In a paper published in the Journal of Contemporary Psychotherapy, Dr. Charlotte Blease of University College Dublin and Harvard Medical School and colleagues call for an expanded informed consent process in psychotherapy, one that more fully reflects the American Psychological Association (APA)’s commitment to evidence-based practice. The authors offer guidelines for thorough informed consent in psychotherapy, illustrating key issues for consideration with supporting case vignettes. They hope to ultimately spark a larger debate in the fields of psychology and psychiatry about informed consent practices in psychotherapy.
“…standard ethical interpretations of informed consent to psychotherapy must go further… [We aim to] launch fresh, serious, pragmatic debate in professional psychology about necessary revisions of ethical codes with respect to information disclosures.”
Informed consent, which is essential in the provision of health care, involves providing patients with sufficient information so that they can be empowered to make educated decisions about their treatment. The aim of obtaining informed consent from patients, the authors write, is to uphold their rights to “autonomous decision making.” However, what information must be minimally provided in order to allow for autonomous decision making?
Blease and her coauthors suggest that medicine and clinical psychology agree on a variety information that should be disclosed, including the spectrum of available treatments, their schedule, and length; complete explanations of how these treatments work; and different treatments’ (including no treatment) levels of effectiveness and associated hazards.
Despite these generally agreed-upon minimum standards of information disclosure, and the fact that informed consent is required by the APA’s ethical code of conduct, the authors state that in practice, informed consent in psychotherapy is often inadequate and/or paternalistic. They urge practitioners to transform informed consent processes in psychotherapy to more fully reflect the APA’s commitment to evidence-based practice in psychotherapy (EBPP).
EBPP is distinguished from empirically-supported treatment (EST) in that it is more inclusive of different kinds of research and seeks to apply research findings and “clinical expertise in the context of patient characteristics, culture, and preferences.”
Thus, Blease and her collaborators write, “EBPP yields ethical considerations that require further attention by the APA (and psychotherapy practitioners).” One implication of the APA’s embrace of EBPP, they suggest, is that practitioners must strive to keep abreast of relevant research findings on available treatments, be able to clearly convey this information to patients, and ensure that patients understand the information shared with them. The authors propose that psychotherapists should:
- Disclose information about the range of treatment options to patients. Practitioners should stay informed about the latest research findings on available treatments and communicate this information to patients. The authors also suggest that psychotherapists should stay aware debates in the field, and even consider sharing information about them with patients when relevant. They write,”In open and honest communication psychotherapists should feel fully able to acknowledge the scientific debate about the effectiveness of treatments.”
- Communicate information about treatment options to clients in an unbiased manner. One of the paper’s vignettes features a psychotherapist who, although aware of the various empirically-supported approaches for depression (e.g. interpersonal, psychodynamic, and cognitive behavioral therapies), steers her patient towards CBT because this is her preferred treatment modality. The authors identify such partiality as a big “red flag.” Particularly given EBPP’s focus on honoring patient preferences, practitioners should stay up to date on all treatment options and present them to patients in a transparent and balanced way.
- Share information on common factors. The authors argue that psychotherapists should not only divulge information about research-supported treatment options and the techniques they use, but they should also inform patients about findings on the role of common factors in therapeutic outcomes. Although still a subject of debate, a number of studies have found that certain elements that are present across therapeutic modalities (i.e. common factors), such as the therapeutic alliance and patients’ hope, contribute to improved patient outcomes.
- Collect feedback from patients on ongoing basis. The authors also encourage psychotherapists to collect ongoing feedback from patients, either verbally or with the support of continuous patient monitoring systems.
The authors conclude by reinforcing their desire to stimulate conversation and debate on the topic of informed consent in the field of psychotherapy. They close by highlighting clinical transparency’s benefits to patients, writing,
“…there is evidence that promoting honest dialogue between psychotherapists and patients about the nature of psychotherapy improves both the therapeutic alliance and patient outcomes.”
Blease, C., Kelley, J. M., & Trachsel, M. (2017). Informed Consent in Psychotherapy: Implications of Evidence-Based Practice. Journal of Contemporary Psychotherapy, 1-10. (Link)
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
Yes…informed consent is crucial. I was not informed of any of the risks of psychotherapy, nor of the methods used by my psychiatrist. Those methods put me in hospital twice with my first “psychoses”, and resulted in involuntary commitment and forced treatment with psychoactive drugs (I had no history of “mental illness” or of being hospitalised previously). After we had managed to form an apparently “therapeutic” relationships he asked me for sex (which I declined), and later, he threw me out of his office, hurling diagnoses and abuse, using everything I had told him in confidence against me.
Then he said I’d be dangerous if my (newer) shrink had access to my records.
…and the ACT Human Rights Commission to whom I complained, took his word and stripped me of all my rights to have my treating doctor given access to my records.
Informed consent? Had I known that I stood to lose everything I had achieved at age 50, be drugged, labelled and would be thrown on the scrap heap, I would have run from psychotherapy as if the devil were after me…and it turned out he was, in the form a a psychiatrist.
