Category Archives: Ethics

Informed Consent in Counseling and Psychotherapy: Problems and Potential

A quick review of recent informed consent research leads me to think that informed consent should be a perfect blend of evidence-based information about the benefits, risks, and process of psychotherapy. Like all good hypnotic inductions, informed consent, has the potential to stir positive expectations or activate fear. But when I look at all that we’re supposed to include in informed consents I wonder, does anyone really read them? Informed consent could have significant effects on treatment process and outcome. But only if clients actually read the written document.

The alternative or a complementary strategy is a good oral description of informed consent. Again, as someone trained in hypnosis and sensitive to positive placebo effects, I’m inclined to use informed consent to set positive expectations. I think that’s appropriate, but it’s also easy for us, as practitioners, to become too enthusiastic and unrealistic about what we have to offer. The truth is that no matter how much passion I may have for a particular intervention, if there’s absolutely no scientific evidence to support my niche passion, and there is evidence to support other approaches, then I could come across like someone promoting ivermectin for treating COVID-19. If you think about the people who promote ivermectin, it’s likely they’re either (a) uninformed/misinformed and/or (b) profit-driven. To the extent that all professional helpers or healers aim to be honest and ethical in our informed consent processes, we should strive to NOT be uninformed/misinformed and to NOT be too profit-driven. I say “too profit-driven” because obviously, most clinical practitioners would like to make a profit. All this information about being balanced in our informed consent highlights how much we need to read and understand scientific research related to our practice and how much we need to check our enthusiasm for particular approaches, while remaining realistic, despite potential financial incentives. 

Informed Consent: Who Reads Them? Who Listens?

If informed consents are difficult to read and comprehend, they may be completely irrelevant. On the other hand, in their obtuseness, they may function like the confusion technique in hypnosis and psychotherapy. Although the confusion technique is pretty amazing and I’ll probably write more about it at some point, it’s inappropriate and unethical to use the confusion technique in the context of informed consent.

In medical and some therapy settings, informed consent often feels sterile. If you’re like me, you quickly sign the HIPAA and informed consent forms, without taking much time to read and digest their contents. The process becomes perfunctory. 

I recall a particularly memorable pre-surgery informed consent experience. After hearing a couple of low probability frightening outcomes and experiencing the sense of nausea welling up in my stomach, I stopped listening. I even recall saying to myself, “I can choose to not listen to this.” It was an act of intentional dissociation. I knew I needed the surgery; hearing the gory details of possible bad outcomes only increased my anxiety. Here’s a journal article quote supporting my decision to stop listening, “Risk warnings might cause negative expectations and subsequent nocebo effects (i.e., negative expectations cause negative outcomes) in participants” (Stirling et al., 2022, no page number)

Informed consent flies under the radar when clients or patients stop listening. Informed consent also flies under the radar because many people don’t bother reading them. In our theories textbook we have nice examples of how therapists can write a welcoming and fantastic informed consent that cordially invites clients to counseling. Do these informed consents get read? Maybe. Sometimes.

Informed consent has the potential to be powerful. To fulfill this potential, we need to contemplate on big (and long) question: “How can we best and most efficiently inform prospective clients about psychotherapy and maintain a balanced, conversational style that will maximize client absorption of what we’re saying, while appropriately speaking to the positive potential of our treatment and articulate possible risks without activating client fears or negative expectations?”

Here’s an abbreviated guide: Provide essential information. Use common language. Be balanced.

For example:

“Most people who come to counseling have positive responses and after counseling, they’re glad came. A small number of people who come to counseling have negative experiences. If you begin to have negative experiences, we should talk directly about those. Sometimes in life, confronting old patterns and talking about emotionally painful memories will make you feel bad, sad, or worse, but these negative feelings should be temporary. Getting through negative or difficult emotions can open us up to positive emotions. My main message to you is this: No matter what you’re experiencing in counseling, it’s good and important for you to share your thoughts, feelings, and reactions with me so we can make the adjustments needed to maximize your benefits and minimize your pain.”

I could go on and on about informed consent, but that might reveal too much of my nerdiness. These are my reflections for today. Tomorrow may be different. I just thought I should inform you in advance that consistency may not be my forte.

MSCA 2018 — Keynote Powerpoints

Hey all.

I’m in Helena in anticipation of a great morning tomorrow with the Montana School Counseling Association. Thanks Renee’ Schoening for the invite. The bad news is that my talk is on stress management and because everyone at the conference has probably already heard my “30 minutes of profanity” story, I’m feeling stressed. Funny how that works.

