In the realm of therapy, protecting the client’s mental wellbeing is paramount. One of the fundamental ways in which therapists do this is by ensuring that clients are aware of the ethical and legal boundaries within which the therapist conducts therapy. In order to ensure such awareness, a well-trained and ethical therapist will always discuss the concept of informed consent with their clients, and provide them with what is called an informed consent document.
So, what is informed consent? In its most nuanced and collaborative form, informed consent is a joint decision-making process in which the therapist gives the client critical information about therapy, and then creates space for the client to ask questions, debate, and ultimately agree or disagree with the boundaries set forth by the therapist. The information that the therapist provides the client allows them to make an informed decision about the nature, benefits, and risks of therapy before consenting to participate in the therapeutic process and relationship.
In order to obtain informed consent, a therapist will not only discuss the different aspects of therapy with the client, but also provide them with a document that explains key therapeutic details. An informed consent document can take many forms. Therapists craft their own versions and use their own language, but there are some topics that are fundamental to all such documents.
First and foremost, the therapist should clearly note their qualifications to practice therapy. This is particularly important in India where lack of regulation in the mental health field has led to individuals who do not have adequate training posing as therapists. When therapists are honest with their clients about their qualifications and years of experience, it allows the client to make an informed decision about whether or not to engage with a particular practitioner.
Alongside such self-disclosure, it is also important that the informed consent document contain a brief description of the approaches that the therapist follows and the ethical code they employ. For instance, I am an eclectic therapist who uses Cognitive Behavioural, Psychodynamic and Person-Centered approaches, and practices from the American Counseling Association’s ethical code.
Moreover, it is important that an informed consent document describes the therapeutic process, highlighting that there are no quick fixes in therapy, and that sometimes in order to achieve one’s goals, the client must delve into difficult personal material. Occasionally, clients hope that the therapist will provide concrete solutions to their mental health concerns. When they discover that the solutions actually come from their own self-exploration, there is some amount of frustration. As such, ensuring that the client understands the therapeutic process from the get-go helps mitigate potentially negative reactions to therapy.
Among the most important and relevant pieces of information an informed consent document will contain is the nature and boundaries of confidentiality. It will explain how everything spoken or written between a therapist and client is indeed confidential except in certain circumstances.
In India, the Mental Health Act of 2017 sets clear parameters for when confidentiality must be breached. I paraphrase some of these instances here: releasing client information to other physical or mental healthcare professionals in order to help them provide necessary treatment to the client (this is almost always done with the consent of the client); releasing client information in circumstances where the therapist deems there is imminent risk of harm or violence to another person; releasing client information in order to protect the client from harm; releasing client information when the High Court, Supreme Court or another statutory body demands the information (usually because of a court case); finally, releasing client information in order to protect public safety. The client can also “nominate” an individual to whom information will be released in other circumstances.
A robust informed consent document will always draw from the laws set forth by the country within which the therapist is practicing and inform the client of the boundaries of confidentiality so that, in the event of a necessary legal breach, the client is not taken aback.
In our technologically dominated world, confidentiality becomes even more complex. For instance, a client must recognize the pros and cons of working with a therapist online – something that must be noted in the informed consent document. As revolutionary as platforms like Zoom and Google Meets have been in the realm of therapy, it is understandably difficult for therapists to absolutely protect the client’s privacy on these platforms. Similarly, if clients text or email clinical information to the therapist, they must recognize the risk of a confidentiality breach that is out of the therapist’s control. An informed consent document will note these risks, and be up front about what is in and out of the therapist’s control.
Finally, alongside basic logistical information such as fees, scheduling, lateness and cancellation policies, a strong informed consent document will also describe the nuances of terminating therapy. It might explain the importance of discussing termination with the therapist before leaving in order to resolve any residual emotions or thoughts pertaining to the client’s mental health concerns, but also ones relating to the therapist-client relationship itself. An informed consent document will discuss how taking the step to terminate therapy is as important as the one taken to begin it.
Ultimately, the power of informed consent lies in its ability to probe the very nature of consent itself. Inherently, the concept rests upon the notion that unless the individual making the decision to participate in a particular activity completely and wholeheartedly understands the nature of the activity, they cannot truly give consent. Furthermore, informed consent recognizes that consent itself is an on-going and fluid concept; consent can be given, and then it can be taken away. For instance, a client could decide to enter therapy, but then decide they do not want to participate in certain therapeutic tasks or do not agree to certain treatments. This is their right; it is always important for the therapist to recognise this right, and help their clients feel empowered to exercise it.
Malika Noor Mehta is a psychotherapist and mental health advocate who runs her own private practice in Mumbai.
Therapy Deconstructed is a monthly column that aims to demystify all aspects of therapy.