Service Delivery Models

by Siegfried Othmer | January 18th, 2006

There has been a lot of discussion round and about with regard to professional ethics in the last few months, mostly as a reference standard for judging who may rightly deliver neurofeedback services. Essentially all of the relevant ethical criteria refer to the relationship of the clinician and the client. The only social dimension in these ethical constraints relates to those situations where that cocoon of mutuality can be broken and the professional may be mandated to report someone who may do injury to another, who may be responsible for ongoing child abuse. The other social dimension relates to the obligations the professional may have vis-à-vis other professionals.

This is somewhat similar to what we have in law, where the attorney-client relationship is privileged in such a manner so as to protect the client. The attorney is, however, also an officer of the court and as such bears responsibility for the integrity of the legal process. So most of the obligations prescribe the relationship to the client, but there is also the social dimension.

Consider, by contrast, the implicit obligations of the soldier in Iraq. Here there are very few individual rights whatsoever. The officer in charge can order to soldier to do virtually anything–even at the risk of his life–that it is somehow connected to the enterprise of war. The soldier’s obligations are entirely in the social realm. He is laboring on behalf of the society at large under circumstances in which his individual rights almost disappear. He has no personal interest in being in the war theater.

This dichotomy between the individual and the social ethics reflects our society at large, in which some religious communities largely view ethical issues in terms of personal morality, whereas others view morality in more large-scale social terms. And in the political sphere things divide according to a more paternalistic and elitist perspective versus a more populist one.

With that dichotomy in mind, is it sufficient to define ethical behavior only with respect to the person(s) who can afford our services, or is there a larger ethical issue here with respect to all those who neither know about nor can afford our services? Further, if the setting of a high bar results in services being unavailable to many, should that also factor in to the ethical considerations? In other words, should the social dimension and the social costs be allowed to modulate and influence what we might otherwise decide in the realm of private ethics, or is the latter domain paramount and inviolate?

A case in point:
A good many years ago (1991) we installed our first neurofeedback system out of state at the private school called “A Chance to Grow” in Minneapolis (now also called “New Visions School.” The school was started by the parents of a brain-injured child who refused to accept the judgment of the doctors that there was nothing to be done for their child. The parents introduced a variety of remedial techniques into their school, neurofeedback among them. Eventually they had some four to six systems cranking out sessions every day. And eventually their daughter thrived also with the program.

After some years, Michael Joyce joined the program and introduced light and sound instrumentation for a more efficient group training. Every participating child would lie down on a pad with his or her own glasses, and all would undergo the light-sound training program to a musical accompaniment. The results were quite respectable in TOVA terms, on the Conners, and by other measures. Those children who did not respond as expected were then routed into the neurofeedback program on a space-available basis. By this hierarchy of services, a much larger group of children could be adequately served, and the more personalized, tailored neurofeedback services reserved for those children who particularly need them.

Is there an ethical problem here, in that not every child is getting the best possible services that might be imagined for them with more individualized neurofeedback? Should the best be allowed to crowd out the merely good? More particularly, should there be a floor set by ethical considerations that would rule out the resort to such “plain vanilla,” “one-size-fits-all” solutions, particularly if these might be supervised by those with less than sterling credentials?

In our own office setting, we operated for years on the basis of having a few clinicians supervise a larger number of training stations. Things were not perfect. Sometimes children would fall asleep; at other times they would end up twirling the electrodes out of boredom, thus corrupting the EEG signal. Yet the training could be done much more economically than on a one-on-one basis. We no longer operate this way because our training protocols have ceased to be formulaic. But it has been claimed that this kind of thing should be condemned as unethical. Really? Is the fact that such training may be somewhat less than the best sufficient to condemn it categorically?

