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Wednesday, August 20, 2008

Informed Consent in Psychotherapy and Counseling: Forms, Standards and Guidelines, and References

Informed Consent in Psychotherapy & Counseling: Forms, Standards & Guidelines, & References
Ken Pope

Here are some resources that may be helpful in thinking through the process of informed consent. They include:
links to a variety of forms for informed consent from the American Psychological Association Insurance Trust; the University of Rochester Counseling Center; the West Virginia University Carruth Center for Counseling & Psychological Services; Laura Brown Ph.D., ABPP; and the Center for Ethical Practice; excerpts addressing informed consent from the standards and guidelines of professional associations (with links to the original documents) including American Association for Marriage & Family Therapy; American Association of Christian Counselors; American Association of Spinal Cord Injury Psychologists & Social Workers; American Group Psychotherapy Association; American Mental Health Counselors Association; American Psychoanalytic Association; American Psychological Association; Association for Specialists in Group Work; British Association for Counselling & Psychotherapy; British Columbia Association of Clinical Counsellors; California Board of Behavioral Sciences; Canadian Counselling Association; Canadian Psychiatric Association; Canadian Psychological Association; European Federation of Psychologists' Associations; Irish Association for Counseling & Therapy; National Association of Social Workers; National Board for Certified Counselors; and Psychological Society of Ireland; and quotes and information about informed consent from articles, books, and studies.

Sample Informed Consent Forms
Sample Psychotherapist-Patient Contract from the American Psychological Association Insurance TrustThis site also includes forms for:
Sample Forensic Informed Consent Contract
Sample Outpatient Services Agreement for Collaterals
Informed Consent for Assessment and Treatment from the University of Rochester Counseling Center
Informed Consent for Psychotherapy or Other Services, and Notice of Privacy Practices from the West Virginia University Carruth Center for Counseling and Psychological Services
Informed Consent for Psychotherapy from Laura S. Brown, Ph.D., ABPP

This site also includes forms for:
Note-taking form for psychotherapy
Agreement to work with attorney as a forensic expert
Informed consent for forensic assessment
Adolescent Informed Consent for Psychotherapy from the Center for Ethical Practice

