It may be easy to view informed consent as one of those obligations all psychotherapists must meet in order to stay out of trouble. After all, no one wants an ethics complaint, licensure board complaint, or malpractice suit. And, if we ever do become the subject of any of these we will definitely want to have met our informed consent obligations to our clients in an exemplary manner.

To support this point, Knapp, Younggren, VandeCreek, Harris, and Martin (2013) highlight informed consent as one of the three essential risk management strategies recommended (along with documentation and consultation) for reducing the risk of the above-mentioned undesirable events from occurring.

But, these authors do not focus solely on the use of risk management strategies to protect the psychotherapist from complaints, disciplinary actions, and law suits. Rather, they focus on an approach that involves doing our best to fulfill our ongoing obligations to our clients to provide them with the highest quality of services possible (Knapp et al., 2013). This approach, known as aspirational ethics (Handelsman, Knapp, & Gottlieb, 2002) guides psychotherapists not to just do the minimum required of us (the floor), but instead to aspire to do the best we can in all our professional endeavors (the ceiling).

From an aspirational ethics approach, informed consent can easily be seen as an essential aspect of the psychotherapy process and of every psychotherapy relationship. A consideration of the goals of informed consent and its likely benefits reinforces this point. But first, just what do we mean by “informed consent”?

Informed consent is a process that involves the psychotherapist sharing sufficient information with the client or prospective client so the client can make an informed decision about participation in the proposed course of treatment. The client provides her or his informed consent based on being adequately informed about what they are considering participating in. With regard to how much information to share in this process, what specific information should be shared, when it should be shared, and in what format(s), the goals and potential benefits of informed consent are relevant to consider.

Goals and Benefits of Informed Consent

Snyder and Barnett (2006) list potential goals and benefits of an appropriately conducted informed consent process as including “promoting client autonomy and self-determination, minimizing the risk of exploitation and harm, fostering rational decision-making, and enhancing the therapeutic alliance” (p. 37). More specifically, informed consent:

• Empowers clients by providing them with needed information, thus reducing their dependence on the psychotherapist and promoting their autonomous functioning (Beahrs & Gutheil, 2001).
• Fosters collaboration between the psychotherapist and the client and sets the tone for a collaborative working relationship, encouraging trust, openness, and sharing in the relationship (Barnett, Wise, Johnson-Greene, & Bucky, 2007).
• Reduces the risk of exploitation or harm of clients by informing clients of reasonable expectations in roles, responsibilities, and behaviors (Barnett et al., 2007).
• Improves the therapeutic relationship by increasing clients’ understanding of the treatment being proposed, thus demystifying the process and reducing clients’ anxiety and apprehension (Beahrs & Gutheil, 2001; Sullivan, Martin, & Handelsman, 1993).
• Promotes ethical practices through fostering respect of the client’s right to dignity, and sense of autonomy, justice, and integrity (APA, 2010).

Informed Consent Essentials

While there are a number of standards that must be met for informed consent to be considered valid, the informed consent process should be customized to meet the needs of each client to ensure that she or he is truly making a fully informed decision about participation in the professional services being offered (Pope, 1991).

For the informed consent process to be considered valid:

• Consent must be given voluntarily.
• The client must be competent (legally as well as cognitively/emotionally) to give consent.
• We must actively ensure the client’s understanding of what she or he is agreeing to.
• The information shared and all that is agreed to must be documented.

Additional important considerations include that:

• Informed consent is an ongoing process, not a single event. The agreements made should be updated over time when changes in the services being offered are proposed and are being considered.
• Informed consent should be woven into the psychotherapy process and not seen as a separate event or entity.
• This sharing of information should begin “as early as is feasible in the therapeutic relationship” (APA, 2010, Standard 10.01 Informed Consent to Therapy) and continue over the course of the professional relationship.
• Information should be shared both verbally and in writing and presented in a manner that can reasonably be understood by the client.
• The client should be actively included in the informed consent process and specific efforts should be undertaken to ensure their understanding (Pomerantz & Handelsman, 2004); clients should not be passive recipients of information who merely sign a form that is presented to them.
• Who “the client” is should be clarified from the outset so that informed consent may appropriately be obtained (e.g., the person seeking evaluation or treatment, a third party requesting or ordering the evaluation or treatment, a couple, a family).
• Cultural and other aspects of diversity must be considered to ensure that the manner of seeking informed consent from the client respects and supports the client’s values and beliefs (e.g., including family members or community elders in the informed consent process, modifying how information is shared for a client who is visually or hearing impaired).
• For those prospective clients who lack the capacity to give informed consent (e.g., individuals mandated into treatment, minors who lack the legal right to give consent, individuals with cognitive impairment) psychotherapists should still engage in an assent process, sharing information with the client to assist the client to participate in this process to the fullest extent possible and obtaining informed consent from their legally authorized representative.

