Informed consent is an essential component of every psychotherapy relationship. When conducted effectively it lays the foundation for the psychotherapy relationship and process to come.

The informed consent process ensures that clients possess the information necessary to make an informed decision about participation in the services being offered.

As Handelsman (2001) articulates, we must provide each client with sufficient information “so that they can make intelligent, reasoned, choices, about whether to participate in treatment” (p. 453).

Informed consent is required by the codes of ethics of each of the mental health professions as well as by each profession’s licensing laws. While many of the details of informed consent are articulated in these standards and laws, how to implement the informed consent process ethically, effectively, and in a manner that promotes positive therapeutic outcomes, is not.

Thus, psychotherapists, clinical supervisors, psychotherapy researchers, and educators may have questions about how to most appropriately and effectively implement this important process into their ongoing work.

Take the Informed Consent Quiz

To assess your understanding of informed consent, test yourself with the following quiz (True/False):

[1] Informed consent is based on autonomy, the basic right of every client, one of the underlying ethics virtues.

[2] Informed consent should occur before you meet with the client.

[3] One of the essential components of informed consent is describing the treatment being proposed and an explanation of its likely course.

[4] Every element of the informed consent agreement should be reviewed with the client at the beginning of the initial session.

[5] One of the four criteria that must be met for informed consent to be considered valid is actively ensuring that clients understand the information being shared and that they are agreeing to.

[6] Every client’s informed consent should be obtained at the outset of the professional relationship.

[7] To ensure their understanding of the details of the informed consent agreement each client should be given a 60-question multiple-choice test to assess their knowledge of all relevant information.

[8] Handing the client a 12-page long informed consent document and having them sign it is considered informed consent.

[9] If you regularly see your client on Mondays at 10:00am and one week you need to make the appointment for 11:00am, you’ll need to update or modify the informed consent agreement.

[10] Telling the client “Don’t worry; everything will turn out fine” is a great example of informed consent.

[11] Even minor clients (typically, those under the age of 18) have the right to decide if they will participate in psychotherapy and what the treatment plan will be.

[12] With Question #11 in mind, we can ethically fulfill our informed consent obligations to minors who we are treating by getting their assent.

[13] Assent follows a “one size fits all” approach so that we are consistent in how we treat others and don’t give anyone special or preferential treatment.

[14] Minors are the only ‘clients’ with whom we should provide assent and not informed consent.

[15] All minor ‘clients’ must assent at the outset of the treatment relationship.

[16] One of the benefits of the informed consent process is that it sets a collaborative tone for the psychotherapy relationship and promotes the therapeutic alliance.

[17] All professional services need informed consent from the recipient at the outset of the professional relationship.

[18] If I teach a course on psychotherapy, I need to obtain informed consent from my students at the beginning of the course.

[19] The one additional element that is added to informed consent for clinical supervision that is not present in informed consent for psychotherapy is the evaluation of the supervisee and with whom it will be shared.

[20] To make your written informed consent document look as professional as is possible, you should include lots of professional jargon and erudite-sounding words?

[21] You don’t need to add in anything else to the usual components of informed consent to psychotherapy when soliciting informed consent to participate in research.

[22] If I have them sign an informed consent document, I can require my students or supervisees to be subjects in a research study I am conducting.

[23] It is okay to secretly audio or video record clients and research subjects as long as they don’t find out about it.

So, How Did You Do?

Did any of the answers surprise you, or give you ideas of how to improve your informed consent process?

Perhaps you can utilize this quiz in your training of students and supervisees to help ensure their understanding of this important process. Whether you’re a clinician, researcher, educator, or supervisor who has been working in the field for many years, are new to the field, or are in training, it is important that we each competently fulfill our informed consent obligations with all those to whom we provide services in our professional roles.

Desired Responses

[1] True. A key goal of the informed consent process is to promote each client’s autonomy. It might be easy to simply inform clients of the treatment we will be providing them based on our assessment of their treatment needs, but each client has the right to decide if they want to participate based on a comprehensive understanding of the services to be offered.[Go Back to the Quiz]

[2] False. The informed consent process may start prior to meeting the client such as through information shared on one’s website or with a written informed consent agreement provided to the client prior to the initial session, but these are not informed consent, only some of the components of it. Informed consent is not a single event, but an ongoing process that may be updated or modified throughout the course of treatment.[Go Back to the Quiz]

[3] True. This is one of several essential elements of every informed consent agreement. These include:

• Confidentiality and all applicable exceptions or limits to include mandatory reporting requirements.
• The involvement of any third parties.
• Fees and financial arrangements to include any charges the client might reasonably anticipate.
• The treatment being proposed and an explanation of its likely course.
• Options and alternatives reasonably available and their likely risks and benefits, to include no treatment at all.
• The voluntary nature of participation in treatment and the right to withdraw from it at any time.
• How to contact the psychotherapist between treatment sessions and when it is appropriate or necessary to do so.
• Any recording of treatment sessions.
• Termination issues and process.

