<p></p><p>Remote training has been around almost as long as the development of NFB technology. Hemoencephalography, a device which measure and provides feedback for the amount of oxygen in the bloodflow at the pre-frontal cortex, is an easy-to-use device that clients can take home.&nbsp;</p><p>Standalone remote training devices—such as the E2, developed by Adam Crane in the 90s—made it relatively inexpensive and easy to provide basic NFB to those who could not travel far or for those engaged in peak performance training such as golfers. As costs of equipment have come down, ease of use has increased and remote training has become more common. Automatic thresholding helps to ensure continuous optimal reinforcement rates that used to be maintained by constant manual adjustment on the part of the clinician. High input impedance on the new amplifiers makes it easier for non-clinicians to achieve good scalp connections with the electrodes. The emergence of live interactive internet programs such as Zoom also provide a means for clinicians to monitor training at a distance in real time and remotely manipulate software.</p><p>The main problem with remote training is the inability to assess clients using the rich context of body language that live, local interaction provides. Important information regarding client status may be lost. Troubleshooting problems with equipment on the fly becomes more difficult as well. In addition, there may be regulations in some states concerning interstate limitations regarding professional activities. The Board of Behavioral Sciences in the State of California makes the following recommendations:</p><p><em>“The Board of Behavioral Sciences (BBS) would like to make the following recommendations to California consumers who choose to seek therapy or counseling over the Internet. Individuals, who provide psychotherapy or counseling—either in person, by telephone, or over the Internet—are required by law to be licensed. Licensing requirements vary by state. Individuals who provide psychotherapy or counseling to persons in California are required to be licensed in California. Such licensure permits the consumer to pursue recourse against the licensee should the consumer believe that the licensee engaged in unprofessional conduct.”</em></p><p>Many other states such as Oregon and Illinois have similar laws. However, since NFB is not presently regulated in most states, it is unlikely that doing NFB across state lines has been evaluated by most state legislatures. Even with regard to counseling across state lines, the issue is still a grey area with regard to legal precedent.</p><h3>The ISNR has a section on guidelines and training for clincians practicing neurofeedback.&nbsp;</h3><p></p><div><div><div><div><h3>Guidelines for practice</h3><div><div><p>These guidelines are intended to provide a reference to both practitioners and the public with regard to basic methods for delivery of neurofeedback, also known as EEG Biofeedback. These guidelines are an extension of the Code of Ethical Principles and Professional Conduct of the International Society for Neurofeedback and Research (ISNR) which can be found on the ISNR.org website.</p></div></div></div></div></div></div><div><div><div><div><h3>The Practice of Neurofeedback</h3><div><div><p>Neurofeedback developed as a multidisciplinary treatment modality, and is now practiced by a wide variety of providers who may or may not be licensed healthcare professionals who treat mental or other illnesses. Its range of practice includes assessment and treatment for conditions diagnosed by licensed healthcare providers, training for optimal performance (e.g., among athletes, executives, students, performing artists, and other healthy individuals), and both clinical and applied scientific research.</p><p>In general, neurofeedback involves placing sensors on the scalp of the individual, and connecting the sensors to an amplifier and computer. Through these connections, the electrical activity of the brain is recorded, and then presented back to the individual on the computer screen in the form of a video game or soundtrack that changes depending on what state the brain is in. This is the “feedback” aspect of neurofeedback that enables the individual to change their brain function and keep the game or sound on more. The means by which this signal is displayed and controlled is the responsibility of the neurofeedback practitioner and should be done in accord with the guidelines below.</p></div></div></div></div></div></div><div><div><div><div><h3>Training and Credentials for Neurofeedback Practitioners</h3><div><div><p>Membership in ISNR and certification by the Biofeedback Certification International Alliance (BCIA) are voluntary and help demonstrate to the public that a neurofeedback provider is able to provide ethical and competent training. When training objectives include the treatment of a diagnosed mental or other health condition and the delivery of a regulated assessment or intervention, it helps demonstrate to the public that the provider is able to deliver ethical and competent neurofeedback training when the provider is licensed by a government-recognized health profession board, and the provider’s scope of practice with their professional board includes assessment and intervention for that diagnosed condition. Regulations regarding licensure and scope of practice are determined and enforced by various governmental agencies, depending on state, country, or province. Consumers should ascertain that the practitioner has appropriate credentials, training, experience, and licensure to treat their problem, or is supervised by someone who does.