POSITION PAPER

STANDARDS OF PRACTICE FOR NEUROFEEDBACK AND NEUROTHERAPY:A POSITION PAPER OF THE INTERNATIONAL SOCIETYFOR NEUROFEEDBACK & RESEARCH

D. Corydon Hammond1, Genie Bodenhamer-Davis2, Gerald Gluck3, Deborah Stokes4,Sara Hunt Harper5, David Trudeau6, Margaret MacDonald7, Joy Lunt8, Lynda Kirk9

1Physical Medicine & Rehabilitation, University of Utah School of Medicine,Salt Lake City, Utah, USA2Department of Rehabilitation, Social Work and Addictions, University of North Texas,Denton, Texas, USA3Center for Family Counseling and Biofeedback, Brain Healing Center of America,Coral Springs, Florida, USA4Private Practice, The Better Brain Center, Alexandria, Virginia, USA5Stress Management Center, Plano, Texas, USA6Department of Family Medicine and Community Health, School of Health Sciences Universityof Minnesota, Minneapolis, Minnesota, USA7Henry Jackson Foundation for the Advancement of Military Medicine, Colorado Springs,Colorado, USA8Private Practice, Brain Potential, Burbank, California, USA9Austin Biofeedback and EEG Neurofeedback Center, Austin, Texas, USA

This position paper of the International Society for Neurofeedback and Research (ISNR)sets forth standards and guidelines for the practice of neurofeedback and neurotherapy.Issues discussed include competency, qualifications of practitioners, scope of practice,informed consent, pretreatment assessment, standards for remote training, record keepingand billing, accountability, standards for practitioner training and qualifications to betrained, adequate supervision and coaching of training sessions, ethical advertising, stan-dards for professional societies, and standards for those who sell and manufacture neuro-feedback equipment.

INTRODUCTION

The guidelines and standards set forth in thispaper are the product of deliberations by theinterdisciplinary Standards of Practice Commit-tee of the International Society for Neurofeed-back and Research (ISNR). This paper has beenaccepted by the Board of Directors of ISNR as aposition paper of the Society.

PURPOSE AND RATIONALE FORPRACTICE GUIDELINES

Practice standards begin to be created withinprofessional specialties as they become wellestablished. Two factors have particularlyencouraged ISNR to develop standards of prac-tice to be made available to both practitionersand members of the public: (a) It has become

Received 1 November 2010; accepted 3 December 2010.Address correspondence to D. Corydon Hammond, PhD, Physical Medicine & Rehabilitation, University of Utah School of

Medicine, 30 North 1900 East, Salt Lake City, UT 84132, USA. E-mail: d.c.hammond@utah.edu

Journal of Neurotherapy, 15:54–64, 2011Copyright # Taylor & Francis Group, LLC

ISSN: 1087-4208 print=1530-017X online

DOI: 10.1080/10874208.2010.545760

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increasingly evident that there are unlicensedindividuals offering neurofeedback services tothe public for psychological, psychiatric, andmedical conditions that they are both clinicallyand legally unqualified to treat, and (b) the pro-fession has come to realize that advancedneurofeedback technologies not only havethe capacity to produce significant improve-ments in brain functioning with various diag-nostic conditions but also are sufficientlypowerful that when misapplied can occasion-ally result in side effects and sometimes moreserious iatrogenic adverse effects. Technologythat has the potential to help remediate signifi-cant problems can also have the potential toharm when practitioners lack appropriate qua-lifications and competence. Therefore, havingstandards of practice is part of a profession’sobligation to the public for consumer protec-tion. Clinical decision making should be gov-erned by what is both clinically sound and inthe client’s best interest. The provider isencouraged to always operate with this thoughtin mind: Would my practice procedures standup under the scrutiny of the public, the courts,and other practicing professionals?

The guidelines presented in this positionpaper are meant to apply to neurofeedbackproviders who are delivering and offeringservices to the public for remuneration (monet-ary or nonmonetary), whether they are inprivate practice, a group practice, or an insti-tutional or organizational setting. These stan-dards are meant to be voluntary and areoffered as guidelines for quality assurance inneurofeedback practice. These standardsdescribe the quality of services that the associ-ation believes providers should strive to attainin acting in the client’s best interest but thatsimultaneously are meant to minimize liabilityrisks when they are followed. The guidelinesdescribe the acceptable levels of educationand training that are believed to be consistentwith the services that practitioners provide.

