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Sunday, December 11, 2016

Neurofeedback for ADHD, An Expensive Placebo Effect

     A while ago, I had written a review of Neurofeedback (biofeedback; NF) for ADHD and other mental health problems, and I recently updated the article to show that the status of NF has not changed, it remains an unproved, experimental therapy for ADHD or other mental health problems.  (my original article here:  https://thementalhealthreview.blogspot.com/2016/09/neurofeedback-and-adhd.html).
   However, after my update, I received seven (7) comments, which to summarize, claimed that my review was incorrect, unfair, and one person even wrote, "dangerous." I cut and pasted the comments below and have responded to each.
     It seems as though the commentators may have perceived my post as a personal attack against NF. I wish that NF was shown to be effective; in fact, I wish NF could cure all people with ADHD; but, one of my roles here is to inform people of the scientific status of mental health treatments. My role is not to support the providers of NF, or NF itself, or any other treatment just because I provide it or like it or for some other non-scientific reason. I'm sorry if my post offends readers who think they have benefited from NF or make a living providing it.  

The first commentator:

Anonymous posted this comment:


This article makes some valid points, but I know many people who have benefited from neurofeedback. I wish
it would consider that results in how a patient feels are just as important as valid scientific data. Perhaps it is 

just too early for studies to have been conducted, that does not in my opinion however discount the merit of 
neurofeedback as an alternative form of treatment. on Neurofeedback and ADHD
My response:  
 A provider of NF may inform patients prior to treatment that "in my clinical experience, NF seems to help many patients, but I cannot predict who will benefit from NF." However, NF providers should not say things like, "this is a proven therapy," or that "it helps most people," and certainly not something like, "85% of people who use NF are cured." Claims like this about NF are not supported by properly designed scientific studies. Provides of NF should also inform patients that NF might not be covered by their insurance company.
     From a scientific standpoint, "the merit" of NF is based only on good scientific data. Someone with a Masters or PhD should know this. Anecdotes from various patients about how well a treatment worked are useless from a scientific standpoint. The sum of anecdotes is not science. That's what sets science apart from things like professional gossip and professional biases.

Anonymous #1, posted this:

There are no sources cited in this "review"; that are of relevance. You simply chose to exclude sources where neurofeedback WAS found to be successful and instead focused on the small sample of tests where it was merely inconclusive. Any psychology training would tell you that there are hundreds of external variables that can influence a study. If you intended to run a "REVIEW"; blog as you have so aptly titled it..try evaluating CURRENT research. on Neurofeedback and ADHD

My response:
     The first source I listed in the article is very relevant. It was a randomly controlled placebo trial conducted by scientists who have no financial interests in NF. The results of the study showed that NF was not any better than a placebo. When you have a published RCT's showing this outcome, then you cannot, in absolute terms, tell patients that NF is "proven."
     A significant problem faced by NF is that most of the studies that have been conducted on its effectiveness have not been good studies, and have been done by people who have direct or indirect financial interests in NF. For example, studies that are not randomized, not placebo controlled, have small sample sizes, or are not blinded are not useful for determining effectiveness.

     There are sources listed at the end of this page. The sources included at the bottom of the page are reviews of NF. Keep in mind that most studies completed on NF are not even included in reviews because they weren't good enough to be included, or if they are included, the authors conclude that more methodologically sound studies need to be done.

Anonymous #2, posted this:



you sound like an individual who is unwilling to do his homework. on Neurofeedback and ADHD
My response:  
     Back at you on this one, Anonymous. I have done my homework. I've read every systematic review and meta-analysis on the subject of NF.  BCBS is right to not reimburse NF for lack of evidence that it works; they've done their homework, too.

Anonymous #3, posted this:


Dear Scott Costello. Your blog and opinion is outright dangerous and misinformed. Unless you want to promote
the use of amphetamines such as Adderall for children, who's brains are still developing of a drug free
alternative, then please state so. The ONE study you referenced concluded: "Conclusions: The current
study found that optimally titrated methylphenidate is superior to neurofeedback and physical activity in
decreasing ADHD symptoms in children with ADHD." The key word is "superior". However,
that assumes that the drug use is without consequences. If addiction is taken into consideration, then perhaps
neurofeedback is more superior. ADHD is a complex mental problem, and neurofeedback is a well proven
technology. To dismiss a technology irrespective of the quality and training of the practitioner, the quality of the
software analysis, the number of electrodes use, the quality of artifacting and so on, dismisses your opinion. A
better advise for parents strugling with ADHD on Neurofeedback and ADHD

