Introduction
A decade after physicians (including psychiatrists) endorsed the shift toward evidence-based
medicine, the world's largest association of psychologists, the American Psychological
Association (APA), belatedly but officially embraced the tenets of evidence-based
practice (EBP) [American Psychological Association (APA), 2006]. Other clinical psychology
associations, including the Canadian Psychological Association, soon followed suit
(Canadian Psychological Association, 2012). The interpretation of medical evidence
is deeply entwined with ethics; although mainstream medicine has until recently paid
relatively little attention to the ethical repercussions of evidence-based practice,
the neglect in the field of psychological treatments is even more glaring.
Why does EBP matter for the ethical practice of psychological treatments? Evidence
carries ethical imperatives. Both the decision about what is considered to be beneficial
in psychotherapy, and the current paucity of research regarding the potential negative
effects of psychological treatments, carry ethical implications. We argue that the
failure to pay attention to psychotherapy research effectively risks undermining key
requisites included in professional codes of practice for clinical psychology, psychiatry,
social work, and allied fields. First, EBP bears repercussions for the clinician's
duty of professional competence, or what O'Donohue and Henderson (1999) have collectively
termed “epistemic duties”—the responsibility to acquire and apply accurate knowledge.
Second, EBP is relevant to the duty to respect patient autonomy—namely, the patient's
right to make informed decisions concerning his or her treatment plans.
Evidence shows that there are divergent views about the importance, and feasibility,
of informed consent among practicing psychotherapists (e.g., Croarkin et al., 2003;
Barnett et al., 2007; Goddard et al., 2008). Some of this variation, we argue, probably
owes to differences in opinion about what is materially relevant to patients in deciding
to undergo psychotherapy; other omissions of informed consent may persist because
of continued debate and confusion about what constitutes “evidence” in psychotherapy
research and practice. We argue that—despite these challenges—the profession of psychotherapy
must find ways to meet the moral obligation of providing adequate informed consent
to patients.
Evidence-based practice and ethical duties
Professional competence—the ability to accurately assess problems, diagnose psychological
disorders, recommend an appropriate course of treatment, and successfully carry out
that treatment—varies depending on the degree to which the clinician keeps up to date
with the latest research and effectively evaluates the evidence. The APA requires
that clinicians be trained in EBP to be equipped to appraise the range of evidence
regarding the efficacy of different forms of psychotherapy, to recognize the strengths
and limitations of clinical intuition, and to understand the importance of patient
preferences and values, as well as the relevance of the socio-cultural context in
treating clients. In this way, the APA acknowledges that EBP requires knowledge of
controlled clinical trials, but also underlines that trial data have inherent limitations.
For example, such trials can be unrepresentative of individual patients given that
they can be largely insensitive to such factors as age of patient, and comorbidity
[American Psychological Association (APA), 2006; cf. Greenhalgh et al., 2014; Sheridan
and Julian, 2016]. The APA also emphasizes the importance of keeping up to date with
the latest process—and not merely outcome—data on how psychotherapies work [American
Psychological Association (APA), 2006].
The duty to be professionally competent carries significant additional implications
for the duty to respect patient autonomy. Historically, paternalism was the largely
unquestioned bedrock of healthcare practice. Paternalism is defined as “the interference
of a state or an individual by another person, against their will, and defended or
motivated by the claim that the person interfered with will be better off or protected
from harm” (Dworkin, 2010); it was defended on the grounds that doctors were the gatekeepers
of medical knowledge, as well as the best judges of how to use that knowledge to serve
the interests of patients. Today, healthcare ethics codes (in the West) eschew paternalism:
professional clinicians are now obliged to be truthful and to provide adequate disclosure
to patients about their diagnosis, the risks and benefits of various treatment options,
and their duration and costs (Trachsel et al., 2015; Blease et al., 2016; Trachsel
and Gaab, 2016). However, the quality of disclosures to patients depends on practitioner
knowledge, illustrating once again why standards of evidence are enmeshed with ethics.
Evidence of failures in informed consent
Evidence suggests that psychotherapists may be routinely failing to provide adequate
informed consent to patients (Dsubanko-Obermayr and Baumann, 1998; Croarkin et al.,
2003; Barnett et al., 2007; Goddard et al., 2008). Surveys in the US and UK reveal
broad variation among psychotherapists, as well as among psychotherapy schools, in
beliefs and practices with respect to information disclosure (Somberg et al., 1993;
Croarkin et al., 2003; Martindale et al., 2009). Psychiatrists and adherents of psychodynamic
psychotherapy appear to be especially doubtful about the practicability and importance
of informed consent (Croarkin et al., 2003; Goddard et al., 2008). Yet even in cases
in which therapists routinely disclose information about the specific techniques of
therapy—as we later argue—this information may be insufficient for adequate informed
consent.
