The interviewed professional is Robin Giesen, a Licensed Marriage and Family Therapist. Giesen explains that informed consent is a term with both legal and ethical implications. She defines it as the permission a client gives to a therapist to proceed on a proposed psychotherapeutic procedure. In other scenarios, the consent may permit research or clinical study.
Informed Consent Process
According to Giesen, informed consent that she gets from her clients must follow three stages; client education, evaluation of the client's ability to understand the information provided, and obtaining the final consent.
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Client Education
At this phase, Giesen explains that her communication with the client is critical. She ensures the client is furnished with the nature of the psychotherapeutic procedure, the risks involved, benefits, and all relevant details that they need to be aware of. Communication must also take various forms to ensure the message is delivered. She writes emails, letters and records audio and verbal sessions while emphasizing detailed information about the procedure to be used. She also encourages clients to ask questions and seek clarifications on arrears they may not have understood. Alternative treatment or procedures are also explained at this stage. Giesen ensures that clients are aware of available options and make choices after elaborating on each option's possible outcomes. Also, she ensures that all this information is availed in a language that is easy to comprehend to enhance informed decision-making.
Evaluation of the Capacity to Understand Client Information
After a sufficient client education process, Giesen embarks on the evaluation process as her second stage. In this stage, she evaluates the client's capacity to understand the provided information and if they understood the information. Evaluating capacity involves analyzing several factors such as the age of the client, literacy levels, mental status, and severity of their conditions. These key parameters give a clue on the capacity of the client to understand the patient education classes. If the client can understand the information, Giesen evaluates whether the information was understood. She explains that capacity and actual understanding must be separated in the evaluation process. The client must demonstrate the ability to explain the basics of the procedure, risks, benefits, and potential outcomes. After this stage, Giesen verifies that the client has opted for a specific treatment choice with clear knowledge of benefits, risks, and potential outcomes.
Final Consent
The final phase that Giesen takes her clients through is the documentation of the consent. This is the acknowledgment phase where she lets her clients express their approval before the procedure begins. The clients confirm through a sign or other approved ways that they have read, understood, and agreed to all terms enshrined in the psychotherapeutic procedure.
Changes to the Informed Consent Procedure with Clients
Giesen explains that the informed consent procedure, in several cases, has to change to fit different clients.
Emergency Situations
One category of clients that makes her alter the informed consent procedure is emergencies. She explains that the need to save a life overrides the right to informed consent. She elaborates that in most cases, clients under emergency care are not able to receive information about risks, benefits, and potential outcomes of the treatment options. The clients may be in hysteria or unable to communicate. Most importantly, time is of the essence in an emergency. Attending to clients immediately they have presented to her averts adverse health outcomes. Therefore, under this situation, clients may not get an education or make choices from available treatment options. Fortunately, these provisions are recognized and allowed in state laws and codes of ethics guidelines. The legal emergency rule applies that "when the patient is unconscious, and there is no one to speak for him, the patient’s consent is implied” (HIPPA, 2001).
Tarasoff and Related Risks
Besides the emergencies, Giesen explains that Tarasoff and related cases are common scenarios that demand an alteration to the consent procedure. In 1985, the California legislature introduced the Tarasoff law, which mandates psychotherapists to protect or warn third parties if they believe they are at risk from their clients (Adi & Mathbout). According to Giesen, her duty to warn third parties implies that she lets out client information without their knowledge.
Changes to the Informed Consent Procedure over Years
According to Giesen, the most recent changes to the informed consent guidelines were effected in 2019. These changes were directed on the consent forms and primarily affected research and clinical practices as well. Gartel et al. (2020) review the changes and conclude that they have strengthened the protection of research participants and patients and reduced psychotherapists' regulatory burden. Among the changes was the introduction of a concise presentation in the Key Information section. Previously, guidelines required professionals to use 8th-grade language, but this rule was elusive due to some terminologies that could not be simplified. The introduction of the concise presentation section ensures clients read the summary of the consent in a simple language for better understanding. Another change witnessed by Giesen is the introduction of a requirement to post approved consents on federal websites. This requirement promotes transparency of a research and consent process.
Changes Due to COVID-19 Pandemic
Giesen admits that she lacked adequate experience with telepsychotherapy before the pandemic happened. She was used to physically attending to clients in her workplace or visiting clients in their private homes to offer her services. The COVID-19 pandemic has made her change this approach and embrace more telepsychotherapy. She has since advanced from frequent use of the telephone to incorporate video-conferencing to provide remote therapy. The switch from physical therapies to remote therapy has affected Giesen and many other psychotherapists globally. For example, in Italy, 42.1 percent of treatments were interrupted due to psychotherapists’ unpreparedness to switch from physical to remote sessions (Boldrini et al., 2020).
Ethical Considerations
Privacy has been Giesen’s most affected ethical challenge during the pandemic. Clients lack privacy at their homes, and at times, they request that she proceeds with remote therapies when privacy is not assured. She has minimized this issue by carrying out some therapies at night when privacy is guaranteed.
Legal and Ethical Challenges
The most challenging legal area for Giesen is abiding by the Tarasoff law. She understands that it is her legal obligation to warn third parties, but at times, there is a thin line when assessing threats and risks to third parties. In some cases, potential threats are downplayed or insignificant threats magnified due to the complexity of the issue. She navigates through this by taking no chances when any threats are shown. She prefers to alert and protect third parties when unsure of the severity of the threats.
Conclusion
The information that I found most helpful is on the use of telepsychotherapy and video conferencing for remote therapies. Psychotherapists should have technical skills and be equipped with resources that promote remote therapies at all times. The use of modern technology offers solutions to emergencies such as pandemics. Inability to use technology and lack of required resources may disrupt services during emergencies, leading to adverse health outcomes.
References
Adi, A., & Mathbout, M. (2018). The duty to protect: Four decades after Tarasoff. American Journal of Psychiatry Residents' Journal , 13 (4), 6-8. https://doi.org/10.1176/appi.ajp-rj.2018.130402
Boldrini, T., Schiano Lomoriello, A., Del Corno, F., Lingiardi, V., & Salcuni, S. (2020). Psychotherapy during COVID-19: How the clinical practice of Italian psychotherapists changed during the pandemic. Frontiers in Psychology , 11 . https://doi.org/10.3389/fpsyg.2020.591170
Gartel, G., Scuderi, H., & Servay, C. (2020). Implementation of common rule changes to the informed consent form: A research staff and Institutional Review Board collaboration. Ochsner Journal , 20 (1), 76-80. https://doi.org/10.31486/toj.19.0080
HIPPA. (2001). Action kit for hospital law . Horty Springer Publications. https://assets.hcca-info.org/