The standards are not meant to rigidlyconstrain practitioners from employing newmethods and innovative procedures anddisseminating those results to others. However,the guidelines seek to identify potential deficits

in the delivery of neurofeedback services and toencourage their correction and to establishminimum standards of professional conduct inthe delivery of neurofeedback services. Theseguidelines are not meant to diminish the scopeof practice of any professional specialty that islicensed in states or provinces. However, theyshould both serve as guiding principles for ser-vice delivery and to provide a basis for evaluat-ing the standard of care and performance ofindividual clinical practitioners and serve to pro-vide guidelines for training new practitioners orgraduate students in EEG biofeedback. Thesestandards may be used by other regulatoryagencies in setting or defining minimum stan-dards of conduct for health care practitionerswho provide neurofeedback services in bothclinical and nonclinical settings.

DEFINITION OF TERMS

The following terms are used in this paper:

Neurofeedback: Also known as EEG bio-feedback, neurofeedback is a process inwhich sensors are placed on the scalpand devices are used to monitor and pro-vide moment-to-moment information thatis fed back to the individual about his orher physiological brain activity for purposesof improving brain functioning. A moredetailed definition may be found on thewebsite of the International Society forNeurofeedback and Research (http://www.isnr.org).

Neurotherapy: The terms neurofeedback andneurotherapy are used interchangeably inthis paper. Neurotherapy is a term thatencompasses neurofeedback and refers tothe use of other modalities used to modifybrain patterns such as audio-visual stimu-lation, magnetic stimulation, and fMRIneurofeedback.

Diagnostic conditions: This term refers todiagnostically labeled conditions such asthose that appear in the Diagnostic andStatistical Manuals (e.g., DSM–IV) from theAmerican Psychiatric Association or in theinternational diagnostic classification system

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(e.g., ICD-10). For instance, ‘‘diagnosticconditions’’ would include (but not belimited to) the following conditions: atten-tion deficit disorder (ADD)=attention deficithyperactivity disorder (ADHD), learning dis-abilities, autism, Asperger’s syndrome,depression, anxiety disorder, panic disorder,obsessive-compulsive disorder, bipolar dis-order, schizophrenia, developmental dis-abilities, epilepsy, traumatic brain injury,stroke, fibromyalgia, chronic fatigue syn-drome, Tourette’s syndrome, Parkinson’s,alcoholism, substance abuse, posttraumaticstress disorder, reactive attachment dis-order, insomnia or sleep disorders.

Client or patient: These are terms that are usedinterchangeably to refer to the recipient ofneurofeedback services.

Practitioner, provider, clinician: These areterms used interchangeably to refer tolicensed professionals who are offering orrendering neurofeedback services to assistin working with diagnostic conditions aspreviously defined.

Technician: This term refers to a person provid-ing neurofeedback services who is notlicensed for independent practice in ahealth care or mental health professionwithin their state or province.

Remote Trainer: This term refers to a client whoobtains neurofeedback equipment for pur-poses of conducting training at home, in ahospital, or other remote location underthe supervision of a qualified practitioner.Due to risks of harm, home training shouldnever be done when a licensed pro-fessional is not supervising it.

Scope of practice: This term refers to the vari-ous mental health or medical conditionsthat are specified as being acceptableproblems for clinical practice in differentprofessions (e.g., physicians, psychologists,social workers, licensed professional coun-selors, marriage and family therapists, chir-opractors, nurse practitioners, registerednurses, physical therapists, speech and lan-guage pathologists, etc.) as commonly deli-neated in the licensure laws of the variousprofessions as set forth in the statutes of the

states, provinces, or countries in which thepractitioner resides.

PROVIDERS, SCOPE OF PRACTICE,AND COMPETENCY

Neurofeedback practitioners who hold them-selves out as qualified to offer services andwork with diagnostic conditions shall be indivi-duals who are licensed by their state, province,or country for independent practice within arecognized mental health or health care pro-fession and who are working within the scopeof practice of their particular state license. Ifoperating outside their scope of practice, theyshould obtain professional support and consul-tation, which should be readily available. Inaddition to their licensure they should be ableto demonstrate training and education withregard to the conditions for which they offertreatment. In the specialty of neurofeedbackit is recommended that providers meet criteriafor being board certified in neurofeedback bythe Biofeedback Certification InternationalAlliance (BCIA) as specified in their Blueprintof Knowledge in EEG Biofeedback (http://www.bcia.org).