Over a decade down the track and I still struggle in ways I never struggles before I enetered psychotherapy. I am isolated and unable to seek medical attention for some physical ailments I have because I am now totally aware of how unaccountable medical practitioners are – they just need to say you are/were a psych patient, and there go your human rights.
Informed consent MUST include not only treatment options but the human rights you give up when you see a “mental health” practitioner. They can hospitalise you against your will, they can forcibly drug you, and they can abuse you.
…and their “diagnoses” can never be expunged from your record.
This all should form part of informed consent.
You said it! Psychotherapy informed consent is atrocious. Professionals offering much cheaper, more concrete, more time limited services go through more robust consent processes than psychotherapists (ex. fumigators, plumbers, etc.), even though therapy is often conceived as a multi-year, expensive, and energy-consuming endeaover that has no guarantees
“Psychotherapy” is a ridiculous gimmick and a system of pseudo-help that maintains the notion that they can solve human suffering, even the kind which either has no solutions, or has solutions which depend on actually practically doing something for the individual without trapping him in a system of endless listening and talking in a closed room.
As far as information about behaviour and practices like mindfulness or whatever other scientistic therapy names they have (“CBT” or what have you), they can simply do their research and put it out in the public domain so that individuals can use the information for themselves.
“practitioners should stay up to date on all treatment options and present them to patients in a transparent and balanced way.”
I will have a go at this: “I need to tell you that there is no such thing as “generalised anxiety disorder”, the thing your GP referred you for. I am not sure how they researched treatment outcomes in trials for something that doesn’t exist and therefore I am unable to tell you what will work for this thing you supposedly have. What I can tell you is that you and I may be able to figure a way out to work together on what is going on for you. There is no one size fits all in psychotherapy and knowing what will work for you in your unique circumstances may take some time. I will not charge you until we know if and how we are going to proceed. How does that sound?”
Sounds a lot better than rambling on about “evidence based practices” and whatnot. Being honest about what is not known and about the very subjective aspects of both “diagnosis” and whatever form of “therapy” is provided would be essential, but I’d bet my life savings that the number who actually provide this is infinitesimally small.
The other thing is, if people want to engage in “psychotherapy”, or “confidential sessions of listening and talking” as Szasz called them, they can do so in the form of one human being communicating with another to find out a solution to some problem, just as individuals do with each other in ordinary society. Not in the roles of:
1.) A labelling, record-keeping, state backed individual.
2.) A person in the patient role.
Such a system (the one that exists right now) only creates 2 more problems in the place of 1 problem it solves.
Doing the version of “psychotherapy” which is a “confidential session of listening and talking” would imply the following:
1.) All people licensed to practice as mental health workers must disband from institutions which engage in institutionalisation, labelling and coercive drugging, and move into private practice as individuals.
2.) To maintain absolute confidentiality, any records must be destroyed on the request of the person in the patient role.
3.) To avoid unwarranted stigma, the individuals must be willing to go from home to home, and not in a building where all their clients are in one waiting room.
How many practitioners would be willing to take this risk? Not many. There might not even be a reward for this kind of practice (for the people playing the role of “therapist”) at the end of the day. Would the law in the country of practice allow for such practices? What if the person in the role of therapist ends up in prison or has a lawsuit filed against him/her?
The other things are:
1.) It is a well known fact that several individuals who end up in any of the forms of “therapy” are people who already dealing with other abusive individuals in their life. What can people in the role of therapists do about the perpetrators, without which, there is no point of any kind of “therapy” in the first place?
2.) There are also people who come from very good families, with no obnoxious individuals in their lives, but rather some problem in living, thinking or feeling that is causing them distress. This is the class of individuals who can benefit the most from such a practice.
I honestly think its time to see about abolishing Mental Health, Inc. I am a Szasz fan, but I’m not a Szasz follower. I -get- that Szasz was a-OK with consentual acts of psychiatry, etc., but…c’mon. This industry is draining the coffers, ruining lives, and warping our minds. Enough is enough!
As for “informed consent” for “psychotherapy…” my concept of what this would involve would look a little something like this: “There is no solid evidence that any ‘mental ilness’ exists. “Psychotherapy” is a very expensive conversation in which the patient pays the psychotherapist to be heard and told what to think, who they are, and what their problems in life really are. The data on the benefits of these expensive conversations is mixed, at best. Some people report fabulous results, others end up labeled, stigmatized, impoverished, and sometimes suicidal. The labels attached to those who pay for these conversations are not scientifically valid, but are permanent, nonetheless. BUYER BEWARE.”
in all likelihood, Mental Health, Inc. is going to become far -worse- in the US, not better, softer, more humane, etc. And yet…one can dream, right? Right.
I agree with your comments. My only proviso is that anyone I would consider a valid therapist (and they are rare, I admit) would never tell someone what to think, who they are, or what their problems really are. If that’s what “therapy” has become (and as I say, it frequently is exactly that), a walk in the woods would be safer and more effective by a long ways!