There is evidence that standards of disclosure relate to, and may influence, outcome
in psychotherapy. A recent UK study found that patients who reported receiving insufficient
information about therapy before it started were significantly more likely to report
adverse effects of treatment (Crawford et al., 2016). This finding, although correlational
and open to rival interpretations (e.g., therapists who fail to provide informed consent
may be less competent in general), supports the notion that the provision of information
about therapy helps demystify the treatment process, may reduce anxiety about treatment,
and may increase trust between therapist and patient, contributing to better outcomes
(Beahrs and Gutheil, 2001; Snyder and Barnett, 2006). It is also conceivable that
negative effects may arise from failures to provide understandable information to
patients, or that negative effects are a consequence of the manner in which information
disclosures are conveyed to patients.
It is worth emphasizing that there are ongoing challenges associated with providing
open and honest disclosures in medical practice, and perhaps especially in the context
of patients with severe mental health problems, which can sometimes impair judgment,
comprehension, or both. At the same time, strong arguments are required to justify
paternalistic action in any professional healthcare context. Indeed, even in those
circumstances in which health professionals determine that a patient has impaired
mental functioning, this does not entail that the duty to provide informed consent
be overridden. For example, the UK's Mental Capacity Act of 2005 states that there
must be a presumption of capacity for patients to make treatment decisions; in addition,
the burden is on health professionals to demonstrate that patients lack any such capacity
(UK Department for Constitutional Affairs, 2005). Notwithstanding these pronouncements,
when it comes to informed consent there may be practical challenges for psychotherapists
who are regularly faced with patients who are extremely anxious, depressed, or agitated
as well as those with pronounced psychotic features. The key challenge, then, is to
find ways to meet the obligation of adequate disclosure while recognizing the contextual
sensitivities involved in providing comprehensible information to patients.
Explanations for problems with informed consent
Why does informed consent to psychotherapy appear to be “vastly underestimated by
many psychologists?” (Barnett et al., 2007). We propose that there are three main
reasons for the resistance to informed consent on the part of many practitioners.
Informed consent is a “process”
First, informed consent to therapy is a process, rather than as a one-time disclosure
of information, such as occurs in biomedical contexts. Some psychotherapists may erroneously
believe that the procedural nature of understanding how therapy works is a sufficient
reason to dismiss or overlook formal disclosure (Barnett et al., 2007). To overcome
any such misconceptions, Barnett et al. propose that a combination of written and
verbal disclosure of information be provided to patients prior to treatment, but that
disclosure should additionally be an ongoing, active exchange of information as therapy
ensues.
The complexities of psychotherapy research
Second, psychotherapy research is highly contentious. Compared with the evaluation
of psychopharmacological treatments, psychotherapy research is even more difficult
to interpret. Debate focuses largely on what constitutes “evidence” in psychotherapy
research (Tanenbaum, 2006; Stuart and Lilienfeld, 2007; Goldfried, 2013). Although
there is not the space to evaluate and appraise the extensive, ongoing debate about
the nature of EBP, we highlight two salient points that we believe transcend this
debate, and that are relevant to informed consent to psychotherapy. First, subjective
impressions of efficacy based largely or entirely on personal clinical observations
can be misleading. A robust body of research strongly suggests that such impressions
are frequently inaccurate (Lilienfeld et al., 2014; Casarett, 2016). Second, although
there is still disagreement regarding the effectiveness of specific techniques in
therapy (e.g., insight-techniques in psychodynamic therapies, or cognitive restructuring
techniques in cognitive-behavioral therapy) a large body of research suggests that
non-specific factors, such as therapist empathy and the working alliance, should be
taken into account when it comes to assessments of psychotherapeutic efficacy. For
example, therapist characteristics appear to be important predictors of outcome and
in some cases—for example, major depressive disorder—it has been argued that such
factors may be more predictive than the specific therapeutic modality (Cuijpers et
al., 2008; Wampold and Imel, 2015). Although, this research is controversial, there
is widespread consensus among psychotherapy researchers and psychotherapists that—whatever
the role of specific factors—the so-called common factors in therapy—are significant
mediators of change in treatment (Lambert and Barley, 2002; Huppert et al., 2006;
Marcus et al., 2014; Cuijpers, 2016).