</p></div></div></div></div></div></div><div><div><div><div><h3>Guidelines</h3><div><div><p>The following guidelines are applicable to neurofeedback practitioners regardless of client background or training objective.<br>ISNR members:</p><ul><li>Follow the ethical principles of the International Society for Neurofeedback and Research and any other professional organization to which s/he might belong.</li><li>Accurately represent their training and any professional qualifications and/or licenses they have achieved, and disclose relevant limitations.</li><li>Provide neurofeedback training only for those problems or goals for which they are competent, as demonstrated by their training, experience, licensure, or supervision.</li><li>Provide neurofeedback training for the treatment of diagnosed mental or other health conditions only if they are regulated healthcare practitioners whose scope of practice includes the diagnosis and treatment of the specific client population, and who are further trained or supervised in the application of neurofeedback for those clients.</li><li>When an unlicensed neurofeedback provider is assessing a client and the severity or complexity of the problem suggests that a diagnosable mental health problem or medical illness may be related to the goal being addressed by neurofeedback, then it is prudent for the provider to discuss this possibility with the client, review the limits of their practice, encourage the client to consult with their family physician or licensed healthcare providers, and document the discussion.</li><li>Maintain their competency through continuing education.</li><li>Regularly seek consultation and supervision for cases in order to assure themselves and the client that training is in keeping with current knowledge and practice.</li><li>Document their client’s consent to the specifics of training, including where and how the client will be touched, acknowledgment of training benefits, risks, and costs.</li><li>Accurately represent the degree of scientific support reported in peer- reviewed publications for assessment and training methods for the various problems to which neurofeedback training may be applied.</li><li>If technicians are used, document the client understanding of the technician’s qualifications, role, and degree of supervision.</li><li>Document the client’s consent for their data to be used for research and/or educational purposes, if applicable.</li><li>Document their client’s acknowledgement of the limits of confidentiality.</li><li>Document their client’s acknowledgment that training will not necessarily achieve agreed upon goals, either completely or at all.</li><li>Further document the client’s acknowledgment that unexpected changes in the client’s experience or behavior may occur during the course of training which may or may not be related to the training itself, and that in those cases it is important for the client to inform the neurofeedback provider so that the training methods can be either adjusted or discontinued, if necessary, and the unexpected changes can be appropriately addressed.</li><li>Provide training regardless of race, creed, color, nationality, gender, sexual orientation, religion, or social affiliation.</li><li>Collaborate with their clients to develop measurable training goals, a clear plan for training, and methods for measuring progress toward those goals. This collaboration includes regular review of progress with the client with the objective of asking for their decision regarding whether the benefit of continuing training merits the cost.</li><li>Carry out effective practices for maintaining good hygiene, applying electrodes and establishing an adequate electrical connection, and maintaining software and hardware in good and up-to-date condition.</li><li>Use hardware and software that is safe, accurate, and effective for the purpose to which it is applied. Equipment which meets the IEEE (Institute of Electrical and Electronics Engineers) standards or has been FDA registered is recommended for clinical use.</li><li>Carefully assess and document the benefits, risks, and the abilities of the person who may conduct remote or home training, before such training is begun. In general, home training should be discouraged for conditions with a clinical diagnosis. Where it is chosen, careful attention must be given to the training and supervision of the person who will be responsible for performing the neurofeedback sessions at the home. Additional full disclosure and informed consent of potential problems, how and when to report them, and methods to resolve them should be discussed, and the client’s understanding of these documented with their signature. Steps to prevent or limit the use of neurofeedback software and hardware beyond their intended purpose should be documented. The issue of performing services outside of one’s geographic region of license or certification must be taken into consideration.</li><li>Plan and carry out neurofeedback training that is based on scientifically validated principles and methods.</li><li>Plan and carry out an organized course of neurofeedback that is based on an initial assessment that is adequate for the presenting problem and goal, including a pre-training EEG assessment.</li><li>Provide therapeutic support, coaching, and direct supervision during client neurofeedback training that is sufficient to achieve the agreed- upon goals of the client’s training. Document the client’s understanding of the degree to which the individual who is responsible for training will be present during training.</li></ul><p>ISNR is the leading non-profit organization promoting the self-regulation of brain activity for healthier functioning through neurofeedback.</p></div></div></div></div></div></div><br><p></p>