Informed consent and clinical psychology
Informed consent underpins everything we do as psychologists. It is an essential ethical principle. Whether we assess, formulate, intervene, evaluate or carry out research. Irrespective of our skills or level of experience ethical dilemmas will arise and, resolving them defensibly, to the best of our abilities, is a central part of our practice. Regardless of the setting, client population or type of intervention, we are bound to have to make decisions engaging multiple and conflicting ethical principles often, not easily reconcilable.
Seeking meaningful consent involves informing potential or actual clients of the basis for our intervention and its rationale. Sharing theoretical and empirical underpinnings and, explaining the anticipated process and possible challenges. Though we may not routinely explore challenges to the core assumptions underlying our practice most of us would, hopefully, routinely explain to clients that our model or our way of working is one of many ways of deriving meaning and of supporting people.
As such, we are in a very privileged position. We are not wedded to any school of thought/therapy or worldview. In theory. This allows us to work with clients using their own explanatory model (s) and attribution style and to some degree, adapt our practice accordingly. Further, because we (usually) use formulations rather than diagnoses to co-construct the meaning of the experiences that have led people to our doors and to make sense of their distress, we can work from multiple epistemologies. In theory.
Outside the therapy room, things are less malleable. For example, if someone is diagnosed with psychosis, it won’t matter much how they formulate or make sense of their distress when they are out in the real world. In the real world, this diagnosis will be documented onto their medical notes. Their personal explanatory model (s) or story may matter even less to the people who hold the most social power. Their psychiatric label will likely take precedence over much else. This is because in the real world, bio-medical explanations are still considered real and are the norms through which human experiences of distress are categorised. Still.
Meanwhile in the real world…
Thus, it matters very little that one might have been and continues to be oppressed or that one might have been repeatedly abused. This is background or additional information to the core issue that one ‘has’ depression, psychosis, a personality disorder or any other psychiatric diagnosis. So, when looking for a job, most potential employers will ask ‘have you suffered from/received treatment for any psychiatric illness’ or something along these lines. Such occupational health questions would typically be closed, inviting a ‘yes’ or ‘no’ answer. There may be space to elaborate or to even enclose a formulation done in therapy but, it would not stop many employers considering those who answered ‘yes’ potential liabilities in terms of sickness absence and think twice about making/confirming an offer of employment (though this may be unlawful).
Nothing of course forces anyone to disclose a psychiatric diagnosis but, failure to do so may not only deprive people of potentially valuable support, it may leave vulnerable individuals succeptible to accusations of breach of trust and confidence and/or of dishonesty; should it later emerge that information related to their psychiatric ‘history’ was withheld. In addition, of course, the additional stress generated by having to worry about the ‘truth’ coming out needs bearing in mind. I became sorely aware of the limits of informed consent when I was asked to sign a discharge before my son could have surgery.
Informed consent and adverse events/consequences
The discharge listed the main risks and potential complications from the surgical intervention. It made clear that I was consenting to the possibility of adverse events both short and longer term by signing the discharge and allowing my son to have surgery. The discharge made no mention of the risks associated with the other options available or of any cost-benefit analysis in relation to the alternative interventions. However, there had been some pre-operative discussions around alternative treatments and the no treatment option upon which the surgical team was relying when presenting me with the information focussing on the intervention at hand. This experience got me thinking.
True informed consent can only be given if clients can compare the risks and benefits of each and every course of action available to them and consider them in the short, medium and long term. Typically, when people access our services they have already been diagnosed or are suspected of having some form of mental ‘illness’ (suspicion alone carries consequences, especially if recorded). This is documented onto their medical notes as a matter of course. But does this practice not amount to forcing a medical framework onto people’s experiences? And if so, does it not problematise informed consent; if patients are not made aware of the of the risks and likely adverse consequences associated with having such a diagnosis?
Though by the time people get to us their health records have already been amended, they may not necessarily have been made aware of the (medium to long term) impact of being diagnosed with a psychiatric ‘illness’ particularly those seen as more ‘serious’ or ‘enduring’. They may never have even heard of alternatives to diagnoses or been made aware of their significant empirical and theoretical limitations. How might we argue then that those diagnosed have given their full informed consent? Isn’t it odd that patients are often given the choice as to whether they want their health records to reflect that they have had a pregnancy termination, sexually transmitted diseases or other stigmatising conditions/interventions but that such consideration is not routinely given to those with mental health problems?
On consenting for stigma
Given the very real, serious and debilitating consequences of stigma and discrimination, isn’t it ethical to seek fuller consent and as part of that, to give patients a choice as to how they make sense of their distress; including within their own health records? In the mist of our distress we may not have the headspace to consider such questions and of course some people may simply not have the capacity to assimilate this information or to decide. However, upon recovery, for the majority who did/could, the reality of having been diagnosed with a psychiatric ‘illness’ may hit home. People may well find that the psychiatric diagnosis they were given matters. That it matters enormously. At which point of course giving informed consent will no longer be an option.
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