This site also includes forms for:
Clinical Consultation Contract
"Notice of Privacy Practices" - Informed Consent Re: Limits of Confidentiality
Confidentiality Contract (Couples Therapy)
Formal Standards and Guidelines for Informed Consent
NOTE: Please follow this link for a more comprehensive array of professional standards and guidelines than those below.
American Association for Marriage and Family Therapy (AAMFT) Code of Ethics
Excerpt: "1.2 Marriage and family therapists obtain appropriate informed consent to therapy or related procedures as early as feasible in the therapeutic relationship, and use language that is reasonably understandable to clients. The content of informed consent may vary depending upon the client and treatment plan; however, informed consent generally necessitates that the client: (a) has the capacity to consent; (b) has been adequately informed of significant information concerning treatment processes and procedures; (c) has been adequately informed of potential risks and benefits of treatments for which generally recognized standards do not yet exist; (d) has freely and without undue influence expressed consent; and (e) has provided consent that is appropriately documented. When persons, due to age or mental status, are legally incapable of giving informed consent, marriage and family therapists obtain informed permission from a legally authorized person, if such substitute consent is legally permissible."
American Association of Christian Counselors: Code of Ethics
Excerpt: "Christian counselors secure client consent for all counseling and related services. This includes the video/audio-taping of client sessions, the use of supervisory and consultative help, the application of special procedures and evaluations, and the communication of client data with other professionals and institutions. Christian counselors take care that (1) the client has the capacity to give consent; (2) we have discussed counseling together and the client reasonably understands the nature and process of counseling; the costs, time, and work required; the limits of counseling; and any appropriate alternatives; and (3) the client freely gives consent to counseling, without coercion or undue influence.... Christian counselors respect the need for informed consent regarding the structure and process of counseling. Early in counseling, counselor and client should discuss and agree upon these issues: the nature of and course of therapy; client issues and goals; potential problems and reasonable alternatives to counseling; counselor status and credentials; confidentiality and its limits; fees and financial procedures; limitations about time and access to the counselor, including directions in emergency situations; and procedures for resolution of disputes and misunderstandings. If the counselor is supervised, that fact shall be disclosed and the supervisor's name and role indicated to the client."
American Association of Spinal Cord Injury Psychologists & Social Workers: Standards for Psychologists and Social Workers in SCI Rehabilitation
Excerpt: "It is assumed that all referenced treatment components and processes of acute inpatient and outpatient rehabilitation are so embraced by the voluntary agreement of the individual with SCI or their legally appointed guardian. If a minor child or incompetent individual refuses treatment, the psychosocial professional is guided by state regulations that govern such situations. If, however, the competent adult refuses rehabilitative treatment with the full benefit of informed consent, the health care system is bound to accept that decision."
American Group Psychotherapy Association: Guidelines for Ethics
Excerpt: "1.1 The group psychotherapist shall provide the potential group patient/client with information about the nature of group psychotherapy and apprise him or her of the risks, rights and obligations as a member of a therapy group."
American Mental Health Counselors Association: Code of Ethics
Excerpt: "Mental health counselors are responsible for making their services readily accessible to clients in a manner that facilitates the clients' abilities to make an informed choice when selecting a provider. This responsibility includes a clear description of what the client can expect in the way of tests, reports, billing, therapeutic regime and schedules, and the use of the mental health counselor's statement of professional disclosure. In the event that a client is a minor or possesses disabilities that would prohibit informed consent, the mental health counselor acts in the client's best interest."
American Psychoanalytic Association: Principles & Standards of Ethics for Psychoanalysts
Excerpt: "III. Mutuality and Informed Consent. The treatment relationship between the patient and the psychoanalyst is founded upon trust and informed mutual agreement or consent. At the outset of treatment, the patient should be made aware of the nature of psychoanalysis and relevant alternative therapies. The psychoanalyst should make agreements pertaining to scheduling, fees, and other rules and obligations of treatment tactfully and humanely, with adequate regard for the realistic and therapeutic aspects of the relationship. Promises made should be honored. When the patient is a minor these same general principles pertain but the patient's age and stage of development should guide how specific arrangements will be handled and with whom."
American Psychological Association: Ethical Principles of Psychologists and Code of Conduct
Excerpt: "3.10 Informed Consent (a) When psychologists conduct research or provide assessment, therapy, counseling, or consulting services in person or via electronic transmission or other forms of communication, they obtain the informed consent of the individual or individuals using language that is reasonably understandable to that person or persons except when conducting such activities without consent is mandated by law or governmental regulation or as otherwise provided in this Ethics Code. (See also Standards 8.02, Informed Consent to Research; 9.03, Informed Consent in Assessments; and 10.01, Informed Consent to Therapy.) (b) For persons who are legally incapable of giving informed consent, psychologists nevertheless (1) provide an appropriate explanation, (2) seek the individual's assent, (3) consider such persons' preferences and best interests, and (4) obtain appropriate permission from a legally authorized person, if such substitute consent is permitted or required by law. When consent by a legally authorized person is not permitted or required by law, psychologists take reasonable steps to protect the individual's rights and welfare. (c) When psychological services are court ordered or otherwise mandated, psychologists inform the individual of the nature of the anticipated services, including whether the services are court ordered or mandated and any limits of confidentiality, before proceeding. (d) Psychologists appropriately document written or oral consent, permission, and assent. (See also Standards 8.02, Informed Consent to Research; 9.03, Informed Consent in Assessments; and 10.01, Informed Consent to Therapy.)"
Association for Specialists in Group Work Best Practice Guidelines: Best Practice Guidelines
Excerpt: "A7# b. Group Workers facilitate informed consent. Group Workers provide in oral and written form to prospective members (when appropriate to group type): the professional disclosure statement; group purpose and goals; group participation expectations including voluntary and involuntary membership; role expectations of members and leader(s); policies related to entering and exiting the group; policies governing substance use; policies and procedures governing mandated groups (where relevant); documentation requirements; disclosure of information to others; implications of out-of-group contact or involvement among members; procedures for consultation between group leader(s) and group member(s); fees and time parameters; and potential impacts of group participation. # c. Group Workers obtain the appropriate consent forms for work with minors and other dependent group members. # d. Group Workers define confidentiality and its limits (for example, legal and ethical exceptions and expectations; waivers implicit with treatment plans, documentation and insurance usage). Group Workers have the responsibility to inform all group participants of the need for confidentiality, potential consequences of breaching confidentiality and that legal privilege does not apply to group discussions (unless provided by state statute)."
British Association for Counselling & Psychotherapy: Ethical Framework for Good Practice in Counselling & Psychotherapy
Excerpt: "Autonomy: respect for the client’s right to be self-governing. This principle emphasizes the importance of the client’s commitment to participating in counselling or psychotherapy, usually on a voluntary basis. Practitioners who respect their clients’ autonomy: ensure accuracy in any advertising or information given in advance of services offered; seek freely given and adequately informed consent; engage in explicit contracting in advance of any commitment by the client; protect privacy; protect confidentiality; normally make any disclosures of confidential information conditional on the consent of the person concerned; and inform the client in advance of foreseeable conflicts of interest or as soon as possible after such conflicts become apparent. The principle of autonomy opposes the manipulation of clients against their will, even for beneficial social ends."
British Columbia Association of Clinical Counsellors: Code of Ethical Conduct & Standards of Clinical Practice for Registered Clinical Counsellors