Completion of an introductory trainingcourse does not qualify a provider toindependently offer neurofeedback servicesor conduct neurofeedback research withoutongoing consultation, mentoring, or super-vision. After completion of an introductorycourse, practitioners should limit their clientsto cases approved by their supervisor or men-tor to ensure adequate supervision and appro-priate matching of the client’s level ofcomplexity to the practitioner’s skills. In agroup providing neurofeedback services, oneor more of the providers in the group shouldmeet the qualifications described in these stan-dards when they are providing neurofeedbackfor diagnostic conditions. It is consideredunethical for someone to conduct outcomeresearch on neurofeedback when they do nothave documented clinical training and com-petence with neurofeedback or are not beingsupervised by such a competent clinician.

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Individuals conducting assessment utilizingquantitative EEG (QEEG) or any type of brainmapping should be able to document trainingin gathering reliable data. A much higherstandard is required for someone to hold him-self or herself out as competent to analyze andinterpret QEEG data (Hammond et al., 2004).If the provider is analyzing and interpretingtheir own QEEG data it is strongly recom-mended that they should hold diplomate statusin QEEG from the Quantitative Electroence-phalography Certification Board or be certifiedby the EEG and Clinical Neuroscience Society(or a comparable neurology board in the caseof physicians), or be analyzing data under thesupervision of such a certified person, or at aminimum be able to demonstrate thorougheducation, training, and work product docu-menting their competence to interpret QEEGs.Otherwise, we believe that QEEG data shouldbe submitted for analysis by an individual withsuch certification. Further details about qualifi-cations for competency in doing QEEG evalua-tions will be provided in another ISNR positionpaper on this topic.

Where neurofeedback services are beingrendered for diagnosable psychological, psy-chiatric, or medical conditions, the facilitywhere the services are provided should havesuch a licensed professional always present atthe facility who accepts ethical responsibilityand accountability for supervising the neuro-feedback services that are being provided forsuch conditions. Such a licensed supervisingprofessional should have the authority andshould participate sufficiently to enable himor her to accept professional responsibility forthe services, to evaluate them, and to monitorthe outcomes, including side effects or adversereactions. When cases present the practitionerwith issues that challenge their level of com-petence or with which they are inexperienced,they are advised to refer such individuals orseek consultation. Providers avoid engaging indual relationships and avoid conflicts of inter-est (e.g., financial, with students, supervisees,relatives) with individuals seeking treatmentfor diagnostic conditions of a medical, psychi-atric or psychological nature.

Those providing neurofeedback services toindividuals with diagnostic conditions asdefined in ICD or DSM manuals and who arenot licensed to work with such conditionsshould be evaluated and supervised by a pro-fessional who is licensed to treat such con-dition(s) and is on-site providing full timeface-to-face supervision with the person pro-viding the direct service. They should providesupervised services only after the licensed pro-fessional has evaluated the patient and set atreatment plan. The tasks assigned to suchunlicensed individuals should be in keepingwith their demonstrated level of competenceand training and with applicable state law gov-erning the health professions and the statuteunder which the supervisor is licensed. It isrecognized that the level of supervision mayvary depending on the complexity of thecondition and individual being treated. Theultimate ethical responsibility and account-ability for services performed by unlicensedpersons to persons with diagnostic conditionsrests with the licensed supervisor who reviewsthe assessment, treatment plans, course oftreatment, and outcomes. Thus the nature ofthe supervisory relationship should be explicitlycommunicated in writing and written agree-ments with the unlicensed technician. Such adocument should detail their duties, range ofresponsibilities, types of services, limits ofindependent actions, and responsibilities forreporting side effects or adverse reactions totheir supervisor.

Neurofeedback practitioners abide by theethical standards of their professions (e.g.,APA, AMA, NASW, etc.) and practice in con-formity with their relevant legal statutes. Theyseek consultation from other licensed profes-sionals when confronted with unique clinicalsituations or significant side effects or adversereactions, or provide referrals when indica-ted. When practitioners become aware ofunlicensed individuals advertising and provid-ing neurofeedback services for individuals withdiagnostic conditions, it represents an issue ofprotection of the public requiring that theyreport such practices to appropriate state orprovincial regulatory authorities. Practitioners

ISNR STANDARDS OF PRACTICE 57

recognize that neurofeedback representssimply one treatment procedure. As such, clin-icians have the responsibility, depending onthe nature of presenting problems and progresswith neurofeedback, to weigh the range of psy-chotherapeutic, medication=medical, periph-eral biofeedback and other treatment optionsfor the condition, including the option of refer-ral. There may be many cases in which neuro-feedback is embedded as one modality in amultimodal treatment package.

