Fulfilling Informed Consent Responsibilities
Informed consent is a basic right and useful process that goes beyond the signing of forms and other formalities at the start of psychological treatment.
The first and often hardest step in providing truly informed consent is setting aside misconceptions that consent is a burdensome formality, a wasteful technicality to be gotten out of the way. Sokol (2009, p. 3224) wrote:
So what is the most redoubtable obstacle to valid consent? It is the still prevalent attitude that obtaining consent is a necessary chore, a … hurdle to jump over. Too often “consenting” a patient is reduced to the mechanistic imparting of information from clinician to patient or, worse still, the mere signing of a consent form, rather than the two-way, meaningful conversation between clinician and patient it should be. If we can change this mindset and view obtaining consent as an ethical duty first and foremost, one that is central to respecting the autonomy and dignity of patients, then we will have taken a major step towards first-class consent.
This process of “meaningful conversation” enables psychotherapist and patient to work together in a way acceptable to both. In the words of the Canadian Psychological Association’s (CPA) Ethics Code, “informed consent is the result of a process of reaching an agreement to work collaboratively, rather than of simply having a consent form signed.”
Informed consent takes the form of negotiation: “While most therapists recognize that negotiation can clear up clients’ misconceptions, fewer recognize that negotiation is also a vehicle for clearing up the therapist’s; misconceptions. An open dialogue can make the therapist aware of features of the case that depart from both the therapist’s model and his or her previous experience, and thus it serves as a corrective to the representativeness and availability biases” (O’Neill, 1998, p. 176).
(p. 658) Keep Up with the Law
A second step in ensuring informed consent is keeping up with the legal standards. Informed consent often requires that the patient be competent to give or withhold consent to assessment or treatment, possess adequate knowledge to make an informed choice, and freely make an independent decision. However, different states, provinces, and other legal jurisdictions define and interpret these principles differently. Some impose additional requirements. Psychologists must keep abreast of the constantly evolving legislation and case law relevant to informed consent.
Legal standards governing confidentiality and privilege—those areas in which therapists may or must take steps that would reveal confidential information—warrant special care in informed consent for assessment and treatment. For example, depending on the jurisdiction, health care practitioners may be authorized or required to report child or elder abuse, threatened violence, or suspected terrorist activity. Only if therapists know these standards can they convey them to patients; only if patients know these exceptions to confidentiality and privilege can they consider how these standards affect the assessment or therapy, and make an informed decision about whether to consent. For a patient to learn about these exceptions only after saying something that triggers a report to an agency or third party represents a violation of the practitioner’s ethical duty to provide adequate consent.
Keep Up with Ethical and Professional Standards
In providing informed consent, psychologists must also take into account relevant ethical and professional standards. The CPA Code of Ethics (2000), for example, uses the word “consent” 50 times. The Web page “Informed Consent in Psychotherapy & Counseling: Forms, Standards & Guidelines, & References” (kspope.com/consent/index.php) provides links to and excerpts from the standards and guidelines of 19 professional associations, including the American Group Psychotherapy Association, American Psychoanalytic Association, American Psychological Association, British Association for Counselling & Psychotherapy, Canadian Psychological Association, European Federation of Psychologists’ Associations, and the Psychological Society of Ireland.
Keep Up with Relevant Research
Maintaining awareness of research in three areas is key to providing informed consent:
• Research focusing on the consent process itself illuminates how the process can affect therapy. Studies tend to suggest that a well-conducted consent process can produce a variety of benefits, such as decreased patient anxiety, increased adherence to the treatment plan, and enhanced therapeutic alliance (Beahrs & Gutheil, 2001; Pinals, 2009; Pope & Vasquez, 2011).
• Research relevant to treatments enables clinicians to provide patients with accurate, up-to-date information about those treatments’ short- and long-term effectiveness, their potential risks or downsides, the degree to which they rest on a solid research base, and how they compare with alternative treatments.
• Decision-making research—especially regarding health issues—can inform the ways in which psychologists present information to patients. For example, one landmark study (McNeil et al., 1982) demonstrated that patients considering outcome data for surgery and radiation treatments for cancer made significantly different choices when faced with the same data depending on whether those data were presented in terms of survival or mortality (i.e., the percentage of patients in each treatment group who survived at each stage vs. the percentage who died at each stage). Our patients’ decisions about whether to consent to psychological services and what sort of therapeutic approaches to try can exert profound effects on their lives, and we have a responsibility to present the information they need to make (p. 659) those decisions in ways that are informed by research.