Excerpt: "In the B.C.AC.C.'s Code of Ethical Conduct, principle #2 (Informed Consent) states: 'Counsellors uphold clients' rights to informed consent, that is the clients' full and active participation in decisions which affect them, and freedom of choice based on the information shared.' Obtaining the informed consent of a client to the proposed clinical counselling is a critical, first-step in the counselling relationship. If a counsellor provides counselling services without consent, the counsellor could be liable for any resulting negative consequences. In most situations, a counsellor can presume that every adult client the counsellor sees is capable of giving, refusing or revoking consent to clinical counselling services. In the rare circumstance that the counsellor believes that an adult client is not capable of giving or is unable to communicate informed consent (e.g. because of mental defect or a physical, psychological or emotional incapacity, as examples), the counsellor should obtain consent from an authorized substitute decision maker.1 Under the Infants Act, a client under the age of 19 who understands the nature of the therapy that he or she will receive can also give their consent and the child can give consent without a parent or guardian's knowledge or approval..... Once the client gives consent, this does not end the process. The counsellor must ensure that informed consent continues throughout the counselling relationship. The counsellor may have to seek the client's consent again if circumstances change, such as when the nature of counselling services changes significantly from what was originally agreed to. The client can also withdraw consent at any time, thus effectively ending the counselling relationship. If a client decides to stop the counselling, but agrees to continue after a brief rest, the counsellor does not have to go through the process of obtaining a new consent, so long as the counsellor is satisfied that the client understood what was involved with the continuation of services. The counsellor should make a note in the clinical record of such an event.... Counsellors should document their client's consent. For example, a counsellor can make a note in the clinical record that the client was informed and gave an implied or an oral consent. A more prudent practice is to ask a client to sign a consent to treatment form. Such a form can be evidence that the client was fully informed and consented freely to the proposed services. A model for a consent form is proposed at the end of this standard. For there to be valid, fully informed and freely given consent to clinical counselling, the counsellor must provide the client with sufficient information to allow the client to understand the purposes, risks and benefits of the proposed counselling. The counsellor must also allow the client to ask questions and receive answers to address any concerns. Only then can it be said that the client gave informed consent without reservation. Generally, the sort of information a counsellor must provide to a client before consent is given is information that a reasonable person in the client's particular circumstances would require so as to understand the proposed services and make an informed decision. Usually, this will include information about the client's condition or situation for which the services are being proposed, the nature of the proposed clinical services, the risks and benefits of those services that a reasonable person would expect to be told about, as well as any clinical options, including not doing anything. A counsellor has a duty to communicate with a client in a way that is appropriate to that client's particular skills, ability and language."
California Board of Behavioral Sciences: Notice to California Consumers Regarding Psychotherapy on the Internet
Excerpt: "According to Business and Professions Code Section 2290.5, prior to the delivery of health care via telemedicine, the health care practitioner who has ultimate authority over the care or primary diagnosis of the patient shall obtain verbal and written informed consent from the patient or the patient's legal representative. The informed consent procedure shall ensure that at least all of the following information is given to the patient or the patient's legal representative verbally and in writing: (1) The patient or the patient's legal representative retains the option to withhold or withdraw consent at any time without affecting the right to future care or treatment nor risking the loss or withdrawal of any program benefits to which the patient or the patient's legal representative would otherwise be entitled. (2) A description of the potential risks, consequences, and benefits of telemedicine. (3) All existing confidentiality protections apply. (4) All existing laws regarding patient access to medical information and copies of medical records apply. (5) Dissemination of any patient identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without the consent of the patient."
Canadian Counselling Association: Code of Ethics
Excerpt: "When counselling is initiated, and throughout the counselling process as necessary, counsellors inform clients of the purposes, goals, techniques, procedures, limitations, potential risks and benefits of services to be performed, and other such pertinent information. Counsellors make sure that clients understand the implications of diagnosis, fees and fee collection arrangements, record-keeping, and limits of confidentiality."
Canadian Psychiatric Association: The CMA Code of Ethics Annotated for Psychiatrists
Excerpt: "Inform your patient when your personal morality would influence the recommendation or practice of any medical procedure that the patient needs or wants.... Provide your patients with the information they need to make informed decisions about their medical care, and answer their questions to the best of your ability."
Canadian Psychological Association: Code of Ethics
Excerpt: "1.19 Obtain informed consent from all independent and particularly dependent persons for any psychological services f=provided to them except in circumstances of urgent need (e.g., disaster or other crisis). In urgent circumstances, psychologists, would proceed with the assent of such persons, but fully informed consent would be obtained as soon as possible."
European Federation of Psychologists' Associations: Charter of Professional Ethics for Psychologists
Excerpt: "3.1.3 Informed Consent and Freedom of Consent * Clarification and continued discussion of the professional actions, procedures and probable consequences of the psychologist's actions to ensure that a client provides informed consent before and during psychological intervention. * Clarification for clients of procedures on record-keeping and reporting. * Recognition that there may be more than one client, and that these may be first and second order clients having differing professional relationships with the psychologist, who consequently has a range of responsibilities."
Irish Association for Counseling & Therapy: Code of Ethics & Practice
Excerpt: "Principle 1: Respect for the rights and dignity of the client. Practitioners are required to treat their clients as persons of intrinsic worth with a right to determine their own priorities, to respect clients' dignity and to give due regard to their moral and cultural values. Practitioners take care not to intrude inappropriately on clients' privacy. They treat as confidential all information obtained in the course of their work. As far as possible, they ensure that clients understand and consent to whatever professional action they propose."
National Association of Social Workers: Code of Ethics
Excerpt: 1.03 Informed Consent (a) Social workers should provide services to clients only in the context of a professional relationship based, when appropriate, on valid informed consent. Social workers should use clear and understandable language to inform clients of the purpose of the services, risks related to the services, limits to services because of the requirements of a third-party payer, relevant costs, reasonable alternatives, clients' right to refuse or withdraw consent, and the time frame covered by the consent. Social workers should provide clients with an opportunity to ask questions. (b) In instances when clients are not literate or have difficulty understanding the primary language used in the practice setting, social workers should take steps to ensure clients' comprehension. This may include providing clients with a detailed verbal explanation or arranging for a qualified interpreter or translator whenever possible. (c) In instances when clients lack the capacity to provide informed consent, social workers should protect clients' interests by seeking permission from an appropriate third party, informing clients consistent with the clients' level of understanding. In such instances social workers should seek to ensure that the third party acts in a manner consistent with clients' wishes and interests. Social workers should take reasonable steps to enhance such clients' ability to give informed consent. (d) In instances when clients are receiving services involuntarily, social workers should provide information about the nature and extent of services and about the extent of clients' right to refuse service. (e) Social workers who provide services via electronic media (such as computer, telephone, radio, and television) should inform recipients of the limitations and risks associated with such services. (f) Social workers should obtain clients' informed consent before audiotaping or videotaping clients or permitting observation of services to clients by a third party."
National Board for Certified Counselors: Code of Ethics
Excerpt: "8. When counseling is initiated, and throughout the counseling process as necessary, counselors inform clients of the purposes, goals, techniques, procedures, limitations, potential risks and benefits of services to be performed, and clearly indicate limitations that may affect the relationship as well as any other pertinent information."
Psychological Society of Ireland: Code of Professional Ethics
Excerpt: "1.3.3. Obtain informed consent from all independent and partially dependent persons for any psychological services provided to them."