ASSESSMENT PROCEDURES PRIOR TONEUROFEEDBACK TRAINING

Prior to providing neurofeedback treatment anadequate history should be obtained of medi-cal and psychological=psychiatric problemsand symptoms, the individual’s prior treatmenthistory, and current medications the patientmay be taking. The nature of the presentingproblem and goals of the neurofeedback train-ing will undoubtedly to some extent determinethe type and extent of pretreatment assessmentprocedures. An objective assessment of theclient’s EEG function should precede neuro-feedback training. There are several proce-dures by which this may be accomplished,the most thorough being a quantitative EEG(QEEG) wherein the functioning of the brainis objectively assessed in comparison with nor-mative data for the patient’s age, clinical andfamily history, and presenting symptoms.

Clinicians are advised to take into accountrisk management factors such as case com-plexity, symptom severity, chronicity of symp-toms, suicide history and potential, Axis 2diagnoses, emotional lability, dissociativesymptoms, history of abuse, oversensitivity toprior treatments, litigiousness, and presenceof various comorbid conditions. These all rep-resent conditions that may pose a potentiallygreater risk for practitioners and that mayrequire a higher level of expertise. Cliniciansparticularly minimize their practice risks intreatment of such patients by using morethorough assessment procedures (e.g., QEEG,psychological or neuropsychological testing),with an active informed consent process;

careful chart documentation that demonstratesa reasonable standard of care with regard tothe assessment, treatment planning, and theimplementation of treatment and regularmonitoring of progress and side effects; as wellas obtaining consultation when confrontedwith challenging clinical situations.

When accepting individuals who areseeking assistance with medically related condi-tions, practitioners should be cautious in deter-mining that appropriate medical evaluationshave been conducted. Neurofeedback practi-tioners work cooperatively and respectfully withother health care or mental health professionals.

Maintaining Competence

All neurofeedback providers should seek tomaintain current knowledge of scientific andprofessional developments related to theservices that they provide through attendingcontinuing education workshops and scientificmeetings and reading professional publications,with the ability to document this professionaldevelopment. If providers offer several neuro-feedback modalities in their practices, theyshould undergo continuing education activitiesin each of these areas to remain current in newdevelopments in equipment, software, andbest practices associated with these services.

Record Keeping and Billing

Neurofeedback practitioners keep accuraterecords of the services provided. Such recordsshould include information documenting aninformed consent process, disclosure of the prac-titioner’s policies and procedures (including pro-cedures in case of emergencies), dates of service,fees charged and payments received, assessmentinformation, types of services, and neurofeed-back and ancillary treatment procedures thatwere used. Any side effects or adverse reactions,as well as regular notations of progress, should bechart noted. Appropriate protections are pro-vided to ensure confidentiality of records andcompliancewith theHealth Insurance Portabilityand Accountability Act (HIPPA), and confidentialinformation is not released without appropriatewritten consent of the client or his or her legalrepresentative. Practitioners are obligated to

58 D. C. HAMMOND ET AL.

insure that information recorded and=or com-municated electronically is appropriately pro-tected and breaches in this information arereported to patients.

When providers bill insurance or flexiblespending accounts, or assist clients=patients inobtaining reimbursement they should accuratelydescribe their services, use appropriate proce-dure codes and inform service recipients of thelimits on confidentiality of claims submitted, inaccord with state or provincial statutes. Practi-tioners do not knowingly falsify claims, diagnoses,or procedure codes, and services provided byunlicensed assistants are not billed as if theywere provided by the licensed professional in amanner that would constitute insurance fraud.Practitioners are also encouraged, in the publicinterest, to consider providing some services ata reduced fee or for no financial return.

Manufacturers, distributors, and resellers ofEEG biofeedback and EEG equipment shouldmaintain records documenting the evidenceof their due diligence in determining thatpurchasers of this equipment are licensed forindependent practice in their mental healthor health care profession, in accordance withFDA regulations which specify that EEGbiofeedback equipment and EEG signal moni-toring equipment represent Type II medicaldevices that should be sold only to licensedhealth care providers.

There have been instances of therapistsbilling neurofeedback services using psycho-therapy codes rather than biofeedback=psycho-physiological psychotherapy codes and usingpsychotherapy procedure codes for biofeed-back procedures constitutes fraudulent billing.