My response:       

     Dear Anonymous #3, calling my blog and opinion "outright dangerous and misinformed," makes you sound like a politician; calling my article dangerous, is hyperbole or dramatic from someone who is behaving in an irrationally defensive manner. 
     You argue that I promote amphetamines when I actually discourage their use (this is called a straw-man argument on your part). The one, randomly controlled trial that I did cite in my post included a literature review which showed that NF is not effective at treating ADHD. So, this was not just one study, but a review of the available studies; this is very significant.
     ADHD meds are considered the most effective treatment for ADHD. However, they probably should no longer be considered the first line of treatment; instead behavioral therapies should probably replace meds as the first treatment. The word "superior" is undefined by scientific authors, and although it is commonly used, it probably should be taken at face value and would mean "above" or simply better than.
     Anonymous states that "neurofeedback is a well proven technology," but  does not provide any studies to support this claim; I'm aware that there are not any that do, but I'm wondering why you think NF is "well proven." Proven is a strong word to use, by the way, but then again, so are "dangerous" and "misinformed."
     I'm sorry Anonymous, but the "quality and training of the practitioner, the quality of the software analysis," etc..., are all irrelevant if the outcome shows that NF does not work better than a placebo. I'm guessing that you're a provider of NF, like the other commentators, and your just defending your practice from scrutiny by resorting to unsound and illogical arguments.

Anonymous #4 commented:



ADHD is a very complex disorder and to simplify the solution down to drugs and therapy as the 'holy
grail' is false too. Brain Maps can be an effective tool to identify brain functions, great tool to help rule
in or out ADHD vs. the over- simplified paper test. Neurofeedback not a cure but can help many imperfect
brain functions work a little better. Give thanks that you don't suffer from something like ADHD, Anxiety
and Depression. on Neurofeedback and ADHD

My response:  

     Another commentator critiquing my article, but failing to offer any real evidence that NF works other than because they say it does. I suspect that this post was written by same person as #3, due to the dramatic style. Anyway, this is an argument from compromise: NF isn't a cure but it can help the brain "work a little better." Sorry, there's no compromise here; at this point, after many studies, NF does not work better than a placebo; and, by the way, how do you know that I don't suffer from ADHD, anxiety or depression?

Anonymous #5 commented:



Neurofeedback is a schedule 1 treatment for ADHD with tons of articles and research supporting the efficacy of the treatment. For you to say it's "experimental" simply is not true. Neurofeedback changes the electrical activity of the central nervous system. Also, the skill you claim that neurofeedback practitioners don't have is ridiculous. Brain function is localized and without knowing where to place electrodes and what frequencies to train you can make people worse. You really need to do some more research on this. on Neurofeedback and ADHD
My response:  
     Yes, NF is a "schedule 1 treatment." Please know that "schedule 1" is the lowest rated type of treatment available. The scale is from 1 to 5, where 5 represents the most safe and effective type of treatment known to science, and 1 representing no scientific support and experimental. So, this is a case where being number 1 is not something to brag about.
     Now that we have the numbers straight, there is not "tons" of research supporting NF. I doubt if we printed and weighed all the NF studies that they would weigh 2000 pounds or more. One sheet of paper is 28 grams, and there are 908,000 grams in one ton. So, that would be 64,857 pages of research, or about 5,416 studies - for one ton, but you wrote, "tons." I'm pretty certain there aren't many more than 100 studies, so we're talking ounces of studies, and most of them lack scientific rigor, but the well-designed studies show that NF does not work better than a placebo. 
     I stand by my comments on skill level of NF providers; I'm not saying it doens't require some skill, my point is that the fees charged for the NF procedures seems high relative to the rigor of the certification process which is open to, what appears to be most human service degrees; I think that is clear in the post.
     Do you inform your patients that NF can, as you write, potentially make them worse? I'll watch for the next systematic review of NF, but until then, NF remains in the realm of experimental and probably not effective as indicated by scientific research.