Quotes and Information about Informed Consent from Articles, Books, & Studies

Ethics in Psychotherapy & Counseling: A Practical Guide, Third Edition by Kenneth S. Pope & Melba J.T. Vasquez. San Francisco: Jossey-Bass/John Wiley, 2007.
Excerpt: "The right to informed consent reflects respect for individual freedom, autonomy, and dignity. It is fundamental to the ethics of theraqpy and counseling. The APA ethics code (see Appendix A) sets forth specific standards for informed consent.... Truscott and Crook (2004) bnote that 'informed consent is the most represented value in the Canadian Code of Ethics for Psychologists; (p. 55; see Appendix B).
This fundamental concept can trip us up if we are not careful. Nothing blocks a patient's access to help with such cruel efficiency as a bungled attempt at informed consent.... The doors to our offices and clinics are wide open. The resources are all in place. But not even the most persistent patients can make their way past intimidating forms (which clerks may shove at patients when they first arrive), our set speeches full of noninformative information, and our nervous attempts to meet externally imposed legalistic requirements such as the Health Insurance Portability and Accountability Act. A first step is to recognize that informed consent is not a static ritual but a useful process."Psychologists should also consider and understand the potential impact of diversity on this process, such as the role that language, age (and developmental level), cultural background, and other factors may play in affecting the informed-consent process. Clinical work with individuals, couples, families, and groups each presents unique challenges with regard to informed consent, as do third-party requests for services, clinical supervision, research, and teaching. Knowing how best to address these challenges is of great importance for protecting clients' rights, promoting their autonomy, and working to achieve the best possible outcomes in the professional relationships we form with them.

"Informed Consent Through Contracting for Supervision: Minimizing Risks, Enhancing Benefits" by Janet T. Thomas. Professional Psychology: Research and Practice, June 2007, vol. 38, #3, pages 221–231.
Excerpt: "Obtaining the informed consent of supervisees at the outset of supervision is critical to minimizing risks and maximizing the benefits. Whether they are seeking supervision to meet academic, licensure, or certification requirements or to assist in rehabilitation following an ethical violation, supervisees all benefit from having clear information about that to which they are agreeing. Many authors and specialty guidelines recommend, and ethical standards require, that informed consent be obtained in writing. The format in which the information is presented will vary with the type of supervision, the context, and the preferences and theoretical orientation of the supervisor."
Clinical Handbook of Psychiatry & the Law by Paul Appelbaum & Thomas Gutheil. Philadelphia: Lippincott Williams & Wilkins, 2007.
Excerpt: "Because the doctrine of informed consent evolved from a series of court decisions, it may differ from jurisdiction to jurisdiction. Despite this, the general outlines of the doctrine are fairly well agreed on. Three components exist: information, voluntariness, and competence.""A Study of the Opinions and Behaviors of Physicians with Regard to Informed Consent and Refusing Treatment" by Adnan Ataç, Tolga Guven, Muharrem Uçarm & Tayfun Kir. Military Medicine, July, 2005, vol 170, #7, pages 566-571.
Excerpt: "Although opinions favoring the duties implied by informed consent are in the majority, these do not always reflect the behaviors in daily clinical practice..."

Ethics for the Practice of Psychology in Canada by Derek Truscott and Kenneth H. Crook. Edmonton, Alberta: University of Alberta Press, 2004.
Excerpt: "All other things being equal, the right to make decisions about whether or not to receive psychological services, and the nature of those services, belongs to the client. This conclusion finds support not only in psychologists' ethical values, particularly the social contract between a profession and society..., but also in our professional standards... and law.... Informed consent is the most represented value in the Canadian Code of Ethics for Psychologists...."

"Confidentiality and informed consent: School counsellors' perceptions of ethical practices" by Ron Lehr, Andrea Lehr, Andria, & John Sumarah. Canadian Journal of Counselling, 2007, vol. 41, #1, pages 16-30.
Excerpt: This study of school counsellors' views "identified five categories of issues and concerns related to confidentiality and informed consent: informing students on issues of confidentiality, age of consent, issues of professional confidentiality, sharing client information with others, and confidentiality with teachers and principals."

Clinical Manual of Psychiatry & Law by Robert Simon & Daniel Shuman. Washington, DC: American Psychiatric Publishing, 2007.
Excerpt: "The legl doctrine of informed consent is consistent with the provision of good clinical care. Informed consent allows patients to become partners in treatment determinations that accord with their own needs and values. In the past, phyisicians operated under the medical principle of primum non nocere - 'first do no harm.' Today, psychiatrists are required to practice within the legal model of informed consent and its concerns with patient autonomy. Most psychiatrists find increased patient autonomy desirable in fostering development of the therapeutic alliance that is so essential to treatment."