ACCOUNTABILITY

Providers practice in a manner that promotesthe welfare of their clients=patients. Therefore,providers work with problems that fall undertheir professional scope of practice and withwhich they are competent to work by natureof their training, study, and available consul-tation. They perform appropriate history takingand assessments prior to providing neurofeed-back treatment, and they regularly assess the

effectiveness of the services provided. Practi-tioners are aware that occasionally side effectsor negative effects may occur (Hammond &Kirk, 2008; Hammond, Stockdale, Hoffman,Ayers, & Nash, 2001; Lubar & Shouse, 1976,1977; Todder, Levine, Dwolatzky, & Kaplan,2010), and they inquire frequently about anyside effects or adverse reactions.

It is recommended that clinicians obtain rat-ings of symptom severity at time intervalsdeemed clinically appropriate to gauge progressor deterioration. Practitioners are also encour-aged as often as feasible to use objective pre-and posttreatment EEG and outcome measuresto assist in evaluating results of training. Whenit is determined that side effects or negativeeffects are occurring, providers document thedetails, discuss them with the client, and takeappropriate action to remediate negative effectsas quickly as possible. Such action may includemodifying neurofeedback protocols, titratingthe amount or frequency of treatment, utilizingadjunctive treatments, and seeking consultation.

INFORMED CONSENT

Informed consent is considered to be a mean-ingful educational process that occurs through-out treatment, rather than a one-time eventthat is done only at the beginning of treatmentwith the client or his or her guardian or legalrepresentative. It allows the patient or rep-resentative to make an informed decisionabout the nature of treatments that are beingrecommended and the rationale for the treat-ment for the presenting complaints or goals.This process seeks to respect the client or thecompetent representative’s right to make aninformed judgment about the recommendedtreatment being offered, about alternativetreatments that would be available for his orher condition, and the anticipated benefitsand risks of each of these. Because the patientmust be competent to provide informed con-sent, provisions must be made for handlingpatient limitations (e.g., language fluency,deafness, impaired cognitive abilities). Neuro-feedback practitioners also explain alternativetreatment options. For example, someone

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seeking neurofeedback treatment may beinformed that medication treatment is an alter-native. In another illustration, for a patient withobsessive-compulsive disorder or depression,the provider may indicate that cognitivebehavior therapy and medication treatmentalternatives have been better investigatedthan neurofeedback and state the possiblebenefits and downsides associated with suchtreatments.

Thus it is important to provide patientswith sufficient information to make aninformed decision, to allow them time to askquestions, and to then give consent in writingor at a minimum verbally, with this processbeing chart-documented. The informedconsent process should clearly indicate thatthe client is free to discontinue neurofeedbackand treatment at any time, without penalty.Informed consent should occur with regard toassessment procedures, fees, procedures forbillings and collections, limits of confidentiality,recommended treatments, the practitioner’squalifications, anticipated frequency and dur-ation of treatment, and right to discontinuetreatment. Written permission should beobtained from clients providing their permis-sion to anonymously use data that are collec-ted as part of research that may be compiled,or as part of courses or presentations. If astudent or technician is providing servicesunder supervision, this information along withthe supervisor’s name and contact informationshould be provided to patients.

The written informed consent also shouldindicate the clinical problems to which neuro-feedback may be applied but for which reason-able peer reviewed research support has not yetbeen obtained. Neurofeedback practitionersmust inform and adequately represent to theclient the current level of efficacy of neuro-feedback for their condition based upon theavailable peer-reviewed literature. For example,at the time this paper is being authored, areaswe regard as lacking adequate research supportto be considered ‘‘probably efficacious’’(LaVaque et al., 2002) would include (but notnecessarily be limited to) depression, bipolar dis-order, obsessive-compulsive disorder, Tourette’s

syndrome, Parkinson’s tremors, cerebral palsy,essential tremor, fibromyalgia, chronic fatigue,schizophrenia, and physical balance. In contrast,considerable research evidence supportsneurofeedback training with ADD=ADHD,uncontrolled epilepsy, insomnia, and addictivedisorders (Sokhadze, Cannon, & Trudeau,2008). Informing patients of conditions forwhich the application of neurofeedback maybe considered an innovative or experimentaltreatment provides both adequate informedconsent and liability protection for the provider.We consider it wise to also openly acknowledgethat even with clinical problems for which theneurofeedback practitioner considers there tobe adequate validation of its effectiveness, someother professionals and insurance companieswho are not well acquainted with the neuro-feedback literature, or who espouse alternativetreatment approaches, may still regard neuro-feedback treatments as experimental.