Information to Be Shared so the Client May Give Truly Informed Consent

The Code of Ethics for the psychotherapist’s profession and relevant laws and regulations in the jurisdiction where she or he is licensed should be consulted for a listing of the specific information to be shared with each client as part of the informed consent process. But, essential information to be included for all clients’ consideration includes:

• The nature and anticipated course of the proposed evaluation or treatment.
• The psychotherapist’s credentials and relevant professional experience.
• The client’s right to refuse or withdraw without penalty, emphasizing the voluntary nature of participation.
• Reasonably available treatment options and alternatives, and their relative risks and benefits, to include no treatment at all.
• Fees and financial arrangements to include billing, payment, and the role, if any, of insurance.
• Confidentiality and its limits to include all applicable mandatory reporting requirements.
• The involvement of any third parties.

Psychotherapists should keep in mind that it is the client who provides their consent to the proposed course of treatment. The amount and type of information shared should be what the typical prospective client would need or desire to be able to make an informed decision about participation (Barnett, et al., 2007).

Thus, we must provide them with adequate information so that they may make a fully informed decision about participation. Failure to provide the client with adequate information and failure to ensure her or his understanding invalidates the consent.

Many clients enter treatment in significant distress and may feel overwhelmed by the experience. Thus, it is vital that we assist them to understand the information being shared, to process their reactions to the information, and to assist them to make decisions in support of their best interests.

For some clients, it may prove to be especially helpful to them to review and discuss the essential information relevant to the professional services being offered on multiple occasions over time. This may help ensure their full understanding of what they are agreeing to.

Informed Consent Challenges

There are several circumstances relevant to the informed consent process that may present challenges for psychotherapists. Commonly occurring situations include:

• Court ordered or other ‘clients’ who are not the actual client – In accordance with Standard 3.07, Third-Party Requests for Services (APA, 2010), psychotherapists must clarify who the actual client is; that is, to whom do we owe which obligations (Fisher, 2009). We may need to obtain informed consent from the third party (e.g., the court, an employer, a state agency), and obtain assent from the individual who will receive the professional services. We must ensure that individual’s right to refuse participation as well as any potential consequences for doing so. Additionally, if there are limits to confidentiality such that all information shared in the evaluation or treatment may be disclosed to the referring party, this must be clarified from the outset.
• Others who are unable to give voluntary informed consent – Individuals such as prisoners, inpatients who are involuntarily committed, individuals who lack the cognitive capacity to give consent, and minors, each may not have the actual right to provide their own informed consent to evaluation and treatment. In these situations we must obtain their assent while obtaining consent from the appropriate third party. In keeping with the practice of reviewing and updating the informed consent agreement over time, if the client’s capacity to provide informed consent changes over time, then their consent for further participation (or for refusal to continue) in treatment should be obtained at that time.
• When the psychotherapist is an unlicensed trainee who is practicing under supervision – In keeping with Standard 10.01 (c), Informed Consent to Therapy (APA, 2010), when a psychotherapist is practicing under the supervision of a licensed professional the existence and nature of this supervision must be shared with prospective clients as part of the informed consent process. The trainee psychotherapist must never state or imply independent practice and must ensure that the prospective client understands the limits to confidentiality this supervisory relationship brings with it. Further, clients should be informed of the supervisor’s name and contact information as well as an explanation of the supervisor’s role in the client’s treatment (See Thomas, 2010 for additional guidance on this).

Concluding Thoughts

While it is true that engaging in the informed consent process with each client is an important risk management strategy for psychotherapists, more importantly it also is an expression of the aspirational goal of ensuring that clients receive the best professional services possible. For psychotherapists, embracing the spirit and practice of informed consent is essential for laying the foundation of a collaborative treatment relationship that promotes the client’s autonomous functioning, that is built upon respect and trust, and that helps to promote positive treatment outcomes.

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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.