"Evolving Standards for Informed Consent: Is It Time for an Individualized and Flexible Approach?" by Doug Johnson-Greene. Professional Psychology: Research and Practice, April 2007, vol. 38, #2, pages 183-184.
Excerpt: "The importance of informed consent is probably vastly underestimated by many psychologists, and I suspect that some may tend to view it more cynically as an initial onetime legal hurdle for psychotherapy and research activities. There also appears to be an overemphasis on content issues (i.e., what do I need to include to make this a valid consent?) and comparatively little attention paid to process issues (i.e., what does a specific patient need to know to have a full appreciation for the parameters of this professional relationship?)."
Clinical Supervision: A Competency-Based Approach by Carol Falender & Edward Shafranske. Washington, DC: American Psychological Association, 2004.
Excerpt: "Ethics codes emphasize informed-consent requirements. For example, the state of Colorado requires psychologists to present certain written information to their clients, including therapist credentials, client rights, and the State Grievance Board address (Handelsman, 1990). Supervisors must be familiar with state regulations."

"Child consent and the law: An insight and discussion into the law relating to consent and competence" by S.A. Parekh. Child: Care, Health and Development, 2007, vol 33, #1, pages 78-82.
Excerpt: "A child can consent to treatment but usually in practice is unable to refuse it. Even if both the child and parents refuse treatment, courts are reluctant to accept this, particularly if it is in the best interest of the child.... The law in relation to child consent is unclear and requires changes in order to clarify what is perceived as the child's best interest."

"Readability Level of Health Insurance Portability and Accountability Act Notices of Privacy Practices Used by Psychologists in Clinical Practice" b y Steven Walfish & Bryan B. Ducey. Professional Psychology: Research and Practice, 2007, vol. 38, #2, pages 203-207.
Excerpt: "With an understanding of what makes a form readable, psychologists may revise their NPPs to include more concise sentences and fewer polysyllablic words. In this way they avoid risking an ethical violation, reduce their liability, and improve their informed consent process, which Handelsman (2001) suggested, can lead to better treatment outcomes. There is a misunderstanding that the federal government requires certain boilerplate language that is mandated for inclusion in these forms. However, what is mandated is that certain concepts be included, but the language is not specifically stated, other than that the forms should be written 'in plain English.' In providing an NPP that is readable, psychologists can better help clients understand how information shared with them will be treated or protected."

"Neuropsychological Considerations in Forensic Child Assessment" by Karen Wills & Jerry Sweet. In Forensic Mental Health Assessment of Children & Adolescents, edited by Steven Sparta & Gerry Koocher. New York: Oxford University Press, 2006.
Excerpt: "Written consent of the parents and of the retaining attorney should be obtained before contacting teachers to gather information about the child's functioning. Teachers and other collateral informants deserve to know, before they fill outa questionnaire or cooperate with an interview about their student, that they information they procvide may be used by the court or attorneys. Even though this knowledge may affect what the teacher says, it is unethical to imply to the teacher that the information athered will remain confidential, when, in fact, it will not."

"Assessment of Patients' Competence to Consent to Treatment" by Paul S. Appelbaum. New England Journal of Medicine, November, 2007, vol. 357, #18, pages 1834-1840.
Excerpt: "Legal standards for decision-making capacity for consent to treatment vary somewhat across jurisdictions, but generally they embody the abilities to communicate a choice, to understand the relevant information, to appreciate the...consequences of the situation, and to reason about treatment choices.... The level of impairment that renders a patient incompetent to make treatment decisions should ideally reflect a societal judgment about the appropriate balance between respecting the patient's autonomy and protecting the patient from the consequences of a bad decision.34 When physicians perform competence assessments, they should attempt to strike the same balance that would result if a court in the jurisdiction decided the case. In that regard, the presumption intrinsic to a modern democracy is that the vast majority of persons are capable of making their own decisions. Hence, only patients with impairment that places them at the very bottom of the performance curve should be considered to be incompetent. In practice, the stringency of the test applied varies directly with the seriousness of the likely consequences of patients' decisions.2,35 Although some commentators object to this "sliding scale" approach,36 it makes sense from a policy perspective, it was endorsed by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research,2 and in the judgment of many experts, it reflects how courts actually deal with these cases."

"Seeking an Understanding of Informed Consent" by Jeffrey Barnett. Professional Psychology: Research and Practice, April 2007, vol. 38, #2, pages 179–182.
Excerpt: "Psychologists should also consider and understand the potential impact of diversity on this process, such as the role that language, age (and developmental level), cultural background, and other factors may play in affecting the informed-consent process. Clinical work with individuals, couples, families, and groups each presents unique challenges with regard to informed consent, as do third-party requests for services, clinical supervision, research, and teaching. Knowing how best to address these challenges is of great importance for protecting clients' rights, promoting their autonomy, and working to achieve the best possible outcomes in the professional relationships we form with them."

"Patients' perceptions of written consent: A questionnaire study" by Andrea Akkad, Clare Jackson, Sara Kenyon, Mary Dixon-Woods, Nick Taub, and Marwan Habiba. British Medical Journal, September 9, 2006, Vol 333, No 7567.
Excerpt: "Our findings add to evidence showing that even when the consent process satisfies administrative and legal requirements, patients' needs may not be met.... Though patients did identify several important advantages of the consent process, there was substantial uncertainty about the implications of signing or not signing the consent form.... Many patients did not see written consent as functioning primarily in their interests nor as a way of making their wishes known.... Although there is no straightforward relation between knowledge of rights and ability to exercise those rights, a lack of awareness of the limits and scope of consent is clearly undesirable, potentially causing patients to feel disempowered and lacking in control."