Potential risks and limitations of theproposed neurofeedback treatment shouldalso be acknowledged, including the fact thatneurofeedback is not always effective. Forexample, prospective clients should be infor-med that at least occasionally it is possible fora side effect to occur (e.g., fatigue, headache,anxiety, difficulty falling asleep) and that,should such an effect occur, the patient isrequested to quickly inform the provider sothat adjustments in procedure can be made.It is considered unethical to tell clients that sideeffects never occur. Likewise, many publica-tions suggest that at least 20% of patients willnot obtain significant improvements fromneurofeedback. We cannot and do not helpeveryone. This is information that should beprovided to new clients. Although it is ben-eficial to convey confidence to the client, itmust be tempered with objectivity and factualaccuracy.

Terminating Services

Practitioners do not seek to induce clients tocontinue neurofeedback unreasonably whenit does not seem to be producing benefits orproviding further improvements. In recom-mending the termination of services, referral,

60 D. C. HAMMOND ET AL.

or a switch to an alternative (or additional)treatment, it is prudent to carefully clarify thereasons for the recommendations and involvethe client in the decision as much as is clinicallyappropriate.

Illustrations of Problems

The authors are aware of diagnostic conditionssuch as ADD=ADHD where published researchstudies have suggested that 40 to 50 sessionshave generally been required for positive out-comes but where a provider has initiallyinformed new patients that they will likelyneed to come for 100 sessions to obtain thedesired benefits (or the opposite, that a smallnumber of sessions will produce lasting results).We have also observed instances in whichneurofeedback is being ‘‘oversold’’ and mis-represented as a highly effective treatment forconditions about which published controlledresearch is not available. We recognize thenumber of sessions required or the decisionto cease treatment is a joint decision betweenthe clinician and patient and is based uponcomplex factors such as diagnosis, responseto treatment, comorbid conditions, and psy-chosocial stressors.

STANDARDS FOR HOME OR REMOTETRAINING

There are times when geographical location orchronicity of patient problems makes it parti-cularly desirable for patients to be able to doneurofeedback training at home or anotherremote setting. In cases like this, some providersrent or allow purchase of neurofeedbackequipment for remote training use. The neuro-feedback practitioner must accept full account-ability and liability for such training, with itsincreased risks. Individuals being consideredfor remote training should be informed thatthere is very limited research (Cortoos, DeValck, Arns, Breteler, & Chuydts, 2010) on theoutcome rates that may be anticipated fromsuch training.

Remote training should occur only after theclinician has gathered history and conducted anevaluation in the office. The person offering

remote training for use with individuals withdiagnostic conditions should also check appli-cable licensure laws with regard to providingservices to someone residing in another stateand whether he or she needs to be licensed topractice in that state. It is incumbent upon thesupervising clinician to train the person who willbe doing on-site supervision of the remotetraining (e.g., a parent, caregiver) in equipmentoperation, preparation and placement of sen-sors, and coaching. The clinician also consultsregularly through periodic office visits, or viatelephone or Internet, to monitor statistics andtreatment progress. It is strongly recommendedthat remote training should not occur until thepractitioner has provided adequate in-officeneurofeedback sessions to the client, adjustingtreatment protocols and thresholds, determin-ing patterns of client response to training, andtutoring the person doing the remote training.Provision must be made for the neurofeedbackprovider to obtain statistics and progress reportson a weekly basis from the remote training,through the Internet, mail, or telephone. How-ever, an ideal method for remote supervisionwould be supervision of individual sessions livevia the Internet. The person training remotelyshould report any side effects or adverse reac-tions immediately. It is also recommended thatequipment be used that does not allow theremote trainer to change treatment protocols,which should be strictly done by the neurofeed-back professional. It is also important for theclinician to have a periodic face-to-face sessionwith the person doing remote training to per-sonally evaluate progress and plan for any mod-ifications in training procedure.

The clinician supervising remote trainingshould have a written agreement with theremote training client that clearly specifies thefrequency with which data must be providedto the clinician, frequency of in-office visitsrequired; that the equipment is not to be usedwith anyone other than the client; and expecta-tions about rental fees and how costs will behandled for damage or repairs to equipment,or for equipment that is stolen. If remote traininginvolves a rental or lease agreement, it shouldprovide for the immediate return of equipment

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to the practitioner should the clinician deter-mine that it is being used inappropriately orused with one or more individuals who werenot part of the original assessment and pro-cedure. Further, the agreement should specifythat the holder of equipment may not hold him-self or herself out to be a practitioner or providerof neurofeedback services, nor may he or sheprovide such services without the express con-sent of the clinician. Where individuals pur-chase equipment from a manufacturer or froma clinician, and the seller or clinician becomesaware that the person is rendering serviceseither for value or for free, outside of the scopeof the agreement with the clinician, the pur-chase agreement should contain a clauseinforming the purchaser that under these con-ditions the clinician is obligated to report thisunauthorized use to appropriate licensingboards in that state for the possible violation ofregulations governing the practice of psy-chology, psychotherapy, or medicine.