In the law there is no middle ground between Cadillac justice and a court-appointed attorney for indigents in the case of criminal proceeding. In civil cases, the person who cannot afford an attorney is simply out of luck. In neurofeedback, the private ethic would similarly apply only to those who can pay the tab. The social ethic, on the other hand, sees an obligation on our part to all who may be in need of our services. We don’t have an ethical posture at all unless the problem of access is resolved. Fortunately, in neurofeedback we are in a position to provide for a whole range of services, accommodating different levels of involvement with the clinician. This permits a wider pricing range to be created, so that people can choose on the basis of their means.

In the following, we present just one such solution. We hope to publish others as they are submitted to us. If you have done something creative along these lines, please consider writing it up for the larger professional community.

ADHD Treated with Neurofeedback over two Months for $500
By Jack McIntyre

There are many alternative ways to provide NFB for ADD that go beyond the standard in-office service delivery. One can utilize stand-alone devices like Play Attention or proprietary franchised options like Smart Brain Games. These options offer incredible backing by researchers and product designers and marketing across the globe. But do you choose these options because they are the best option for you or because they are the best option for the patient?

In my office, I employ the following treatment model for ADD:

Month #1 — 10 sessions of psychotherapy billed to the family’s health insurance. Average co-pay $20 per session = $200 out of pocket for family. In the first two sessions I complete a thorough psychosocial evaluation, TOVA, Conners Rating Scale, and QEEG scan at CZ using my mighty BrainMaster. I now have enough data to justify an accurate diagnosis and a great baseline from which to measure progress.

Sessions 3-10 (approximately) are completed within the first month. During this time I begin training, determine optimum reward frequency and training site selection, and train the parents on what I am doing so they are prepared to do the same thing the following month. While this is going on I will provide information on nutritional supplementation, organizational skills for ADD, parenting tips for dealing with the ADD child, and other material covered under the rubric of psychotherapy. This enables me to bill for psychotherapy and not just biofeedback, a practice that is supported by the insurance companies I have consulted.

Month #2 — Family rents a BrainMaster from me for home training. Cost to family = $300. I rent the BrainMaster from EEG Support for $150 per month and add on my fee of $150 to cover supervision of their home efforts and monitoring. The family can now train their ADD child at will, daily or more, to achieve the gains they desire within the time allowed. They can choose when to train, how often to train, and how long to train, all independent of my schedule. By the end of the month, they can easily complete enough sessions to achieve the “20-Hour Solution.”

Do the math: The family spends about $500 in two months and notices remarkable gains in their child. I earn about $750 for my efforts ($200 in co-pays, approximately $400 in insurance reimbursements, and $150 for supervising home training). Everyone wins! The family, the therapist, and the insurance company!

There are providers whose delivery model requires a complete QEEG brain map before undertaking only clinician-supervised neurofeedback sessions for ADD. I admire their thoroughness, their precision and their commitment to excellence. I fear they are driving Edsels. How much better results do they achieve with that approach? Are the differences significant? If the results are not what we expect at the end of the program, then that is the right time to dig deeper. To do so at the outset is overkill. The families I work with are simply consumers who want affordable relief from their conditions. And more of them want relief without medication these days.

You can pick this model apart. “What about atypical ADD or comorbid conditions?” Make the best of your first ten sessions. Be a good clinician and figure this out so the family doesn’t have to struggle. That’s what you’re getting paid to do. “What if they have no insurance?” OK, 2 months, $1000 — still cheaper than purchasing a home-use system like a Play Attention. Bill them over a period of months if you like. Or go out to Rotary and Knights of Columbus and solicit donations for indigent clients you treat and make known your humanitarian efforts. Picking this model apart is likely to be just a waste of time. This can be done, so more than likely it will be done by someone in your neighborhood.

When this is done on a grander scale, the news of the efficacy of neurofeedback will become commonplace. The next step will be, “What can you do for depression?” Answer: Same thing! Our job as providers is to do the tough clinical work up front, and then put affordable technology in the hands of the consumers.

Jack McIntyre, MA, LMFT
Licensed Psychotherapist
Clinic Director, ADD Longmont
Longmont, CO
(O) 720-304-0461

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