Negotiating consent in psychotherapy by Patrick O'Neill. New York: New York University Press, 1998.
Excerpt: "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."

"Consent, Disclosure, and Waiver for the Forensic Psychological Evaluation: Rethinking the Roles of Psychologist and Lawyer" by William Foote & Daniel Shuman. Professional Psychology: Research & Practice, 2006, vol. 37, #5, pages 437–445.
Excerpt: "Separately and collectively, professional, ethical, and legal standards require that psychologists obtain consent from litigants prior to the initiation of forensic psychological evaluations. Psychologists have assumed this responsibility but may not have examined their professional capacity to fulfill this obligation. Psychologists lack the necessary legal training to fully inform the litigant of many legal ramifications of the psychological evaluation process. Even psychologists who are well informed in legal matters are not in a position to provide legal advice to litigants. Lawyers have also had the responsibility of preparing their clients for forensic psychological evaluations, and they may be hampered in this duty by a lack of understanding of psychological testing and interview procedures, psychological ethics, and the details of forensic evaluations. In this article, we have explicated the rationale for a joint procedure for informing the litigant about the psychological evaluation."

"Increasingly informed consent: Discussing distinct aspects of psychotherapy at different points in time" by Andrew Pomerantz. Ethics & Behavior, 15(4), October 2005, 351-360.
Excerpt: "Results indicate that, although psychologists believe that they are capable of presenting some information, such as payment and confidentiality policies, at the outset, they believe that a discussion of more substantive issues, such as psychotherapy duration, goals, orientation, and activities, can take place only after some therapy has transpired."

"Informed Consent in Psychotherapy" by John O. Beahrs and Thomas G. Gutheil. American Journal of Psychiatry, January, 2001, pages 4-10.
Excerpt: "While written consent might best meet formal legal criteria, it is our opinion that written contracts with the patients run the risk of sacrificing clinical rapport so essential to positive therapeutic outcome and fail to address new questions that emerge. Where written forms are required, nonetheless, they should be constructed with therapeutic intent, be relatively simple and straightforward, be framed in ordinary language without jargon, cover the key contractual business parameters and differential responsibilities, note the relevant uncertainties, and summarize general principles and specific emergency resources for what to do whenever the therapist is unavailable (58). Optimally, they also should mention the necessary role of patients’ self-therapeutic activity, which in certain cases can be elaborated to include voluntary abstinence from specific problem-maintaining behaviors such as abuse of controlled substances. Personalizing written informed consent forms has been shown to foster rapport and more constructive patient expectations (59). Finally, written forms should not be considered a substitute for ongoing verbal consent."

Ethics in Psychology: Professional Standards and Cases, 2nd Edition by Gerald P. Koocher and Patricia Keith-Spiegel. New York: Oxford University Press, 1998.
Excerpt: "Obtaining consent to treatment from a minor presents another set of issues.... Although a small number of states (e.g., the Commonwealth of Virginia) permit minors to consent to psychotherapy independently of their parents, such authority is an exception to the norm. In some states, such services could conceivably be provided as adjuncts to a minor's right to seek, without parental consent, birth control, or treatment for sexually transmitted diseases or substance abuse. Usually, however, a parent's permission would be needed to undertake psychotherapy with a minor client. When a child wishes to refuse treatment authorized by a parent, there is, under many circumstances, no legal recourse for the child even if the proposed treatment involves inpatient confinement...."

How To Survive and Thrive As a Therapist: Information, Ideas, & Resources for Psychologists in Practice by Kenneth S. Pope and Melba J.T. Vasquez. Washington, DC: American Psychological Association, 2005.
Excerpt: "As we discussed in more detail in Ethics in Psychotherapy and Counseling, informed consent cannot be reduced to a written form or confined to a static moment. It is a process that involves the therapist's ability to communicate with a particular person and make an informed judgment that he or she is in a good position to decide whether to consent to or decline specific psychological services. The information provided and the way it is provided depend on what kind of service (e.g., assessment or therapy) is under consideration, but the consent process can be assessed in terms of how well it addresses such questions as:
Does the person understand who will be providing the service and the psychologist's qualifications (e.g., license status)? If the service will be provided under supervision, with consultation, or other arrangements involving more than the individual psychologist, does the person understand the arrangement and its implications (e.g., for privacy, confidentiality, privilege, and record-keeping)?
Does the person understand the reason for meeting with the psychologist? Most people consulting an independent practitioner will have scheduled their own appointment on their own initiative, but some may show up because they were told to by an internist, an attorney, or a court and have no clear idea why they are there.
Does the person understand what services the psychologist will be offering and what the effects of these services may be?
Does the person understand the factors that may limit or significantly affect the services (e.g., the managed care coverage only authorizing five sessions of therapy)?
Does the person understand the relevant fee policies, including those for unpaid bills and for missed or canceled appointments?
Does the person understand the limitations to privacy, confidentiality, or privilege (e.g., conditions under which the psychologist either must or may disclose information to a third party)?"

"Informed consent documents of marriage and family therapists in private practice: A qualitative analysis" by Darryl Haslam and Steven Harris. American Journal of Family Therapy, 32(4), July-September 2004, 359-374.
Excerpt: "Findings suggest that there were both substantial consistency in the major areas of the documents but variance in their more detailed aspects. The latter was viewed as indicative of the subjectivity involved in creating ICDs and suggests that developing a universal document could be nearly impossible."