[Go Back to the Quiz]

[4] False. This is definitely not realistic. Would you spend the first 30 minutes going over all this information with a client who is in crisis, such as an actively suicidal client? We must use our clinical judgment and determine how much information to share, and when to share it, based on the client’s clinical needs and presentation. We do need to review all of the informed consent agreement with each client, but not necessarily all at once. Most codes of ethics require us to obtain the client’s informed consent as early as is feasible in the professional relationship. We are authorized to use our professional judgment to determine when and how much to share based on each client’s particular needs and presentation.[Go Back to the Quiz]

[5] True. The four criteria that must be met for the informed consent process to be considered valid are:

• The consent must be given voluntarily. It cannot be coerced.
• We must actively ensure that clients understand the information being shared and that they are agreeing to.
• The client must be competent to give consent. This means that the client must possess legal competence (the legal right to give her or his own consent) and mentally/emotionally competent (a client with dementia or who is psychotic will likely not be able to understand the information provided).
• The informed consent must be documented (Barnett, Wise, Johnson-Greene, & Bucky, 2007).

[Go Back to the Quiz]

[6] Trick question. This really gets at who the client is. The ‘client’ is not always the individual who you are treating in psychotherapy. One must assess who has the right to provide informed consent for the treatment being offered. At times, the client might be an agency, the court, or a parent who is bringing her or his child to treatment. We must determine who the various parties involved are and what our obligations are to each of them, clarifying all this from the outset (Fisher, 2009). [Go Back to the Quiz]

[7] Definitely not. That’s the state jurisprudence exam for licensure that is a 60-question multiple-choice exam. We don’t want to do that to any client! But, we do need to actively ensure their understanding of that to which they are agreeing. Having clients explain to us in their own words the details of the informed consent is preferable to asking, “Do you have any questions?” That doesn’t actively ensure their understanding and most clients will simply respond that they don’t have any questions, which doesn’t mean they actually understand the details of the informed consent agreement. [Go Back to the Quiz]

[8] False, false, false. See items 5 and 7 above if you need more of an explanation.[Go Back to the Quiz]

[9] Let’s not go overboard here. It is true that we should update the informed consent agreement if any significant or substantial changes will be made to the parameters of treatment that the client agreed to. This could include adding group therapy or couples therapy to a client’s individual psychotherapy, or the number of sessions you’re having per week. What makes these substantial changes to the informed consent agreement is that they bring with them additional potential risks and benefits that the client has the right to be informed about before agreeing to participate. [Go Back to the Quiz]

[10] You even had to look here to see if you were correct? Of course not. First of all, we can’t promise any specific results. Secondly, there was no relevant information shared to assist the client in making her or his decision. It is not for us to decide what the course of treatment is. We recommend, not dictate. [Go Back to the Quiz]

[11] False (sort of). While there are some exceptions in each jurisdiction’s laws that allow certain minors to give their own consent to treatment, in general, the parent(s) or guardian(s) have this right, thus technically making them the client, not the minor to whom you are actually providing treatment. [Go Back to the Quiz]

[12] True. While the parent(s) or guardian(s) typically have the legal right to give or withhold informed consent for the minor’s treatment, we must obtain the minor’s assent to treatment. Assent involves providing information to a minor ‘client’ in a manner understandable to her or him. Even if they do not have the legal right to give their consent to treatment they have the right to be informed of the parameters of the relationship and the treatment to follow. [Go Back to the Quiz]

[13] No way. Information should be shared with minor ‘clients’ in a manner appropriate with their developmental level. Thus, one would share information differently with a five-year old, a 10-year old, and a 15-year old. In fact, minors’ abilities to understand the information being shared and its potential impact on them, as well as to participate in the decision-making process, increases over time (McCabe, 2006). [Go Back to the Quiz]

[14] False. Answers to questions 5 and 6 would be good refreshers. We must seek assent with any individual who is not competent legally or emotionally to provide her or his own consent to treatment. This could include adults who suffer from dementia or a psychotic disorder, for example, and thus are unable to meet the criteria detailed in the answer to question 5. [Go Back to the Quiz]