Anonymous #6 commented:

I have used a type of neurofeedback called NeurOptimal® in clinical practice for a decade and based on what
clients tell me, neurofeedback works. People feel less anxiety and more capable of dealing with life. Children
suddenly function better and can better self regulate. People are more resilient and have better focus. And they
 tell their family and friends about us. I stopped paying attention to research long ago, especially given that the
work of Dr. Barry Streman proved that neurofeedback works. This was in the 1960s. What I now listen to is what
 clients tell me about how they are feeling. on Neurofeedback and ADHD
My response:  
     This is similar to the first comment, that because your clients say it works, then that's good enough, but unfortunately, if you want to have the support of the scientific community, then that's not good enough. The sum of anecdotes is not science, it's gossip. NF practitioners seem to be similar to pharmaceutical companies, always expanding the mental health problems that can allegedly be treated with NF - from ADHD, to depression, to anxiety, and so on, and producing poorly designed studies with small sample sizes. 
     Sorry to hear that you "stopped paying attention to research long ago." Nothing was "proven" in the 1960's, that's sounds absurd. The scientific process has changed substantially since then. I think it's completely irresponsible to use NF and pretend that it's supported by scientific research. Patients rightfully assume that you'll be using interventions that are based on sound science. So, by not keeping up with scientific studies, you're being irresponsible. The level-system used by researchers is to be used by providers when giving informed consent to their patients. So, the status of NF as a level 1, possibly level 2 treatment should be known to patients before they consent to treatment. I suspect that people would not be willing to pay as much for NF if they knew that it was not better than a placebo.

References:

Sibley, Margaret, et al. (2014). Clinical Psychology Review. Pharmacological and psychosocial treatments for adolescents with ADHD: An updated systematic review of the literature. Elsevier, ltd. 
     "Review of past 13 years of research on treatment of ADHD in adolescence" (218). "There was no evidence that... neurofeedback improved the functioning of adolescents with ADHD" (218). Authors do not recommend stimulants as the preferred treatment for ADHD.

Loaiza, Juana Gaviria, et al. (2014)Psychology Journal (Revista CES Psicologia)Is Neurofeedback training an efficacious treatment for ADHD? Results from a systematic review.  University of Deleware. 
     "The results point to a level of efficacy located between level two (potential effectiveness) and level three (probable effectiveness), therefore, it is necessary to conduct a research with a higher level of variables and larger samples." CES Psicologia, 7(1), 16-34.

Liew, Ashley. (2014)Journal of Neurology, Neurosurgery, and Psychiatry. EEG Biofeedback Therapy for ADHD: A Systematic Review.  J Neurol Neurosurg Psychiatry 85:e3 doi:10.1136/jnnp-2014-308883.34.
     "There is growing evidence for neurofeedback as a non-pharmacological alternative in the treatment of ADHD, but the existing literature displays a range of methodological weaknesses. Further and more convincing research is required." (Abstract).

Vollebregt, Madelon A., et al. (2014). The Journal of Child Psychology and Psychiatry. Does EEG-neurofeedback improve neurocognition function in children with attention-deficit/hyperactivity disorder? A systematic review and a double-blind placebo-controlled study. Volume 55, Issue 5, May 2014, pages 460-472. Errata.
     "No significant treatment effect on any of the neurocognitive variables  was found. A systematic review of the current literature also did not find any systematic beneficial effect of EEG-neurofeedback on neurocognitive functioning.... Overall, the existing literature and this study fail to support any benefit of neurofeedback on neurocognitive functioning in ADHD, possibly due to small sample sizes and other study limitations."

Sonuga-Barke, Edmund J.S., PhD, et al. (2013). American Journal of Psychiatry. Nonpharmacological Interventions for ADHD: Systematic Review and Meta-Analyses of Randomized Controlled Trials of Dietary and Psychological Treatments. March 2013, 170;275-289. ajp.psychiatry.online.org.
     "Better evidence for efficacy from blinded assessments is required for behavioral interventions, neurofeedback, cognitive training, and restricted elimination diets before they can be supported as treatments for core ADHD symptoms."

Willis, Grant, et al. (2011)Journal of Applied School Psychology. Neurofeedback as a Treatment for Attention-Deficit/Hyperactivity Disorder: A Systematic Review of Evidence for Practice.  July 2011, 27(3):201-227.
     "Commonly used guidelines regarding empirically supported treatment approaches show that, at present, neurofeedback is not well supported as a treatment for ADHD."