Neglect of research on negative effects
Finally, unlike in pharmacology, evidence of possible negative effects of psychological
treatments is both under-researched and largely underappreciated in clinical psychology
and allied fields. The routine failure to consider the possible harms of psychotherapy
may stem, in part, from intuitive ontological considerations: namely, in psychotherapy
the treatment modality involves “talking” rather than the administration of a “physical”
treatment such as a drug or surgery (Blease, 2015b). Findings indicate that approximately
10% of patients experience worsening of symptoms following long term treatment in
psychotherapy—although it is unclear what proportion of these deterioration effects
is due to the treatment, as opposed to a naturally-occurring worsening of symptoms,
negative life events outside of therapy, or other influences (Lilienfeld, 2007). In
their UK study, Crawford et al. (2016) reported that 1 in 20 patients who enter into
psychological therapies report long-lasting negative effects of treatment. At an institutional
level, unlike drug treatments in which the FDA requires adverse risks of medications
to be investigated and listed, there are no comparable requirements for psychological
treatments (Duggan et al., 2014; Markowitz and Milrod, 2015). The longstanding lack
of attention to potential harms of psychotherapy may perpetuate the erroneous assumption
that psychotherapy carries negligible risk.
Future directions: what and how to disclose information to patients?
EBP—in its broadest sense—requires therapists to attempt to put aside or find ways
to compensate for their biases, and to approach psychotherapy research systematically.
Although there is ongoing debate about how to interpret process and outcome research
evidence in psychotherapy, there is a duty among therapists not only keep up to date
with findings about specific treatments, but to be well-informed about broader debates
regarding the potential mechanisms and mediators of therapeutic outcomes. As noted,
a wide range of research suggests that explanations for the techniques involved in
psychological treatments cannot be taken at face value. For example, given the evidence
for the importance of the common factors across different forms of psychotherapy,
such as the working alliance, therapist empathy, and the patients' expectations about
treatment effectiveness, a strong case can be made for their inclusion in initial
information disclosures (Gaab et al., 2015; Blease et al., 2016). It is also likely
that there are ways of disclosing the importance of the therapeutic relationship to
patients, for example, without undermining that relationship (Blease, 2015a,b; Trachsel
and Gaab, 2016), and we strongly encourage research on this issue.
Clients also have a right to be fully informed about the efficacy and effectiveness
of specific techniques in therapy. For example, patients with obsessive-compulsive
disorder (OCD) have a right to know that exposure and response prevention is the best-supported
intervention for their condition—and hence a first-line treatment (Olatunji et al.,
2013). Additionally, when it comes to overall efficacy claims, treatment specificity
tends to be considerably higher for certain conditions than for others; for example,
in contrast to OCD, for which behavioral interventions are the clear treatment of
choice, major depression tends to respond to a broad range of psychological treatments
(e.g., behavioral, cognitive, interpersonal; see Hollon et al., 2002). Moreover, because
certain conditions, major depression again being a prime example, appear to be etiologically
heterogeneous, it unlikely that even a highly efficacious intervention will work for
virtually all clients. Therefore, clients need to be informed that, depending on their
diagnosis, therapeutic interventions may work well for most patients but not all.
The point is that research must percolate into disclosure procedures: patients have
a right to be furnished with adequate, understandable information about treatment
techniques, the importance of common therapeutic factors as well as specific therapeutic
techniques, and the risks of harm from a minority of psychological treatments (see
Lilienfeld, 2007).
Finally, we recommend that informed consent to psychotherapy is best conceived as
a process—initial disclosures of information will require active, ongoing refinement
as therapy ensues. Research suggests that including ongoing patient feedback during
therapy is one important means of monitoring progress, thereby helping therapists
to enhance patient outcomes (Lambert et al., 2001; Sapyta et al., 2005; Shimokawa
et al., 2010; Beidas et al., 2015). The bidirectional flow of information about how
therapy works, as well as how patients believe therapy is progressing, should be built
into the therapeutic process (Barnett et al., 2007).
Conclusions
Therapists should decisively disavow the pervasive assumption that psychotherapies—although
generally effective—carry no risk of harm, and that disclosure (or its omission) somehow
carries a different moral valence for psychotherapy than for biomedical treatments.
Legally and morally, licensed clinical and counseling psychologists, psychiatrists,
and other psychotherapists are duty-bound to eschew healthcare paternalism. Patients
deserve to be fully informed if they are to make autonomous choices regarding psychological
treatment modalities. Psychotherapy must incorporate best evidence into training and
practice if it is to establish and maintain high ethical standards of care. The discussion
about how best to accomplish this crucial goal must now begin in earnest.
Author contributions
CB devised and structured the paper. CB, SL and JK jointly co-authored the content.
Conflict of interest statement
The authors declare that the research was conducted in the absence of any commercial
or financial relationships that could be construed as a potential conflict of interest.
The reviewer LF and handling Editor declared their shared affiliation, and the handling
Editor states that the process nevertheless met the standards of a fair and objective
review.