SUPERVISION AND COACHINGNEUROFEEDBACK SESSIONS

Published research in the field has commonlybeen based on having an experiencedpractitioner providing the services, remain withthe patient, and coach the paitent during neu-rofeedback. This should be considered theacceptable standard of care in the field. In con-trast, we have become aware of too manyoffices in which technicians hook up clientsto equipment and then leave them alone fora significant portion of sessions rather thanremaining with them and serving as an addi-tional source of feedback, reinforcement, andencouragement. An adequate standard of carerequires coaching of the client rather than atreatment mill environment with multiplebooths where clients are hooked up to equip-ment by technicians and then left largely unsu-pervised. As an example, individuals withADD=ADHD can just as easily lose focus andallow their minds to wander while in front ofa computer screen doing neurofeedback asthey can in a classroom. Furthermore, manyclients are sleep deprived and they can easily

become drowsy and lose focus when a pro-vider does not remain with them to note suchactivity and encourage vigilance, thus reducingthe likelihood of treatment being ineffective orrequiring an inordinate amount of time. Ifproviders leave technicians or parents withthe client to provide the coaching, the processof how this is done should have been demon-strated and the coach should receive ongoingsupervision from the provider.

When practitioners are asked to provideconsultative training for new practitioners, theyshould clarify in writing the nature of theirrelationship. For instance, if mentors do notintend to provide supervision with the accoun-tability that it entails, for their own liability pro-tection they may want to obtain a documentfrom the person they are mentoring indicatingthat their instruction time represents individualcontinuing education and not supervision.

TRAINING, ADVERTISING, ANDEQUIPMENT SALES

Manufacturers, professional societies, andmembers of this field’s societies should notbe admitting individuals to clinical trainingworkshops that focus on improving brainfunction associated with diagnostic conditionsunless they are licensed for independentpractice in a health care or mental healthprofession, have a letter from their graduateschool advisers in accredited institutions, orcan verify through a letter from their employerthat they are a technician who is beingsupervised full time, on-site by a licensedprofessional who meets criteria for BCIAcertification in EEG biofeedback.

Professional societies, such as ISNR and theAssociation for Applied Psychophysiology andBiofeedback (AAPB), should not allow stu-dents, manufacturers, or unlicensed personsto be listed under ‘‘clinical provider’’ sectionsof websites, or even be listed as members inthe same list as licensed individuals. Societiesand manufacturers should not allow unlicensedpersons to be listed in a manner that implies tomembers of the public that these individualsare qualified to offer clinical services. Listing

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unlicensed individuals in such a manner placesorganizations in the untenable position ofimplicitly allowing unlicensed persons toadvertise to the public and misrepresent cre-dentials. For persons to be identified under aprovider section on a website they should berequired to provide a copy of their state orprovincial license each year to continue to belisted. Websites should have separate sectionsfor Licensed Clinical Providers, Researcher=Educators, Students, Manufacturers, andUnlicensed Members. In print or websiteadvertising, clinicians should not promote neu-rofeedback as effective for conditions wherecontrolled research evidence is not present.

The individual practitioner assumesresponsibility for the accuracy and ethicalnessof all information in any advertising or listing,whether in print or in Internet listings or adver-tising. Advertising (whether printed, broadcast,or Internet) should consist of ethical announce-ments of the availability of neurofeedbackservices and contact information. Claims ofefficacy of neurofeedback should be discour-aged in advertising, and especially claims forefficacy in conditions for which there is noclear evidence in peer review professionalpublications. Statements claiming cure orremission from neurofeedback treatment of acondition are unethical and undermine therelationships of clients with legitimate ethicalproviders. Advertising that claims any associ-ation between a product, technique, or clinicalpractice because the technique, product, orpractitioner has been the subject of a presen-tation or displayed at ISNR meetings is mislead-ing. ISNR does not explicitly or implicitlyendorse any neurotherapy practice, product,or technique. Any inferences made by adver-tisements that products, practitioners, or tech-niques are endorsed by ISNR are patentlyfalse and misleading. Serious harm is done tothe scientific credibility of neurofeedback byadvertising based on unsubstantiated claims,and such advertising is unethical. Neurofeed-back practitioners who are associated withmultidisciplinary practices with marketing andpublic relations delegated to managers areresponsible for reviewing that advertising to

ensure that it is ethical and factual. Neurofeed-back practitioners are expected to adhere tothe commonly accepted ethical standards forpublic relations and advertising that prevailfor licensed health care providers.