Mental Health Disclaimer: The information included in this post and blog is for educational 
purposes only. It is not intended nor implied to be a substitute for professional mental health 
treatment or medical advice. The reader should always consult his or her mental health provider to
determine the appropriateness of the information for their own situation or if they have any questions
 regarding a mental health or medical condition or treatment plan. Reading the information on this 
website does not create a therapist-patient relationship.











Friday, September 23, 2016

Neurofeedback and ADHD

UPDATE [September 23, 2016]:
Recently, a couple of people were surprised to hear me tell them that Neurofeedback, Biofeedback (or whatever other scientific-sounding names people are using these days) is "experimental," and in my opinion people should be informed of this prior to trying it, and the cost should be much less that I hear people are charging for it, for two reasons: (1) it's experimental; when something is experimental, the patient it taking a risk of wasting their time and money and potential harm from an unknown procedure; and (2) there's very little skill necessary on the part of the practitioner (it's not like performing a surgery, for example), and the certification is available for many different types of degrees.
People are still be told that Neurofeedback "cures" ADHD, but it does not, and, people are being referred to Neurofeedback as though it is a Standard of Care, but it is not. There are only two scientifically supported treatments for ADHD: behavior modification and stimulants or amphetamines. You can read more about ADHD on this blogs under several posts. It's a highly controversial syndrome concept. So, consumers beware.
You can read this official Medical Policy of Blue Cross Blue Shield of Illinois regarding why Neurofeedback is considered experimental: BCBSIL Medical Policy PSY311.011.

_______________ Original Post ________________

There have been several studies of comparing Neurofeedback to a placebo for ADHD. Up until 2012, it was not clear if Neurofeedback (also called Biofeedback) was helpful. Other issues were not addressed by most studies, for example, if a particular child did show improvement, how long did their improvement last? 


Neurofeedback has no predictable benefit for ADHD
or any other mental health problem.

In 2013, an independent group of researchers from the Netherlands published a study in the Journal of Clinical Psychiatry, in the United States, showing that biofeedback did not work better than a placebo (The Journal of Clinical Psychiatry 


Many parents are being told that neurofeedback will "cure" ADHD
in a certain percentage of cases, but, this is completely false.

To begin with, there is no known cure for ADHD, only different therapies (please refer to other posts on ADHD for more information about this complicated issue). Also, neurofeedback has no clear benefit for any other mental health problem; however, it is being used to treat many different type of issues, especially anxiety and even autism. With regards to anxiety, it seems to be a distraction and relaxation technique more than a treatment, and there are no generally effective treatments or cures for autism (regardless of what Jennifer McCarthy says on TV). You might as well use mindfulness, at least that's free.

ADHD is not a disease in a medical sense. Psychiatry is that branch of medicine that includes diagnosis that are not diseases. For example, depression is a state of consistent sadness combined with other problems, like problems with diet, sleep, or motivation. There are no lab tests or scans that can be done to determine if a child has ADHD, or any other psychiatric disorder because, ADHD is a set-of behavior problems. 

In their prestigious 2003 publication, Child Psychopathology, by Eric J. Mash, and Russell A. Barkley (2nd edition), the authors state on page 93, that ADHD is a real disorder because children who are diagnosed with ADHD often have behavior problems later in life and have differences in brain scans.  It's strange enough that the authors find it necessary to state that ADHD is a "real disorder," but moreover, their logic is embarrassingly flawed with regards to cause and effect (i.e., an abnormal brain scan, therefore, these abnormalities cause ADHD; or, problems later in life, therefore, ADHD is a real disorder). The fact is that brain scans of children with ADHD are full of inconsistencies, and no clear conclusions about the meaning of these inconsistencies can be made at this point. Some psychiatrists have come to what I see as spurious conclusions about these inconsistencies, like Dr. Daniel Amen and his 7 types of ADHD (if there were 4 categories of inconsistencies of brain scans, then there probably would of been 4 types of ADHD - get it?). There are still many technical problems with using brain scan technology that make the data derived from these methods unreliable (fMRI, Spect, etc...) (see my post about Spect scans, but there are more current articles by scientists as well, see Neuroskeptic at Discover Magazine).