[15] False. See #11 above. Carefully read the relevant laws in your jurisdiction. In some states 16- and 17-year olds have the same rights as adults to consent to their own treatment. Laws can vary by state, so being familiar with the laws in your jurisdiction is crucial. [Go Back to the Quiz]

[16] True. Not only does it benefit rapport-building, but it promotes the client’s autonomy and empowers the client to play an active role in the treatment process, promotes shared decision-making power in the relationship, and it helps minimize the risk of exploitation of, and harm to, the client by helping them understand acceptable parameters of the relationship and treatment process (Barnett et al., 2007). [Go Back to the Quiz]

[17] True. If it is a service you are providing in your professional capacity or role, you must first obtain the recipient’s informed consent before providing the service. This includes psychotherapy, assessment and testing, consultation, research, and clinical supervision. [Go Back to the Quiz]

[18] Okay, so if you are thinking of this in terms of how you obtain a client’s informed consent that is not feasible – so false. But, what about the course syllabus? Does it include expectations and obligations of each party, and does it provide sufficient information so that the student has reasonable expectations about what to expect (a term paper, pop quizzes, a mid-term and final exam, attendance is taken and is worth 10% of the course grade, class participation counts and is worth 15% of the course grade, all papers must comply with APA style, are there any penalties for turning in work late, how do students contact you in between classes if they have questions, etc.)? In that case, True; having a course syllabus and reviewing it with students addresses informed consent obligations in the educational setting. [Go Back to the Quiz]

[19] True. Evaluation of the supervisee’s performance and with whom this is shared, such as with the supervisee’s training director, is what gets added to the informed consent in supervision. All supervisees have the right to receive timely and constructive feedback on an ongoing basis so they have the opportunity to remediate any deficiencies. They also have the right to know what these evaluation criteria are from the outset of the supervision experience and to know with whom the evaluation feedback will be shared. [Go Back to the Quiz]

[20] Wow; erudite might be a good word to include in informed consent agreements. How about propitious or sanguine? We like to use these intelligent-sounding words whenever possible. Just kidding! Although these are great GRE words, written informed consent documents should be at a level appropriate for the vast majority of likely clients. Noting that approximately 50% of the adult population in the U.S. reads at less than the 9th grade reading level, ideally, this will be at the 6th to 8th grade reading level to ensure maximum comprehension of these documents (Walfish & Ducey, 2007). Sadly, in one study, Handelsman et al. (1995) found that two thirds of the informed consent documents they analyzed were written at above the college level. Use the Flesch-Kincaid Grade Level tool in Microsoft Word to determine the grade level of reading difficulty of all your documents. [Go Back to the Quiz]

[21] False. There are many other aspects that should be included in this type of consent. For example, the right to decline to participate and to withdraw from the research at any time without penalty; possible consequences of declining or withdrawing; any potential risks, discomfort, or adverse effects; and any compensation or costs associated with participation. [Go Back to the Quiz]

[22] Where to begin with this one? First, signing a document is not informed consent. Second, ‘requiring’ them to do anything violates the obligation that informed consent be given voluntarily. And, can one of your students or supervisees really decline freely without any fear of consequences to them in their roles as students or supervisees? There is an imbalance of power in the faculty/student and supervisor/supervisee relationships that should not be exploited or taken advantage of (Gottlieb, Robinson, & Younggren, 2007). [Go Back to the Quiz]

[23] No way! Unless we first obtain the client’s or research participant’s permission through the informed consent process, no recording is allowed. [Go Back to the Quiz]

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Jeffrey E. Barnett, Psy.D., ABPP

Jeffrey E. Barnett, Psy.D., ABPP is a Professor in the Department of Psychology at Loyola University Maryland and a licensed psychologist who is board certified by the American Board of Professional Psychology in Clinical Psychology and in Clinical Child and Adolescent Psychology. Additionally, he is a Distinguished Practitioner in Psychology of the National Academies of Practice. Among his many professional activities, Dr. Barnett is a past chair of the ethics committees of the American Psychological Association, the American Board of Professional Psychology, and the Maryland Psychological Association. He previously served on the Maryland Board of Examiners of Psychologists and has been a consultant to licensing boards across a range of health professions. His numerous publications and presentations focus on ethics, legal, and professional practice issues in psychology. Dr. Barnett is a recipient of the APA’s outstanding ethics educator award.