure that in the conduct of research the welfare of research participants
(human and animal) is protected. All research will adhere to federal and state regulations and the professional standards of the certificant’s profession with regard to the conduct of research. Research involving humans is subject to governance by local institutional review boards and to the Federal regulations as appropriate or required by the Department of Health and Human Services.5 All animal research is subject to local institutional animal care and use committees and must be in compliance with Federal policies on use of animals.6

  1. The results of research will be released in a manner which accurately reflects research results and only when the findings have satisfied widely accepted scientific criteria. Any limitations regarding factors such as long-term effects and population samples will be explicitly stated. All descriptive materials distributed regarding clinical practice will be factual and straightforward.

  2. Responsibility for the establishment and maintenance of acceptable ethical practice in research always remains with the individual investigator. The investigator is also responsible for the ethical treatment of research participants by collaborators, assistants, students, and employees, all of whom also incur similar obligations.

  3. Information obtained about research participants during the course of an investigation is confidential. When the possibility exists that others may obtain access to such information, ethical research practice requires that this possibility, together with the plans to protect confidentiality, be explained to the participants as part of the procedure for obtaining informed consent.

  4. Ethical practice requires the investigator to inform the participant of all features of the research that reasonably might be expected to influence willingness to participate and to explain all other aspects of the research about which the participant inquires. The ethical investigator protects participants from physical and mental discomfort, harm, and danger. If the risk of such consequences exists, the investigator is required to inform the participant of that fact, secure informed consent before proceeding, and take all possible measures to minimize distress. A research procedure may not be used if it is likely to cause serious and lasting harm to participants. As risk for participants increases so does the responsibility of the researcher to protect the research participants. Written informed consent or a verbal plus written summary of the research is customary for most kinds of non-survey research (including a signature by the research participant in both cases). Written consent form signatures to participate in research will be obtained from children 7 years of age and older in addition to signatures of a parent or guardian.

  5. Ethical research practice requires the investigator to respect the individual's freedom to decline to participate in research or to discontinue participation at any time. The obligation to protect this freedom requires special vigilance when the investigator is in a position of power over the participant. The decision to limit this freedom increases the investigator's responsibility to protect the participant's dignity and welfare.

  6. After the data are collected, ethical practice requires the investigator to provide the participant with full clarification of the nature of the study. When scientific or human values justify delaying or withholding information, the investigator acquires a special responsibility to assure that there are no damaging consequences for the participant.



When the above standards are unclear and whenever appropriate, the ethical standards of the American Psychological Association, American Psychiatric Association, the American Nurses Association, the American Physical Therapy Association, the American Medical Association, the American Dental Association, the American College of Sports and Rehabilitation, the American Academy of Physical Medicine & Rehabilitation, or other professional associations pertinent to the individual in question shall be used as a guide in determining whether the certificant has violated his/her professional standards.



When a complaint is made, the BCIA Ethics Committee shall use the EPOB in evaluating BCIA certificants conduct. The BCIA Ethics Committee Operational Guidelines and Procedures will be followed. The major concerns of the Ethics Committee of BCIA are to protect the public against unethical practices by BCIA certificants and to educate the certificants concerning acceptable ethical practice. The Committee attempts to have complaints resolved by the ethics committee of a member's profession whenever possible or the
local or state biofeedback society, if one exists. When that avenue fails or is inappropriate, or when the BCIA certificant is not professionally licensed or certified, the committee attempts to resolve complaints privately and informally and to recommend disciplinary action when unethical conduct is found to exist. The goal of the Ethics Committee is to be constructive and educative, rather than punitive.





Based on your own clinical experience, what are the hardest ethical decisions you've made in biofeedback practice? Which issues do you think are are the most confusing for biofeedback practitioners?




Association for Applied Psychophysiology and Biofeedback (1995). Ethical principles of applied psychophysiology and biofeedback. Wheat Ridge, Colorado: Author.

Striefel, S. (2004). Practice guidelines and standards for providers of biofeedback and applied psychophysiological services. Wheat Ridge, CO: AAPB.

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

Yucha, C., & Gilbert, C. (2004). Evidence-based practice in biofeedback and neurofeedback. Wheat Ridge, CO: AAPB.

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

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

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

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. Thousand Oaks, CA: Sage Publications, Inc.