Barden, R.C. (2001) "Informed consent in psychotherapy: A multidisciplinary perspective," Journal of the American Academy of Psychiatry and the Law, 29 (2), p. 160-166.
Beahrs, J.O. & Gutheil, T.G. (2001) "Informed consent in psychotherapy," American Journal of Psychiatry, 158:1, p. 4-10.
Cannell, J., Hudson, J.I., Pope, H.G. (2001) "Standards for informed consent in recovered memory therapy." Journal of the American Academy of Psychiatry and Law, 29, p. 138-147.
Davis, D., Loftus, E. & Follette, W. (2001) "Commentary: How, when and whether to use informed consent for recovered memory therapy," Journal of the American Academy of Psychiatry and Law, 29, p. 148-159.
Statements on Informed Consent
"The physician’s obligation is to present the medical facts accurately to the patient or to the individual responsible for the patient’s care and to make recommendations for management in accordance with good medical practice. The physician has an ethical obligation to help the patient make choices from among the therapeutic alternatives consistent with good medical practice.... Social policy does not accept the paternalistic view that the physician may remain silent because divulgence might prompt the patient to forego needed therapy."
Section 8.08 AMA Code of Medical Ethics, 1994 Edition
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"In general, informed consent should be obtained from all adult patients prior to the initiation of psychiatric treatment...
"Psychiatrists should offer patients or others from whom consent is being obtained information about the nature of their condition, the nature of the proposed treatment, benefits of the proposed treatment, risks of the proposed treatment, and available alternatives to the proposed treatment along with their benefits and risks."
American Psychiatric Association
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(a) Psychologists obtain appropriate informed consent to therapy or related procedures, using language that is reasonably understandable to participants. The content of informed consent will vary depending on many circumstances; however, informed consent generally implies that the person (1) has the capacity to consent, (2) has been informed of significant information concerning the procedure, (3) has freely and without undue influence expressed consent, and (4) consent has been appropriately documented.
From section 4.02 Informed Consent to Therapy in the Ethical Principles of Psychologists and Code of Conduct, Effective date December 1, 1992. The APA’s Ethics Code has been revised, with effect as of June 1, 2003.
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Given the strength and clarity of the statements above, a reader could reasonably expect that informed consent would be an integral part of the therapy process. However, that is not the case. A large percent of the lawsuits filed by former patients against their recovered-memory therapists contained the complaint that the therapist failed to obtain informed consent.
In 1997, the state of Indiana passed an Informed Consent Law. Although similar laws have been introduced in other states, they have not passed in the face of professional opposition.
The following two-part article by Allen Feld is reprinted from the FMSF Newsletter, September 1999, Vol. 8, No. 6
PERSPECTIVES ON INFORMED CONSENT
No doubt many readers are aware of the disagreement about informed consent between some therapists and others -- mostly non-therapists (FMSF members and supporters) along with a number of concerned mental health professionals. Some individuals in the latter group have proposed that states pass laws requiring informed consent for people seeking help from therapists.
Many proponents of the legislation are reacting to what they understand happened in therapy to some clients. Clients who sought therapy for contemporary issues of living, or for specific psychological, behavioral or emotional symptoms did not have those problems addressed but instead were were led to delve into their pasts, leading to the creation of false memories.
Proponents for legislation argue that informed consent is necessary because some therapists ignore the reasons a client seeks help and instead emphasize what they (therapists) think is important.
They note that significant harm has been done to clients and their families when clients were unsuspecting of this dramatic shift in therapy. The group in favor of legislation maintains that clients were provided neither the opportunity nor the information to agree to the type of therapy to which they were exposed. Some also argue convincingly that informed consent is a necessary and desirable component of appropriate therapy. I agree with this group’s thinking.
Some therapists have vigorously attacked this group and the informed consent proposal. Their counter-arguments often seem wedded to the therapists’ power and authority in therapeutic relationships and to what some of these therapists may refer to as the "art" of therapy.
It is interesting to note that although informed consent is now widely accepted in medicine, many of those who attack the proposed legislation are MDs. I wonder if the people who believe that informed consent legislation is misguided also advocate "parity" (legislation that mandates insurance coverage for psychological services be similar in scope to insurance payments for medical service)? I believe that to be inconsistent. That is saying "We want to be like medicine in getting payments but we don’t want to be like medicine in providing informed consent."
