Informed consent in counseling and psychotherapy refers to the process by which clients or prospective clients receive information about the proposed treatment and subsequently decide whether to provide consent for the counselor or therapist to proceed with the treatment. Historically, informed consent requirements were applied to surgery and other medical procedures; later these requirements were expanded to include counseling and related activities. Currently, informed consent is mandated by the ethical codes that govern most counselors and psychotherapists. There is significant variability, however, in the beliefs and practices of professionals regarding informed consent, including its content, timing, method, and effect.
Content of Informed Consent Procedures
What information should counselors and psychotherapists include during the informed consent process? Ethical codes and legal regulations typically offer little guidance regarding the specific topics to cover or particular details to address. In the absence of unambiguous guidelines, counselors and psychotherapists have developed and employed a wide variety of approaches to informed consent.
A number of topics have traditionally been included in the informed consent process. Prospective clients are generally informed about the nature of the counseling or therapy being proposed. This includes what the therapeutic approach is called, how it usually works, what activities it may involve, and how long it may last. They are also typically informed about the effectiveness of the proposed treatment, as well as potential risks and alternative treatments. Of course, the pragmatics of the treatment arrangement are also usually covered: how appointments are scheduled, where and how often sessions will take place, payment arrangements and responsibilities, and emergency contact information. Finally, informed consent procedures have customarily included confidentiality policies, including situations in which the counselor or therapist may need to break confidentiality without the permission of the client (e.g., when the therapist becomes aware of a legal duty to warn a third party of potential danger).
In addition to these essentials, a number of additional topics may merit inclusion in the present-day informed consent process. Recently, numerous authors have identified contemporary issues in the counseling or therapy field about which the client may have a right to be informed. For example, the increasing involvement of insurance companies, managed care organizations, and other third-party payers has had a widespread and well-documented influence on the counseling and psychotherapy professions, and some members of these professions believe this topic merits inclusion in their informed consent procedures. Similarly, therapy manuals (or empirically supported therapies, or best practices guidelines) have resulted in many clients in recent years receiving treatment that is to some extent predetermined or preplanned according to a diagnostic category or presenting problem. Informing prospective clients about their use by a counselor or therapist may be another relatively new addition to the informed consent procedure.
Timing of Informed Consent
When should counselors and therapists obtain informed consent? Ethical codes and legal regulations generally suggest that informed consent be obtained as early as possible in the therapeutic relationship. The rationale behind this suggestion is clear: Clients should have the opportunity to choose whether to proceed with counseling or therapy before finding themselves immersed in it. However, counseling and psychotherapy are fundamentally different from other practices that utilize informed consent procedures. Consider, for example, a physician who obtains informed consent from potential patients facing the same medical procedure. The procedure is assumed to be essentially similar for all patients, and to be a one-time event, so the physician can provide a uniform informed consent document to all potential patients at the outset.
Counseling and psychotherapy are unique in two important ways: They unfold gradually over time in ways that cannot always be accurately predicted at the outset, and they necessarily differ from client to client. For these reasons, a standardized informed consent procedure cannot be offered to all clients at the outset. Of course, some basic information can and should be provided at the very beginning, including confidentiality and payment policies. However, discussion about more substantive issues, such as treatment orientation, duration, goals, and activities may need to be delayed until the therapist has learned enough about the client to provide personalized information. Thus, many authors on informed consent promote a “process” model rather than an “event” model, such that informed consent represents not a distinct occurrence, but an ongoing and recurrent element of counseling and psychotherapy.
Whether informed consent is viewed as a process or an event, at times it may need to be delayed as a result of client variables. If the client is in an acute crisis state or is temporarily unable to adequately comprehend the information to be provided, it may be clinically and professionally wise to delay informed consent until a more appropriate point in time.
Methods of Obtaining Informed Consent
How should counselors and psychotherapists go about obtaining informed consent? Historically, two methods—written and oral—have been utilized.
Written informed consent procedures feature the advantage of enabling clients to read over information at their own pace, as well as the opportunity for the counselor or therapist to keep a hard copy of a signed form in the file as proof that informed consent was obtained. Oral informed consent procedures allow for more flexibility and customization of information for particular clients. They also facilitate discussion between the client and the counselor or psychotherapist.
In practice, a combination of written and oral informed consent procedures may be ideal. Numerous standardized written informed consent forms have been made available, and they can be adapted by counselors or psychotherapists working in particular contexts or with particular types of clients. However, these forms, or others originally designed by counselors or therapists for their own practices, should not stand alone. Instead, clients should be given the opportunity to ask questions during the informed consent process, and the counselor or psychotherapist should provide answers to the fullest extent possible. Counselors and psychotherapists can combine the written and oral approaches by supplementing a standard information form with a written list of questions that clients may choose to ask. Whether written, oral, or both, the method by which counselors and psychotherapists obtain informed consent should be consistent with professional ethical codes, applicable laws, and the Health Insurance Portability and Accountability Act (HIPAA).
Effects of Informed Consent
Research by Mitchell Handelsman and others suggests that as a rule, the informed consent process has a positive effect on clients and prospective clients. Rather than perceiving the process as unnecessary or excessive, clients who are provided with readable, personalized information—as well as a chance to discuss this information—generally look favorably upon the informed consent procedure and the counselors and therapists who provide it. At its best, the informed consent procedure can facilitate not only an informed decision by the client, but a strong therapeutic alliance in which the counselor’s or therapist’s acknowledgment of the client’s autonomy is an important component.
It is also important to note that the informed consent procedure offers professional benefits to the counselor or therapist as well as the client. By appropriately obtaining and documenting informed consent, the counselor or therapist precludes ethical violations or legal liability that may otherwise arise.
References:
- American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060-1073.
- Beahrs, J. O., & Gutheil, T. G. (2001). Informed consent in psychotherapy. American Journal of Psychiatry, 158, 4-10.
- Braaten, E. B., & Handelsman, M. M. (1997). Client preferences for informed consent information. Ethics & Behavior, 7, 311-328.
- Handelsman, M. M., & Martin, W. L., Jr. (1992). Effects of readability on the impact and recall of written informed consent material. Professional Psychology: Research and Practice, 23, 500-503.
- O’Neill, P. (1998). Negotiating consent in psychotherapy. New York: New York University Press.
- Pomerantz, A. M. (2005). Increasingly informed consent: Discussing distinct aspects of psychotherapy at different points in time. Ethics & Behavior, 15, 351-360.
- Pomerantz, A. M., & Handelsman, M. M. (2004). Informed consent revisited: An updated written question format. Professional Psychology: Research and Practice, 35, 201-205.