Children who have behavior problems when they are young may have behavior problems when they are older for many other reasons. In fact, psychiatrists and many psychologists have failed to adequately study or have omitted many environmental factors when trying to understand causes of ADHD. For example, failing to adequately analyse the relationship between corporal punishment and ADHD, poverty and ADHD, parent mental health and ADHD, gender and ADHD (boys are diagnosed 5:1 compared to girls) and many other factors. Neuro-psychologists and psychiatrists spend plenty of time developing fancy guesses about why the results of a different brain scan would result in "attentional problems," but do not spend enough, or any, trying to figure out how and why corporal punishment, permissive parenting, or poverty might contribute to the same behavior problems. Paying lip-service to these factors or mentioning them at face-value does not help anyone understand the relationship between these factors and ADHD, perpetuates the labeling of children as ADHD, misses the opportunity to address serious systemic problems in primary education, and address ineffective parenting rooted in cultural ignorance (e.g., continued use of corporal punishment in many States and about 50% of homes, as well as other permissive or authoritarian parenting techniques).


Many parents look for simple and easy explanations and solutions to ADHD. So, neurofeedback or drug therapies with their pseudo-medical explanations are very appealing, but they're also very spurious and sometimes just patently false. In the end, it's unlikely that your child will derive any long term benefit from neurofeedback, so proceed with caution.

Mental Health Advice Disclaimer: The information included in this post and blog are for educational purposes only. It is not intended nor implied to be a substitute for professional mental health treatment or medical advice. The reader should always consult his or her mental health provider to determine the appropriateness of the information for their own situation or if they have any questions regarding a mental health or medical condition or treatment plan. Reading the information on this website does not create a therapist-patient relationship.

Tuesday, December 8, 2015

How Does Divorce Mediation Work?

I practiced divorced mediation, in Illinois, from 2009 and until this Summer. I enjoyed helping people work through disagreements and conflict. I have ceased providing mediation services in order to focus on other areas of practice, specifically on the front-end, pre-marital therapy, in order to help new couples prevent divorce.

In this post, I'll explain my perspective on mediation with the hopes that it will help you understand it and get a better idea if it's something that you should try. In my experience, most people did not understand the role of the mediator or the purpose and limitations of mediation; and, in many cases, people described situations where mediators had performed duties that were questionable and charged fees that were unreasonable. 

Divorce is expensive. Most Americans will spend between $10,000 and $30,000 from start to finish. Divorce is stressful**. Many spouses will feel anxious or depressed for months to years afterwards; most children are negatively affected by divorce for two years on average. Divorce is time consuming. The average divorce will take 1.5 years from start to finish and others will drag on for 3-4 years (see this post: http://thementalhealthreview.blogspot.com/2012/10/divorce-in-slow-motion-how-to-live_25.html).  


Trying to resolve disagreements at home can be
unproductive and intolerable. Mediation offers
a safe and calm environment with the guidance
of a professional.


**Divorce, per se, is not bad. It's full of pros and cons just like any other change in our life. Bad divorces happen when one or both spouses act badly. For example, one spouse will usually be angry at the other, and they get on their high horse, feeling full of self-righteous indignation, and they punish their soon-to-be former spouse. They are the ones who will often cut off their nose to spite their face; they give divorce a bad name; they are the ones who will put their kids in the middle or throw their former spouse under the bus; they will air dirty laundry on social media, in attempts to shame their spouse. These are mostly good people who behave badly because, under that anger, they are very sad. 

The right thing to do is get help dealing with the intense sadness. 
Anger is destructive. It's probably what drove your spouse away to begin with, and displaying more anger is only proving to them that
they made the best decision. 

The primary reason divorce is so expensive isn't because of lawyer's fees, it's because of angry, self-righteous, indignant spouses. If you're like this, then mediation probably isn't for you.

Most couples will let their attorneys "fight it out" in court, trying to get as much as they can for their side. It's an antagonistic process for which mediation is one of several alternatives.

Divorce mediation was developed to for two reasons, first, to provide couples with an alternative dispute resolution process. Divorce is the ending of a contractual agreement ("marriage") between two people where property was to be jointly owned and to be passed down to their children. The dispute is about how that property should be divided. Mediation was also supposed to be less expensive. However, today most attorneys have become certified mediators and charge just as much for mediation services as legal fees. So, you should shop around for the best price; don't assume that you get what you pay for. Mediation does not require a lot of training. Many non-attorney mediators charge large fees only because they know that couples must attend because it's ordered by court, or because of a false prestige associated with the legal aspect of mediation.

There are some important facts to understand about mediation. Most mediators are social workers, lawyers, counselors, pastors, former educators and judges. Even if your mediator is a lawyer or former judge, they are not permitted to give legal advice to either party during mediation or through the divorce.