Practitioners must tailor the consent process to specific contexts such as culture, number of patients, parents or guardians of minor clients, setting, and changing circumstances. Examples:
• A therapist from the majority culture might start working with a patient who has recently immigrated. The degree of acculturation can influence (a) the desire for independent decision making, (b) ways of relating within cultural contexts, and (c) how psychological disorders, authority, and so on are viewed (Wang, 2009).
• Therapies involving more than one client present special issues in ensuring that patients understand the ground rules. Will the therapist keep material from one patient secret from his or her partner in couples therapy? If a patient in family therapy waives privilege in a court proceeding, will it result in the disclosure of information about other family members? If a former patient authorizes both a subsequent treating therapist and an insurance company to receive all records relating to group therapy, will any information about other group members be included?
• Attending to the limited rights of minor clients and responsibilities to parents or guardians presents special challenges. What legal and ethical rights, if any, does a minor possess in regard to informed consent or assent? Can a practitioner present information relevant to consent or assent at the appropriate developmental level? Do parents or guardians understand and agree to any limitations to their learning from the therapist what the minor client tells the therapist and what the therapist says to the client? The context changes significantly depending on whether the minor client is younger (e.g., 6 years) or older (e.g., 15 years).
• Settings are a third context warranting special attention. If treatment occurs in a military setting, does the patient understand the special limits of confidentiality? If the therapy is provided by interns or other trainees, does the patient understand whether the intern possesses a doctorate, is licensed, will be supervised, and will no longer be available at the end of the internship? If the treatment is court-ordered or takes places in a prison setting, does the patient understand what reports might be filed and how these may affect the patient’s prospects?
• Changing circumstances illustrate why therapists must remain alert to consent issues throughout the course of therapy. A patient seeking one-session hypnosis for performance anxiety about presenting an annual report may end up wanting additional sessions with the same therapist to explore career options that would be more fulfilling. A 10-session course of behavior therapy for agoraphobia may suddenly shift when the patient reveals being battered and terrorized by a spouse and now feeling hopeless and suicidal.
Psychotherapy is a complex, evolving endeavor shared by two (or more) unique individuals. Set scripts and inflexible steps to informed consent do not work, but considering the questions in the following inventory can help to identify aspects that need attention. Some items may not be relevant in some situations, and some may need adapting.
• Are you up on the legislation and case law governing informed consent in your jurisdiction?
• Are you up on the relevant ethical standards and professional guidelines?
• Are you up on the research enabling you to handle consent efficiently and effectively?
• Are there any language or cultural circumstances that might interfere with meaningful conversation and clear understanding?
• Is this patient competent to provide informed consent?
• What factors, if any, might affect the patient’s freedom to give or withhold truly voluntary consent? (p. 660)
• Does the patient understand the treatment approach you suggest, the intended benefits, risks, and alternative approaches?
• If the treatment involves more than one patient (e.g., couple, family, group therapy), do the patients understand the ground rules and how the presence of others may affect the treatment?
• Does the patient understand whether you are licensed to practice independently?
• Does the patient understand whether you will be supervised and/or whether there may be others who will be discussing his or her treatment?
• Does the patient understand who besides you and the patient will have access to the patient’s records?
• Does the patient understand limitations to confidentiality and privilege?
• If you use any forms as part of your consent process, are they clear, direct, free of jargon, and readable by those without advanced degrees in linguistics?
• If you imagine yourself in the role of this particular patient, is there anything else you might want to know at this point that might influence your decision about whether to give or withhold informed consent?
References and Readings
Beahrs, J. O., & Gutheil, T. G. (2001). Informed consent in psychotherapy. American Journal of Psychiatry, 158, 4–10.Find this resource:
Canadian Psychological Association. (2000). Canadian code of ethics for psychologists (3rd ed.). Ottawa, QB: Author.Find this resource:
McNeil, B., Pauker, S. G., Sox, H. C., & Tversky, A. (1982). On the elucidation of preferences for alternative therapies. New England Journal of Medicine, 306, 1259–1262.Find this resource:
O’Neill, P. (1998). Negotiating consent in psychotherapy. New York: New York University Press.Find this resource:
Pinals, D. (2009). Informed consent: Is your patient competent to refuse treatment. Current Psychiatry, 8(4), 33–43.Find this resource:
Pope, K. S., & Vasquez, M. J. T. (2011) Ethics in psychotherapy and counseling: A practical guide (4th ed.). New York: Wiley.Find this resource:
Sokol, D. K. (2009). Informed consent is more than a patient’s signature. British Medical Journal, 339. doi: 10.1136/bmj.b3224.Find this resource:
Wang, C. (2009, August). Managing informed consent and confidentiality in multicultural contexts. Paper presented at the Annual Meeting of the American Psychological Association, Toronto, Ontario. Retrieved February 2013, from psycnet.apa.org/psycextra/606622009-001.pdf