"Informed consent to undergo treatment for substance abuse: A recommended approach" by Robert Walker, T.K. Logan, James Clark, & Carl Leukefeld. Journal of Substance Abuse Treatment, 29(4), December 2005, 241-251.
Excerpt: "Standard treatment consent issues include (1) the clinical characteristics of the problem, including diagnosis; (2) treatment recommendations; (3) the risks and benefits of treatment; (4) the financial costs of the intervention; (5) alternative services or interventions should a client refuse the recommended form of care; and (6) freedom to choose or refuse treatment."

"Informed Consent Revisited: An Updated Written Question Format" by Andrew M. Pomerantz and Mitchell M. Handelsman. Professional Psychology: Research and Practice, 35(2), April 2004, 201-205.
Excerpt: "This updated question form offers many strengths. It facilitates open and honest discussion about important issues in psychotherapy, including common contemporary issues like third-party payment, manualization, and psychopharmacology, which reasonable people seeking contemporary psychotherapy would find relevant (Braaten & Handelsman, 1997; Canterbury v. Spence, 1972). Discussions around this form may also improve the effectiveness of whatever written information therapists give their clients or ask them to read and sign. Such open discussion enables the growth of a strong therapeutic relationship between therapist and client (Appelbaum, Lidz, & Meisel, 1987; Handelsman, 2001), one based on autonomy and empowerment through information rather than withholding, distrust, or patronization. Moreover, such a practice not only matches the recommendations of the newly revised APA ethics code (APA, 2002a), but it is also self-protective in that it helps psychologists to avoid legal problems (Plante, 1999). As with the original form (Handelsman & Galvin, 1988), discussion of these questions alone does not constitute a completed informed consent process, but it is one important facet of a process that will enable clients to make genuinely informed decisions regarding contemporary psychotherapy."

"Internet-mediated psychological services and the American Psychological Association Ethics Code" by Celia B. Fisher and Adam L. Fried. Psychotherapy: Theory, Research, Practice, Training, 40(1-2), Spring-Summer 2003, 103-111.
Excerpt: "Informed consent is seen by many as the primary means of protecting the self-governing and privacy rights of those with whom psychologists work. In the previous APA (1992) Ethics Code, the obligation to obtain informed consent was limited to research and therapy. The broader informed consent requirements introduced into the current revision of the Ethics Code reflect the societal change from a paternalistic to an autonomy-based view of professional ethics. Required elements of informed consent specifically relevant to Internet practice are detailed in Standards 9.03, Informed Consent in Assessments, and in 10.01, Informed Consent to Therapy. The obligations described in Standard 3.10, Informed Consent, apply to these other consent standards. When psychologists provide assessment, therapy, counseling, or consulting services over the Internet, these psychologists must obtain the informed consent of the individual by providing an appropriate explanation of the nature and purpose of services provided, fees, involvement of third parties, and limits of confidentiality as well as sufficient opportunity for the client/patient to ask questions."

"Informed Consent" by Marilyn Berner, in The Mental Health Practitioner and the Law edited by Lawrence E. Lifson and Robert I. Simon. Cambridge, MA: Harvard University Press, 1998.
Excerpt: "Competence is another essential 'element' of informed consent, like voluntariness and disclosure of adequate information. It includes four basic and interrelated sub-elements, the first of which is that the person in question have a factual understanding of the situation, which includes relevant needs and alternatives.... The second sub-element requires an appreciation of the seriousness of the condition and the consequences of accepting or rejecting treatment.... The third sub-element is the requirement that the patient express a preference. This preference does not have to be consistent with the clinician's preference, or with what she thinks would be in the patient's best interests.... The fourth and final sub-element of competence demamnds that the patient be capableo f working with the information disclosed by the clinician in a rational fashion."

"Mental Illness and the Freedom to Refuse Treatment: Privilege or Right" by Ronald Bassman. Professional Psychology: Research and Practice, 36(5), Oct 2005, 488-497.
Excerpt: "Most people are allowed to make extremely foolish life decisions without facing government intervention. You can choose to smoke until you die. You can eat so much that you cannot get through the doorway to leave your home. Being a member of a recognized religion allows you to make a health decision based on a tenet of your religion even if it may put your life in danger. But if you are a mental patient, there is an automatic bias to believe that you are incapable of making good decisions. Therefore it is necessary for the court to determine what is in your best interest regardless of your beliefs. The freedom to make poor choices is a privilege that is denied to the person who is labeled mentally ill. Chronicity means always having to prove that you have the capacity to make appropriate independent choices. To comply with the requirements of your supported group-living arrangement, you may be forced to attend a day treatment program from morning until evening. Your money, and how you spend it, can be controlled by a court-appointed payee or guardian. When being a mental patient is the overriding explanation of who you are, you must endure others' suspicion and monitoring of your personal decisions. When judging whether a person with a serious mental illness diagnosis has the capacity to understand the cost-benefit ratio for making a decision, an underlying assumption of global incapacity often guides that determination. In health decisions, Gert (1997) advises that capacity evaluations for a particular decision should always be situation-specific. Other medical ethicists want capacity determinations to be based on assessments that reflect general reasoning ability rather than being situation-specific (Freedman, 1981). Also, there are ethicists who argue for the inclusion or exclusion of risk and consequences as primary factors to consider in capacity evaluations (Wicclair, 1991). Ethicists do agree that significant efforts need to be made to include a person's preferences and values in the decision-making process regardless of disability. Substituted judgment that is deemed to be in the best interest of the patient occurs too frequently for people with mental, physical, sensory, and cognitive disability (Mitchell & Snyder, 2000; Prilleltensky & Nelson, 1997). The complexity of these decisions demands more than the loose and arbitrary practices that a person faces today."

