Informed consent is an extremely important part of the therapeutic process. But what is it? What should informed consent include? And what are the best practices for informed consent?! This post (and the corresponding video) cover all that and more!
Of course, the best place to start is to define what informed consent is. According to the American Counseling Association, or ACA, they define informed consent as “a process of information sharing associated with possible actions clients may choose to take, aimed at assisting clients in acquiring a full appreciation and understanding of the facts and implications of a given action or actions.”
In other words, informed consent is about helping a client understand the benefits they may experience from therapy, but also understanding the possible risks that could be associated with it. The idea is that you want to give clients the information they need to make an informed decision about if therapy is right for them, and if the potential risks are worth the benefit they might receive.
While we generally talk about informed consent for individual therapy, this isn’t the only situation where it applies. Informed consent also needs to be given in research settings, as well as other counseling settings, such as group, couples, or family therapy.
Let’s talk about some of the general best practices related to informed consent. I should say, this is not an exhaustive list, but it is some of the common things to consider with informed consent.
Verbal & Written Formats – First, it’s best to go over informed consent with clients in a verbal and written format. Meaning that you’ll want to talk through the information with them. But you’ll also want to have the information in a written format for them to review as well. The client should also sign a document confirming their agreement with the information covered.
Start with Informed Consent – Ideally, informed consent will be covered at the beginning of the therapeutic process. In other words, it should be covered at the beginning of the first therapy session, or at the beginning of a group session. Of course, there are times where people may come in for their first session and immediately start to talk about what has brought them in. It can be as if they are a bottle of Coke with Mentos put into it, if you’ve ever seen that, where all the pressure has been building and building, and now they have an opportunity to let that pressure go a bit and they can’t stop themselves. In those cases, it’s probably necessary to let them get a bit of this out, validate what they’ve said, and then direct the conversation to the informed consent aspects. Once you’ve discussed that and they provide consent, you can bring things back to what has brought them in.
On-Going Informed Consent – Often, people can have this idea that informed consent is a one-time thing. However, the third important piece for us to cover here is that informed consent is an on-going process. Clients can end their consent for treatment at any point. Not only that, but they should be made aware of the risks and benefits throughout their treatment. This isn’t something we should only discuss at the beginning.
Assent vs Consent – Fourth, if you’re working with a minor or an adult who has a legal guardian, it is important to remember that your client cannot provide informed consent themselves. Instead, the guardian is the one who has to provide informed consent. Of course, it is important that your client also agrees with what was covered there. Their agreement uses a similar term, which is assent. We want to have the client—even though they cannot consent themselves—provide their assent for treatment.
Consideration for Mandated Clients – Fifth, it is also important to remember that mandated clients will have additional information they need to be aware of when providing informed consent. Commonly, this would include any potential limitations to the confidentiality of sessions. For example, if they were court-ordered to come to therapy, the court may require records from sessions to be provided as proof the client attended, and that they are appropriately engaging in services. Of course, clients still have the right to refuse therapy. However, the counselor will also want to do their best to make sure clients are aware of the potential consequences of refusing services. Therefore, they need to be informed of the risks and benefits of receiving therapy, and also those related to refusing these services.
Let’s take a look at a list of common information you’ll want to cover as part of the informed consent process. This is a somewhat lengthy list, but keep in mind that this still is not a complete list. This will hopefully help you figure out what should be covered in relation to informed consent in your practice.
Risks – In no particular order, number one is to cover the potential risks. We need to make sure that clients know what risks exist from therapy, and any risks that may be more specific to them as an individual.
Benefits – Number two, clients should also know the benefits they might get from therapy. This can help them have more realistic ideas of what the process might look like, and also help them see what therapy can help with since they might not be aware of that.
Ending Therapy – Three, they should be made aware that they can end therapy at any time. This might mean they stop entirely, take a break, or that they switch to a different therapist.