The good news is that the amazing Salena Beaumont Hill will be my co-presenter. I’m hoping she’ll have a story with the F-word to replace mine. Haha. Kidding Salena.

Here are the ppts. Let’s have some fun tomorrow! MSCA Keynote 2018

A Summary of the American Psychological Association’s Record Keeping Guidelines

The American Psychological Association (APA) has an online guide to record keeping for psychologists. Of the different mental health disciplines, the APA’s guidelines are the most extensive. For the full guide (and tons of fun), go to: A brief summary of the guide follows.

As an introduction, the APA emphasizes that clinical records are beneficial for clients and practitioners. When done well, clinical records can:

1. Document that planning has occurred
2. Guide treatment services.
3. Allow providers to review and monitor their work.
4. Enhance continuity when there are treatment breaks or referrals to other providers.
5. Protect clients and providers during legal or ethical proceedings.
6. Fulfill insurance or third-party reimbursement requirements.

The APA’s document is a guide and not a mandate. It’s designed as aspirational. APA also notes that there’s no significant empirical research foundation upon which their guidelines are based. Instead, the guidelines are broadly based on APA policy, professional consensus, and other sources of ethics and legal information.

The following list paraphrases and summarizes APA’s 13 guidelines. There’s always the possibility that our list and descriptions include minor mistranslations. Consequently, please see the full document for comprehensive coverage of this important content.

1. Responsibility: Practitioners are responsible for the development and maintenance of their clinical records. This includes training staff in the appropriate confidential handling of client records.

2. Record Content: Records include information about the nature, delivery, treatment progress and outcomes, and fees. Information included is directly relevant to the clinical purpose of client contacts. Although detail is important, the following factors guide the level of details included in individual client case files:

a. Clients’ wishes
b. Disaster or emergency settings
c. Ethical or legal limitations (e.g., HIV testing results)
d. Contracts with third party payers
e. The APA guide includes extensive information regarding what content may or may not be appropriate.

3. Confidentiality: Maintenance of confidentiality is essential. In situations where who has access to records may be unclear (e.g., child custody conflicts), the provider seeks pertinent legal information to guide decision-making.

4. Informed Consent: Practitioners provide clients with information regarding their record keeping procedures, including limits to confidentiality.

5. Records Maintenance: Records are organized to comply with federal law (HIPAA) and accuracy is maintained.

6. Records Security: Records are kept safe from physical damage. Access to records is controlled via a variety of methods, including locked cabinets, locked storage rooms, passwords, data encryption, etc.).

7. Records Retention: Records are retained for a time period consistent with legal requirements. The general guide is seven years after service ended for adults and three years after a minor reaches age 18 (whichever is later).

8. Records Context: Because client symptoms or condition can vary with situational contexts, providers frame the content of client records within the appropriate historical context.

9. Electronic Records: Electronic records use and storage presents ongoing challenges. The best guidance is for practitioners to follow the HIPAA Security Rule, conduct a security analysis, and consistently upgrade policies and practices to keep up with changes in technology.

10. Records within Agencies: Practitioners must balance their professional ethical requirements and agency policy. The APA identifies three main areas: (a) conflicts between the agency and other requirements, (b) records ownership, and (c) records access.

11. Multiple Client Records: When providing couple, family, or group services, records management may become complex. You can consider either creating separate records for all clients or to identify a primary client and keep records for that person.

12. Financial Records: The nature of the fee agreement (including bartering agreements) as well as adjustments to account balances should be specified. Financial records include essential information such as procedure codes, treatment duration, fees paid, fee agreements, dates of service, etc.

13. Records Disposition: In the case of unexpected events, there may be a need for records transfer or disposal. This implies a need for a records transfer and disposal policy, including information on how current and former clients will be informed if the policy needs to be enacted.

The APA guide is a comprehensive document that can help all practicing clinicians maintain high ethical standards with respect to documentation.

Handouts for the American Mental Health Counseling Association Conference

These past two days I’ve been hanging out in Seattle with some very cool mental health counselors (as well as my very cool sister and her only mildly deranged husband). As a consequence, I promised to post these two powerpoint presentations to enable quick internet access. And so, if you were at the conference or you’re just a powerpoint presentation junkie, links to the two presentations are below:

1. Ethics: A Fresh Approach (two hour workshop with Rich Ponton — who is also very cool)

Ethics A Fresh Approach

2. How to Listen so Parents will Talk (three hour workshop)

How to Listen for AMHCA