Manufacturers, distributors, and resellers ofEEG biofeedback equipment or EEG devicesshould perform due diligence to determinethat those purchasing equipment meet thequalifications for providing clinical servicespreviously specified.

SUMMARY AND CONCLUSIONS

As we have indicated, practice standards beginto be created within professional specialties asthey become well established, and the estab-lishment of standards of practice is part of aprofession’s obligation to the public for con-sumer protection. We believe that thesestandards will help the public evaluate if provi-ders of neurofeedback services have adequatequalifications and are offering an adequatestandard of care to their clients. It is expectedthat these standards will be further refined ascontinuing research provides more informationon best practices in neurofeedback. It is hopedthat these standards also will provide a basis forgreater uniformity in legislative, regulatory, andlegal actions and for accreditation of trainingprograms in the future.

REFERENCES

Cortoos, A., De Valck, E., Arns, M., Breteler, M.H. M., & Chuydts, R. (2010). An exploratorystudy on the effects of tele-neurofeedbackand tele-biofeedback on objective andsubjective sleep in patients with primaryinsomnia. Applied Psychophysiology &Biofeedback, 35, 125–134.

Hammond, D. C., & Kirk, L. (2008). First, dono harm: Adverse effects and the need forpractice standards in neurofeedback. Journalof Neurotherapy, 12(1), 79–88.

Hammond, D. C., Stockdale, S., Hoffman, D.,Ayers, M. E., & Nash, J. (2001). Adversereactions and potential iatrogenic effects in

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neurofeedback training. Journal of Neuro-therapy, 4(4), 57–69.

Hammond, D. C., Walker, J., Hoffman, D.,Lubar, J. F., Trudeau, D., Gurnee, R., &Horvat, J. (2004). Standards for the use ofQEEG in neurofeedback: A position paperof the International Society for NeuronalRegulation. Journal of Neurotherapy, 8(1),5–26.

La Vaque, T. J., Hammond, D. C., Trudeau, D.,Monastra, V., Perry, J., Lehrer, P., . . .Sherman, R. (2002). Template for developingguidelines for the evaluation of the clinicalefficacy of psycholophysiological interven-tions. Journal of Neurotherapy, 6(4), 11–23.

Lubar, J. F., & Shouse, M. N. (1976). EEG andbehavioral changes in a hyperactive childconcurrent with training of the sensorimotorrhythm (SMR): A preliminary report. Biofeed-back & Self-Regulation, 1, 293–306.

Lubar, J. F., & Shouse, M. N. (1977). Use ofbiofeedback in the treatment of seizure dis-orders and hyperactivity. Advances in Clini-cal Child Psychology, 1, 204–251.

Sokhadze, E. M., Cannon R.L., & Trudeau D. L.(2008). EEG biofeedback as a treatment forsubstance use disorders: Review, rating ofefficacy, and recommendations for furtherresearch. Journal of Neurotherapy, 12(1),5–43.

Todder, D., Levine, J., Dwolatzky, T., &Kaplan, Z. (2010). Case report: Impairedmemory and disorientation induced by deltaband down-training over the temporal brainregions by neurofeedback treatment. Journalof Neurotherapy, 14, 153–155.

APPENDIX 1

Additional Reading

Bennett, B. E., Bricklin, P. M., Harris, E.,Knapp, S., VandeCreek, L., & Younggren, J.N. (2006). Assessing and managing risk inpsychological practice: An individualizedapproach. Rockville, MD: American Psycho-logical Association Insurance Trust.

Striefel, S. (2000). The role of aspirationalethics and licensing laws in the practice ofneurofeedback. Journal of Neurotherapy, 4,43–55.

Striefel, S. (2003). The applications ofethics and law in daily practice. Chapter inM. S. Schwartz & F. Andrasik (Eds.), Biofeed-back: A practitioners guide (3rd ed.,pp. 835–880). New York: Guilford.

Striefel, S. (2004). Practice guidelines andstandards for practitioners of biofeedback andapplied psychophysiological services. WheatRidge, CO: Association for Applied Psychophy-siology and Biofeedback.

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