Confidentiality – Number four, clients need to be made aware of the confidentiality that exists in the therapeutic relationship. Many people are surprised by the confidentiality they get in this setting, so helping them understand this can help them feel more comfortable.
Limits of Confidentiality – Five, they also need to have an understanding of the limitations of confidentiality. This can include the more obvious examples, such as if they were a risk of harm to themselves or someone else. But it also includes how notes are kept, if they are coming as part of a court order and how that can change things, or if they are using insurance and how that information is handled.
Costs – Six are the costs that can be associated with therapy. This might include the fee for sessions and what insurances are accepted, if any. Another aspect of this is expectations for payment, and what happens if there is non-payment. Some practices offer variable fees, such as a sliding scale, and clients should be made aware of this.
Boundaries – Number seven is helping clients understand the various boundaries that exist. This might be how they can contact you, and that something like trying to connect with you on your personal social media isn’t appropriate. What hours your office is open, and setting the expectation of what response times can look like might also be a part of this. Covering what happens if you and the client come into contact out of session something that can be covered as well, especially if you are in a rural setting such as I am. Another example in this area might be what clients should do if they are in a crisis state or an emergency situation, and whether they can contact your office in that situation.
Supervision & Consultation – Eight, you should help clients understand supervision and consultation, how this can impact their confidentiality, the role that this plays in their care, and how those who supervise or consult you are held to the same confidentiality.
Qualifications – Number nine, clients should be made aware of your qualifications, credentials, and your professional experience. For example, if you are a student, let them know that you are under supervision, and that they have the option to see a licensed professional if they choose.
Technology – Ten, clients should be made aware of technology, the benefits and risks of technology. If you are meeting with the client virtually, this could include information about the virtual platform being used. It might also include information about the setting where they are joining from and if they have privacy, the setting where you are and how you are maintaining their confidentiality, and what happens if privacy is interrupted.
Records – Number eleven. Letting clients know that you keep notes on the sessions is important. You’ll also want to help them understand their ability or limitations to accessing these records, how their records are maintained, and what other people have access to these records. The others that might have access will vary, but could include their insurance provider, other providers they are seeing, or those they have signed a release for to be able to access those records.
Policies – Twelfth, this would include any other information that is specific to your practice that they should be aware of. This could include policies about no-shows, policies and expectations about cancellations, or the scheduling process or limitations.
And More – Finally, there is some other information that might apply. This might include, diagnosis and the potential implications of this; the approaches, modalities, or techniques used; any testing that is being done and the relevant information regarding this; reports that are being generated and what happens with them; the relevant research policies for the setting you’re practicing in; and the client’s goals for therapy.
The question remains, what if a client does not consent to therapy? This does happen, and obviously will change a bit based on the context this is happening in. But, at the most basic, if a client does not consent, therapy cannot continue.
When this happens, it might be a good idea to ask the client if they have any specific concerns. Keep in mind though, you don’t want to try to change the client’s mind if they have decided. That said, clarifying their reasons can be helpful as they might have misunderstood something. This would give you an opportunity to re-explain something, and they may then consent with that improved understanding.
For example, if you tell them that you are under the supervision of another professional who maintains the same confidentiality as you. Then, after all the needed informed consent information has been reviewed, the client says they do not want to continue because they don’t know what your supervisor will tell other people, this would give you the opportunity to reiterate that your supervisor is also bound by confidentiality. The client may have missed that information and then feel comfortable consenting to treatment.
In other cases, such as if you are a student, the client may just decide they are not comfortable seeing a student. There may be no amount of information that will change this. In that situation, the client should be informed that therapy cannot continue. And then, depending on the policies at your location, they should be offered services from a licensed professional.
In some situations, clients might be coming to therapy because a guardian has brought them, or due to a court order. If these clients do not provide assent or consent, they still have the right to end services. But, to the best of your ability, you should help them to understand any consequences that may come from their choice not to continue with therapy.
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