Being an attorney does not make someone a
better mediator. The mediator's skill-set is
quite different from a lawyer's skill-set.

A mediator represents the couple, where an attorney represents only one party. Also, the role of the mediator is not as proxy, referee or judge. Mediators will know and understand divorce laws, but they cannot tell you what legal action you should take with regards to your divorce; in other words, they should not apply the law to your case or make legal predictions, but they may advise you to consult with a lawyer, or ask you to follow up with your lawyer regarding specific issues.

How can mediators help you?


Mediators can do the following:


1. Provide you with a safe and relaxed environment to resolve disputes. Compared to court rooms, a mediator's office should feel more like your living room, with a comfortable couch to help absorb some of that tension. It's also private, unlike a courtroom where all kinds of people can watch and listen to your personal affairs.


2. Offer an objective perspective from an impartial position. Lawyers are looking to "win" a fight, mediators are wanting to facilitate understanding and mutually acceptable decisions or compromises.


3. Mediation can help you save lots of time and money. Mediation can be as low as 10% of the cost of a typical divorce.


4. Mediation will teach you to resolve disagreements with your former spouse or partner and build skills and confidence that you could do so again in the future, if needed. You will learn communication techniques that you can use independently. The goal of mediation is not to build dependency on the mediator, but to help you learn to independently resolve future disputes. However, you're free to use a mediator if you are at an impasse at any point in the future.



______________

As a mediator, I would try to make the cost as low as possible. I usually had one initial session for one hour in order to assess the situation and determine a course of action. Many times, the problems are resolved in the first session, if you're coming in with one problem. At the first session, I will offer you options about how to move forward, and this will include making an attempt to resolve the disagreements independently. If that fails, then we can work together, and I will facilitate the process as much as necessary going forward.

I sometimes would meet people who have been to mediation and tell me that their old mediator made decisions for them and would write down decisions that were made. Mediators are not supposed to behave that way. Mediators may take notes for you, but they should give the impression that what they write has any legal standing. What is said in mediation is not admissible in court. Decisions that are made in mediation are non-binding; people are free to change their mind after mediation. Decisions are final only after you have a court order entered by the circuit clerk. So, I would not take notes or write down resolutions for you.


______________

Many people that come to mediation try to manipulate the mediator. Some people will try to taint the mediator's perception of their spouse, directly or implicitly. Sometimes people will be passive-aggressive, or try to signal to the mediator that they are a great parent and great person, or victim of their former partner's shortcomings. What these people fail to realize is that they are wasting their time. Mediators will maintain an impartial role regardless of what one spouse says or implies about the other or themselves. The mediator's role is just to facilitate mutually acceptable agreements - not to take sides or judge people they have never met. Mediators are sophisticated enough to recognize these behaviors and will usually ignore them. The non-manipulative party shouldn't worry that the mediator will be biased because of this kind of behavior. The mediator is not a moralizer or judge. They're an impartial, non-judgmental facilitator.

If you decide to try mediation, you will probably be screened for disqualifiers, first. For example, cases where there is domestic violence are often not appropriate for mediation. People who are actively abusing drugs or alcohol may not be able to participate in mediation, and people with advanced Dementia or who suffer from severe mental illness, like Schizophrenia or Bipolar disorder that is not effectively managed by medication may not be appropriate for mediation. 

With regards to fees, I do not think mediators should be charging more than $100 to $150 per hour, no matter how much education, training or experience they have, and I think they should provide a sliding scale based on ability to pay, for at least 10% of their clients. I believe this for the following reasons: (1) mediator skills are not esoteric or very complicated, (2) although helping distressed couples with a divorce is a stressful thing to do, the process itself is not very demanding, (3) the primary purpose of mediation was to open up competition in the market to bring costs down.

If you're shopping for a mediator, feel free to ask them any question you wish. Also, feel free to try to negotiate fees. Finally, don't agree to pay more than $20 to $25 for mediation sessions that were missed. Paying fees for services that were not received, regardless of the reason, is probably not enforceable in court. Ask mediators how their process works. If they don't seem to have a process, then you may run the risk of not making any progress.



Legal Disclaimer: The information included in this post and blog are for educational purposes only. It is not intended nor implied to be a substitute for legal advice. Scott Costello is not a lawyer and Personal Solutions Counseling is not a law practice. You have the right to consult with an attorney regarding your divorce at any time.