The importance of considering individual differences and diversity in our clinical work has rightly received increased attention in recent years. The relevance of individual differences and diversity to all aspects of the professional services psychologists provide is clearly articulated in the Ethical Principles of Psychologists and Code of Conduct (Ethics Code, APA, 2010) in Principle E, Respect for People’s Rights and Dignity, which states in part:
Psychologists are aware of and respect cultural, individual and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status, and consider these factors when working with members of such groups. (p. 4)
This emphasis on considering individual differences will necessitate modifying how we think about clients, impacting our understanding of their treatment needs, how we assess and provide treatment to them, and even how we interact with them (Fouad & Arrendondo, 2007). This is reflected in Standard 2.01(b), Boundaries of Competence, which requires that psychologists are educated and trained sufficiently to understand the roles that individual differences play when evidence indicates that this understanding “is essential for effective implementation of their services” (p. 5).
Similarly, the APA Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists (APA, 2003) emphasizes the awareness, sensitivity, knowledge, and skills needed to be multiculturally competent so that psychologists may effectively meet “the different needs for particular individuals and groups historically marginalized or disenfranchised within or by psychology based on their ethnic/racial heritage and social group identity or membership” (p. 1).
Psychotherapists are highly trained and experienced professionals who aspire to meet or exceed professional standards of clinical competence. A significant focus in each psychotherapist’s education and training is the development of clinical competence. In addition to developing the knowledge and skills necessary to provide effective clinical services to clients, to be considered competent, psychotherapists must also possess the attitudes and values necessary to effectively address each client’s individual clinical needs (Haas & Malouf, 2005). As professionals who value the well-being of every individual with whom we work, it is our ethical imperative to understand, value, and attend to all individual differences in our clients in order to provide the highest quality of care possible.
Informed Consent as a Foundation of the Psychotherapy Relationship
Informed consent is the process of the psychotherapist sharing sufficient information so that the client may make an informed decision about participation in treatment (Barnett, 2015). The informed consent process is a collaborative interaction with the client that sets the tone and lays the foundation for the relationship, process, and treatment that follows. It respects the client’s autonomy by promoting shared decision-making power and empowers clients to play an active role in treatment. And for many first-time clients or those unfamiliar with the services, it demystifies the process by increasing understanding of the proposed treatment, which can help to reduce anxiety and apprehension (Coffman & Barnett, 2015).
Yet, informed consent must be tailored to meet each client’s individual needs; there can be no ‘one size fits all’ approach. This necessitates an understanding of the many aspects of diversity that clients bring with them to psychotherapy along with the ability to modify the services we provide to best meet our clients’ needs (Dadlani & Scherer, 2009). Failure to do so may be alienating to the client and result in an ineffective treatment relationship being established; confusion, misunderstandings, or shame on the client’s part; and a lack of engagement in treatment.
Individual Differences and Informed Consent
Diversity factors can impact the informed consent process in a number of ways. Each individual difference mentioned in the APA Ethics Code (APA, 2010) may influence how psychotherapists implement the informed consent process. Yet, the APA Ethics Code and those of the other mental health professions (in the United States) are based on underlying principles that reflect Western values such as individuality and autonomy (Meer & VandeCreek, 2002). But, this may differ in other cultures. The various identities that clients hold may affect how they perceive, conceptualize, and view or value principles such as autonomy and confidentiality as well as mental health and health care in general. It is important that psychotherapists understand each client’s worldview and beliefs, not imposing our own values on clients.
As Padela, Malik, Curlin, and de Vries (2015) emphasize, the values that underlie the informed consent process, such as autonomy, are based on a Western viewpoint that may conflict with many clients’ worldviews. For some, a cultural norm of respect for authority figures and an expectation that highly educated health professionals know what is best for them can result in a reflexive response of deferring to the professional’s judgment and recommendations. In such situations, psychotherapists should be cognizant about the potential for influencing clients’ decision-making and endeavor to explore and understand each client’s best interests.
Clients from collectivistic cultures may have a very different view of autonomy and decision-making than those from Western (or individualistic) cultures. Some clients might be more comfortable having their family, parent(s), elders, community leaders, or religious leaders participating in the informed consent process or making treatment decisions for them. As clinicians in the Western world, our valuing of autonomy and independence may conflict with some clients’ values and beliefs. The value of respect may necessitate our acceptance of this “second-order autonomy” (Padela et al., 2015, p. 102) even if it appears on the surface to violate our accepted need to promote the client’s autonomous functioning. It is essential that we inquire about, understand, and respect each client’s values and work to integrate them into how we pursue the informed consent process.
Women who are members of certain churches and who hold certain religious values may defer to their husbands on all decision-making. The same may be true for individuals from a range of cultural backgrounds. Failure to respect these values and to impose our own values on them may result in misguided efforts to promote these clients’ autonomy and independent decision-making that will likely prove ineffective at best and may result in needed treatment services not being received.
The informed consent process may need to be modified for clients whose primary language is not the same as the psychotherapist’s or who are deaf or blind. The use of an interpreter, the need to modify one’s written informed consent materials, and the general need to ensure the clients are able to receive and understand the information necessary so they may make an informed decision about participation in treatment is essential.
Recommendations for Ethical Practice
It is essential that psychotherapists keep diversity factors in mind when preparing for and engaging in the informed consent process with each client. Not all forms of diversity are readily apparent so it is important not to make assumptions about clients’ individual differences, values, and needs. We should inquire about individual differences as they may be relevant to and impact the informed consent process for each client.
Some suggestions for integrating diversity factors into the process of informed consent include:
- Do your homework. Whenever possible, familiarize yourself with clients’ backgrounds prior to the first session and how they may affect the informed consent process. Learn about the various individual differences and backgrounds that clients may bring with them to psychotherapy. Since no one can be an expert on all individual differences and forms of diversity, seek supervision/consult with competent colleagues when necessary.
- Ask clients questions to gain a better understanding of what cultural values and beliefs clients may have about decision-making, confidentiality, psychotherapy, and mental health in general. Consider the impact of family structure, worldviews, and values, and how they may impact treatment.
- Be aware of how laws may at times conflict with behaviors practiced by different groups. Be prepared to address your legal and ethical obligations in a respectful and non-shaming manner.
- When possible, use the language preferred by clients. You may also choose to use an appropriately trained interpreter or refer clients to clinicians who can proficiently use the language. It is best not to use family members, such as an adult client’s child, as an interpreter, if this can be avoided.
- Consider whether the questions on your initial forms/applications respect the client’s identity, perhaps allowing the client to write in a response for how they identify rather than choosing from a finite number of discrete categories.
- Utilize Universal Design in the development of websites to ensure that clients with visual disabilities are not limited in their access to needed information (University of Washington, 2017). The use of a translation function on websites can assist clients whose primary language is not English to have access to needed information relevant to the psychotherapy services being offered.
- Open the topic up to clients – do they perceive any aspect of their age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language or socioeconomic status affecting their ability to consent to the proposed treatment? Do not assume anything; always ask.
- Remember that informed consent is not a single event, but an ongoing process. Engage in ongoing discussions with clients, and when appropriate, with others in their lives who are appropriate to include in the informed consent process.