ETHICAL CHALLENGES IN BIOFEEDBACK PRACTICE, II. Donald Moss, PhD (2010) Saybrook University

Transcription

1 ETHICAL CHALLENGES IN BIOFEEDBACK PRACTICE, II. Donald Moss, PhD (2010) Saybrook University

2 ETHICAL CHALLENGES: SCOPE OF PRACTICE Sandor K., PhD, BCB, LNC, was a licensed psychologist, BCIA certified in general biofeedback, and also licensed as a nutrition counselor. Sandor developed an integrative model for treating anxiety, stress related medical disorders, and attention deficit and hyperactivity disorders. Sandor utilized a combination of psychological testing, nutritional testing, including hair mineral analysis, and clinical interviews, to conduct a holistic evaluation of each patient.

3 ETHICAL CHALLENGES: SCOPE OF PRACTICE (CONT.) Sandor found that many patients improved more rapidly with a combination of nutritional supplements, psychotherapy, and biofeedback. Many of his ADHD clients showed specific nutritional deficits, such as Zinc deficiencies, and showed improved attention with mineral supplementation. Some improved so much that no psychological services were needed. Others thrived on the combination of nutritional supplements and neurofeedback.

4 ETHICAL CHALLENGES: SCOPE OF PRACTICE (CONT.) Sandor also found that anxiety patients often calmed when given nutritional supplements. In addition, he used well-documented cognitive behavioral therapy and biofeedback protocols for anxiety. Sandor s practice was in an affluent suburb, and his community responded positively, given a strong interest in alternative and integrative care.

5 ETHICAL CHALLENGES: SCOPE OF PRACTICE (CONT.) A psychologist colleague filed a complaint with the state psychology licensing board, alleging that Sandor was practicing outside the scope of practice for the psychology licensing act. Sandor and his attorney were not concerned, and filed a brief with the licensure board, documenting that each of his interventions fell within the scope of practice of one of his two professional licenses. He argued the value of integrative care, and obtained depositions from several leaders in biofeedback, nutrition, and integrative health care.

6 ETHICAL CHALLENGES: SCOPE OF PRACTICE (CONT.) Discuss the ethical principles and practice standards relevant for Sandor s case. Is there anything Sandor should do differently, or are his current practice patterns acceptable as is?

7 ETHICAL CHALLENGES: SCOPE OF PRACTICE (CONT.) To Sandor s surprise, he was censured by his state licensing board. He was fined, and allowed to practice under an action plan. The Board held that his marketing strategy amounted to a bait and switch practice. He was instructed that any new referral must be scheduled either as a client for his nutritional services or his psychological practice, and that no session should include both types of service.

8 ETHICAL CHALLENGES: SCOPE OF PRACTICE NO INTEGRATION! If Sandor perceived potential relevance of nutritional counseling for one of his psychology patients, Sandor must refer that individual to 3 licensed nutritional counselors, one of whom could be him. Any follow up with such a patient must be on a different date. Conversely, if he perceives a potential benefit for a nutritional patient of psychological services or biofeedback, he must refer that patient, in the same fashion.

9 ETHICAL CHALLENGES: ADVERSE TREATMENT EFFECTS Alexa T., PhD, BCN, licensed psychologist and certified neurofeedback practitioner, provided EEG biofeedback for a 44 year old patient, Lucy L., with generalized anxiety disorder. Alexa initially used a training screen designed to guide the patient to reward Alpha range amplitude, and inhibit Beta range amplitude. The patient learned very quickly to increase Alpha, and reduce the Beta range activity. In the first three training sessions, Alexa was able to modify the threshold several times, requiring increasing the Alpha amplitudes needed to produce audio tones.

10 ETHICAL CHALLENGES: ADVERSE TREATMENT EFFECTS (CONT.) Lucy L. was excited at the idea that she could control her brain activity through biofeedback. However, in the fourth training session she expressed concern. She reported her usual moderate anxiety becoming severe over the past two weeks, and the onset of severe migraine headaches. She had seen her physician for the headaches, and the physician discovered a blood pressure of 159/106, the highest BP that Lucy had ever shown. She asked whether the neurofeedback could possibly be causing her new problems.

11 ETHICAL CHALLENGES: ADVERSE TREATMENT EFFECTS (CONT.) Alexa T. called her supervisor, and together reviewed the biofeedback data. Alexa had followed the textbook protocol for anxiety. But Lucy L. did not present the textbook baseline for anxiety. Lucy s EEG baseline showed excessive slow wave activity, and deficient fast wave activity. Her baseline resembled more an individual with an attention deficit, and her Theta to Beta ratio of 3.4 actually suggested the diagnosis of ADHD.

12 ETHICAL CHALLENGES: ADVERSE TREATMENT EFFECTS (CONT.) Alexa s supervisor reformulated a diagnostic formulation, suggesting that Lucy was so disorganized and inattentive that her anxiety was a reaction to feeling her life sliding into chaos. The anxiety was likely the trigger for the increased BP and migraines. Alexa T. discussed the new diagnosis with Lucy L., and began implementing a Lubar/Monastra protocol for ADHD, rewarding increased amplitude in low Beta range activity, and inhibiting Theta. Lucy reported a remission of migraine headaches and moderation of BP within two weeks.