With informed consent, a client gives a therapist permission to implement a specifically defined service to deal with the reason(s) a client chose (or was required) to seek therapy. It also commits the therapist to working on those areas for which the client has given her/his permission. Implicit in informed consent is the assumption that the client has received accurate and creditable information on which to base a reasonably educated decision as to whether to proceed with the service being recommended or offered by a particular therapist.
I believe that informed consent is a process that requires discussion, thought, and a decision by both client and therapist. The process is the essential ingredient of meaningful informed consent. I view the process as interactive. The process can be a genuine offer to help, as well as an opportunity for the client to experience the therapist’s approach to helping. A written statement, one that is a joint effort and not merely proffered by the therapist, culminates the process.
Informed consent should not be viewed as a bureaucratic requirement. If it descends to that level, it may lack some of the positive aspects that lead me to value the process. The next Newsletter will describe some of what may be desirable to consider in such a process and statement.
More Thoughts on Informed Consent
Last month, I wrote about the disagreement between some therapists and others -- mostly non-therapists -- over proposals to require therapists to offer informed consent. Among my comments, I stated that I believed informed consent should be an interactive process.
The importance of a collaborative process and a joint agreement to achieve meaningful informed consent cannot be understated. However, a written statement is also an essential element of informed consent and it should accurately mirror the joint verbal agreement reached about the service being offered. Some elements that are vital in both the interaction and written statement include: detailing what caused the patient to seek therapy, what the therapist hopes to accomplish and how he or she plans to proceed, and what is expected of the patient in therapy. The therapist should explain in lay language his or her theoretical orientation and approach to helping, as well as prior experiences with this therapeutic approach and a summary of published outcome studies. It is reasonable for society to expect a therapist to be familiar with the research that supports his or her chosen theoretical orientation and that describes its effectiveness when used with the patient’s problems.
This process also allows an opportunity to discuss what the therapist perceives to be the risks, side-effects or anxieties that may be common in therapy in general and known to be associated with the chosen therapeutic approach. This is also a suitable time for a therapist to make the patient aware of the emergency procedures available should they become necessary. Essential logistics regarding fees, appointments, confidentiality standards and how changes in informed consent will be incorporated into the relationship are other important ingredients to make the written statement complete. It is reasonable to expect that the therapist and client may want to amend the informed consent agreement as therapy proceeds.
The emphasis therapists place on a patient’s past is related to a therapist’s theoretical preference. Patients generally seek therapy to deal with some contemporary life situation they find troubling. When therapists believe a patient’s past is a necessary element in the theoretical approach being used, they should initiate a discussion about the role that the past may play in the patient’s current concerns and how understanding that past history will be used to help him or her. I believe it is essential to include a brief and specific statement in the informed consent document noting that without independent verification, memories of the past are not necessarily accurate or reliable.
Assuming there is no crisis that needs to be addressed, informed consent can be introduced in the first therapy session. I believe this is a suitable and sound beginning for therapy. This exchange allows for exploration of the reasons that led the patient to seek therapy, introduces the reciprocal expectations of the patient and the therapist and describes how therapy will proceed. A rough draft of the informed consent statement could be given to the patient with the suggestion that it be taken home and reviewed. I recommend that the patient and therapist delay signing the document until there has been adequate time for review and thought by both parties. The patient should be asked to return to the following session with questions about and reactions to the informed consent agreement.
I believe that informed consent is an essential element in therapy, particularly when coupled with the fundamental aspects of initiating a therapeutic relationship. It fails to be vital to therapy if it is handled in a casual or bureaucratic manner. When a therapist uses something similar to the process described here, the cooperative nature of the therapeutic interaction has been experienced and respect is shown for the patient. A genuine offer to help has been extended and an agreement to try to work together has been jointly reached. The therapist and the patient have specified and agreed to collaborate on the issues being brought to therapy. If professional organizations and licensing boards developed appropriate standards for informed consent, legislation for informed consent would not be necessary -- an obvious win/win situation.
Allen Feld is Director of Continuing Education for the FMS Foundation. He has retired from the faculty of the School of Social Work at Marywood University in Pennsylvania.