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.
"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
"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
Principles of Informed Consent in Psychiatry, June, 1996
(NB: This is a "resource" and does not represent APA policy.)
(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.
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. Almost all 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 May/June and July/August issues of the FMS Foundation newsletter:
PERSPECTIVES ON INFORMED CONSENT
Allen Feld (Part 1)
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 (Part 2)
Allen Feld
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.