13 ETHICAL CHALLENGES: ADVERSE TREATMENT EFFECTS (CONT.) Discuss ethical aspects of the problems that Alexa T. encountered with Lucy. What precautions could have prevented the adverse effects in this situation? Sebastian Striefel has suggested that QEEG as preparation for neurofeedback treatment is fast becoming the expected standard of care. Discuss this controversial issue.

14 ETHICAL CHALLENGE: PROFESSIONAL BOUNDARIES AND DISCLOSURE OF INFORMATION Gary F., PhD, BCB, was a licensed psychologist and biofeedback practitioner. Gary practiced in a small mid-western community, and focuses on children and adolescents. Gary worked to balance small town friendliness with professional boundaries. He could not live and work in the same town without frequent accidental encounters with his patients and their families.

15 ETHICAL CHALLENGE: PROFESSIONAL BOUNDARIES AND DISCLOSURE OF INFORMATION (CONT.) Gary F. carefully avoided developing friendships with his patients families, but his community service through the local Rotary Club frequently brought him into situations where he and a patient family member would work on the same community project. While cooking pancakes for a community fund-raiser, Gary saw one of his pre-teen clients mother, waiting on tables. When she approached the griddle, she greeted him, Hello Dr. F. He responded, Good morning to you, Mrs. J., great to see you helping here.

16 ETHICAL CHALLENGE: PROFESSIONAL BOUNDARIES AND DISCLOSURE OF INFORMATION (CONT.) Mrs. J. returned several times to the griddle and asked him a stream of questions about how he thought her son was doing. Dr. F. responded cautiously, with generalities such as You have a great young man there, Mrs. J. Finally she seemed to accept his reticence and the questions stopped. The following Monday, Mrs. J. called Dr. F s clinic and asked to speak with the administrator. She complained that Dr. F. had discussed confidential aspects of her son s treatment in a public place, violating her privacy.

17 ETHICAL CHALLENGE: PROFESSIONAL BOUNDARIES AND DISCLOSURE OF INFORMATION (CONT.) Discuss the ethical principles governing such community encounters with patients and their families, and governing the discussion of treatment information. Do you have any advice for Dr. F. on managing this situation or any similar future situation?

18 ETHICAL CHALLENGE: COMBINING MULTIPLE PROFESSIONAL ROLES IN TREATMENT Jurgen H., PhD, BCB, was trained and licensed as a psychologist and a massage therapist, and certified in biofeedback. Dr. H. studied Reichian bodywork and Feldenkrais technique, and became convinced that PTSD could most effectively be treated by a combination of massage and psychotherapy. Effective massage could release the muscular armor inhibiting traumatic emotional discharges, and facilitate a dynamic psychotherapeutic recovery from traumatic experiences.

19 ETHICAL CHALLENGE: COMBINING MULTIPLE PROFESSIONAL ROLES IN TREATMENT Dr. H. began combining biofeedback relaxation, with deep muscle massage and Reichian bodywork interventions to produce affective discharges, related to past trauma. This integrative treatment appeared to accelerate the healing of traumatic memories and emotions. Discuss the potential ethical and legal challenges, and potential solutions.

20 ETHICAL CHALLENGES: DUAL RELATIONSHIPS John A., PhD, BCB, a licensed psychologist and BCIA certified biofeedback practitioner, accepted a patient, Alyse, for psychotherapy, tension headache, and stress management. In the course of the evaluation, Dr. A. decided that Alyse was his soul mate, and that he might want to build a relationship. Dr. A. began to kiss and cuddle with Alyse, during sessions, and excused these actions as helping her to overcome a repressive religious background. When Alyse expressed a deep love and desire for him, he responded with sexual relations.

21 ETHICAL CHALLENGES: DUAL RELATIONSHIP (CONT). Dr. A. transferred Alyse to a colleague for psychotherapy, explaining that he wanted to pursue a personal relationship with her. Dr. A. was married, but saw Alyse for six months, until his wife caught the two of them at a motel, and threatened divorce. Alyse encouraged him to repair his marriage, and agreed to break off the relationship. She wanted only what was best for him.

22 ETHICAL CHALLENGES: DUAL RELATIONSHIP (CONT.) One year later, Alyse re-contacted Dr. A. Her new therapist felt that biofeedback would be helpful for her headaches and stress management. In addition, she expressed that the new therapist had never understood her like Dr. A. Dr. A. agreed to accept Alyse as a patient, and began to provide biofeedback, with brief psychotherapy in each session. Alyse thrived, her headaches remitted, and in gratitude she offered to resume their sexual relationship.

23 ETHICAL CHALLENGES: DUAL RELATIONSHIP Dr. A. declined to resume sexual relations, and attempted to refer Alyse back to her other therapist. Alyse threatened to report Dr. A. to his licensing board if he would not continue to see her as a patient. He continued and they gradually began to include cuddling at the end of each session. Discuss the ethical principles governing this situation. What options does Dr. A. have now in this situation?