Decoding the ethics code: A practical guide for psychologists by Celia B. Fisher. Thousand Oaks, CA: Sage, 2003.
Excerpt: "Informed consent is seen by many as the primary means of protecting the self-governing and privacy rights of those with whom psychologists work. In the 1992 Ethics Code, the obligation to obtain informed consent was limited to research and therapy. In the 2002 Ethics Code, the broader informed consent requirement for most psychological activities reflects the societal sea change from a paternalistic to an autonomy-based view of professional and scientific ethics."

Ethics and Values in Psychotherapy by Alan C. Tjeltveit. London: Routledge, 1999.
Excerpt: "[F]eminist therapists (Feminist Therapy Institute, 1990), explicitly religious therapists (e.g., Jensen and Bergin, 1988), and others have argued that therapists should be explicit about their ethical convictions. As the Feminist Therapy Institute Code of Ethics states, "feminist therapists recognize that their values influence the therapeutic process and clarfiy with clients the nature and effect of those values" (FeministTherapy Institute, 1990: 38). Doing so makes truly infomed consent possible. And if clients know their therapist's values, therapists are less likely to have an untoward influence on client values."

Medical Choices, Medical Chances by Harold J. Bursztajn, Richard I. Feinbloom, Robert M. Hamm, and Archie Brodsky. San Jose, CA: iUniversity Press, 2000.
Excerpt: "The term informed consent is used to describe the requirement that a doctor inform the patient (within reason) of the available options and the risks of each. The weakness of this concept lies in the word consent, which implies a passive consumer accepting options that the doctor (like a car dealer) presents, rather than participating in creating the options. The words informed choice better describe the scienfific gambling that patients and doctors...must do together."

"Informed Consent: Do You Know It When You See It? Evaluating the adequacy of patient consent and the value of a lawsuit" by Michael Lamport Commons, Joseph Anthony Rodriguez, Kathryn Marie Adams, Eric Andrew Goodheart, Thomas Gordon Gutheil, and Ellen Davis Cyr. Psychiatric Annals, 36(6), June 2006, 430-435.
Excerpt: "This study consisted of brief vignettes of counselors obtaining informed consent. Each vignette represented an order of hierarchical complexity as explained in the introduction. Rasch analysis was used to determine--in an objective, empirical manner--the degree of perceived effectiveness of informed consent in each vignette."

"Manageing Uncertainty: The Therapeutic Alliance, Informed Consent, and Liability" by Thomas G. Gutheil, Harold J. Bursztajn, Archie Brodsky, and Victorial Alexandra, in Decision-Making in Psychiatry and the Law edited by Thomas G. Gutheil, Harold J. Bursztajn, Archie Brodsky, and Victorial Alexandra. Baltimore, MD: Williams & Wilkins, 1991.
Excerpt: "The most serious problem with the consent form, however, is not its language, the response it elicits from the patient, or the circumstances in which it is profeered and signed. The overriding danger of the form is that it tempts the clinician to treat the transaction as a discrete tas that is accomplished, and thus terminated, once the patient has signed the form. This unfortunate misuse of the form defeats the very purpose of informed consent, which is to foster and sustain an ongoing diablogue between patient and physician, as part of the process of joint decision making. Ideally, informed consent is never over. At any point along the way, the patient should feel free to ask questions about the impact of the treatment...."

"APS Position Statement on the Use of Placebos in Pain Management" by Mark Sullivan, Gregory Terman, Brian Peck, Darin Correll, Ben Rich, Cawford Clark, Kenneth Latta, Allen Lebovits, and Gerold Gebhart. Journal of Pain, 6(4), Apr 2005, 215-217.
Excerpt: "The American Pain Society (APS) opposes the inadequate treatment of pain using any therapeutic modality including the use of placebo.... Informed consent is essential in all therapeutic situations, including the use of placebo. The deceptive use of placebos and the misinterpretation of the placebo response to discredit the patient's pain report are unethical and should be avoided....Health care providers, when using placebos, have an ethical obligation to ensure that placebos are not used for the punishment, deception, or long-term undertreatment of patients with pain. The use of informed consent is essential in all therapeutic situations, including those involving placebos."

"Informed Consent to E-therapy" by Patricia R. Recupero and Samara E. Rainey. American Journal of Psychotherapy, 59(4), 2005, 319-331.
Excerpt: "Although e-therapy has numerous proponents, no clinical trials have assessed its long-term effectiveness. To limit liability and to protect patients, e-therapy providers should disclose material risks as well as possible benefits and engage patients in an active dialogue. A thorough informed consent procedure enables patients to make an educated decision about whether e-therapy is right for them. In the future, e-therapy and informed consent online may become more common; in the mean time, clinicians must be prepared for e-therapy's uncertain legal status and allow patients to decide for themselves whether or not to seek counseling on the Internet."

Related Material:
A Practical Approach to Boundaries in Psychotherapy: Making Decisions, Bypassing Blunders, and Mending Fences
Boundary Issues in Psychotherapy: Widely-used Guides, Research, & Resources
Ethics Codes & Practice Guidelines for Assessment, Therapy, Counseling, & Forensic Practice
Ethics for Psychologists: 7 Essential Steps
Psychological Assessment: Clinical and Forensic
Ethics & Malpractice
Psychology Laws & Licensing Boards In Canada & the United States

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