The therapeutic misconception and our models of competency and informed consent

The doctrine of informed consent rests on empirical claims. This is true particularly of what commentators have characterized as the "strong" model of informed consent. This model assumes that if adequate information is given to a competent individual, understanding will result and, permitted to make a voluntary decision, the individual will make a rational decision. However, the "therapeutic misconception" posits that individuals may confuse the goals of research with those of treatment and may make decisions that do not rest on adequate understanding. This article reviews research suggesting that this may in fact be true, and concludes that, as a result, traditional notions of informed consent may not yield results consistent with the assumptions on which the doctrine of informed consent rests.     

Increasingly informed consent: discussing distinct aspects of psychotherapy at different points in time

Psychologists are ethically obligated to obtain informed consent to psychotherapy "as early as is feasible" (American Psychological Association, 2002, p.1072). However, the range of topics to be addressed includes both information that may be immediately and uniformly applicable to most clients via policy or rule, as well as information that is not immediately presentable because it varies widely across clients or emerges over time. In this study, licensed psychologists were surveyed regarding the earliest feasible point at which they could provide information regarding specific aspects of psychotherapy. Results indicate that, although psychologists believe that they are capable of presenting some information, such as payment and confidentiality policies, at the outset, they believe that a discussion of more substantive issues, such as psychotherapy duration, goals, orientation, and activities, can take place only after some therapy has transpired. Implications are discussed regarding the process and event models of informed consent.     

Parents' disclosure of their own concerns to their adolescent children

This study examines middle-aged parents' disclosure about their own lives and current concerns, with their late-adolescent children. Three hundred seventy-two parents of college freshmen, averaging 47 years of age, participated by filling out an anonymous questionnaire that asked about 28 topics, varying in intimacy, of concern to adults. The subjects indicated whether they had discussed each topic with their child, and, if they had, the motivations that prompted them to do so. The data revealed that mothers disclosed more than did fathers, and they were more likely to cite “venting,”“asking advice,” and “seeking emotional support” as reasons for disclosure; fathers were more likely to cite “trying to change his/her behavior” as a rationale for disclosure. Child's gender did not affect disclosure rates, but sons and daughters were disclosed to for different reasons. Divorced parents disclosed more than did parents from continuously intact families, and they cited somewhat different reasons for disclosure.     

Object elicitation: A compassionate and culturally informed method for psychotherapy research

This study provides an innovative, compassionate and culturally informed method for psychotherapy research, using object elicitation with 13 participants from vulnerable groups. It examines the positive impact it has on building the research alliance, enhanced depth of sharing within qualitative research interviews and emic ways of knowing through the engagement with a culturally relevant, tangible, internalised or transitional object brought by vulnerable participants from diverse cultural contexts of origin. Results showcase how a creative and compassionate research method can promote a culturally informed research alliance with vulnerable participants, helping to build trust, rapport and relational depth; encourage elicitation of experiences; and empower emic and subjugated voices. The implications of this study make the case for the inclusion of object elicitation as a creative and compassionate method in qualitative research with traumatised and vulnerable individuals, which should be used as part of a culturally informed approach to psychotherapy research.     

'Joined-up psychotherapy': the place of individual psychotherapy in residential therapeutic provision for children

This paper looks at the provision of individual psychotherapy within a residential setting for young children. It gives a brief historical context of the work of therapeutic communities, and describes one such community in detail. The paper emphasizes the need for psychotherapy to be fully 8 integrated into the overall treatment of severely damaged children, and seeks to raise questions about the need to modify ideas on confidentiality and boundaries in such a setting. Case material is presented to illustrate this.     

Obtaining informed consent for HIV antibody testing: the decision making process

All patients referring themselves for HIV antibody testing must receive pre-test counselling and must give their informed consent before testing can proceed. All patients being referred by their doctors for HIV antibody testing must also receive pre-test counselling and must give their informed consent before testing can proceed, except in very unusual circumstances. This paper is written primarily for medical and nursing staff who are considering referring a patient for testing and it is particularly relevant to those staff working in the field of mental health. This paper draws on professional guidelines and suggests that staff use a two-part decision making process. In the first part die referrer decides whether there are substantial clinical grounds for needing the test result immediately. If there are, the referral is made for pre-test counselling and testing, for example at the local Genito-Urinary Medicine (GU) clinic. In the second part experienced AIDS counsellors try to enable the patient to decide whether or not to proceed. If the patient is not able to understand or make a decision the AIDS counsellors, in consultation with other staff, will decide whether to proceed. Whatever the decision, it should be respected by professional staff.     

The practice of empathy as a prerequisite for informed consent

The patient-physician relationship, as formulated in the traditional biomedical model of medicine, is inherently flawed. In entering this relationship, most patients seek simply to be delivered from illness back to normal psychosocial functioning. The physician, however, almost invariably responds with a purely biologic approach to diagnosis and treatment that often does not effectively address the patient's needs. This precludes the opportunity for a consensus between them, and may in fact lead to the physician manipulating the patient's decisions about the course of therapy. The relationship should be reshaped within a new scientific model of patient care that combines the biomedical analysis of disease with an empathic understanding of the patient's illness experience. Truly informed consent is viewed as a natural outcome of the application of this more comprehensive framework.     

Mothers' attributions and expectancies regarding their conduct-disordered children

As an extension of Patterson's family coercion model, we hypothesized that parental attributions about the causes of child misbehavior and parental expectancies concerning the effectiveness of parenting techniques are involved in the establishment and maintenance of coercive exchanges. Mothers of 40 conduct-disordered children and 40 matched control children completed questionnaires measuring their attributions regarding the causes of their children's misbehavior and their expectations concerning the general and personal effectiveness of parenting techniques. Results supported the hypotheses: parents of conduct-disordered children were more likely to regard their children's misbehavior as intentional and to attribute it to stable, global causes beyond the parents' control. They also were less likely to see their own parenting as effective. We speculate that these parents hold cognitive stances of blame and helplessness that contribute to aversive parent behavior as well as to parent withdrawal in the face of escalating child aggressiveness.This article is based on a doctoral dissertation conducted by Anne Davison Baden while at Peabody College of Vanderbilt University, and was presented in part at the annual meeting of the American Psychological Association, New Orleans, August 1989.     

Parents' consent to the post-mortem removal and retention of organs

Parents of children who died following complex heart surgery have recently discovered that organs were removed and retained in post-mortem investigations to which they consented. It has been established that many of these parents did not give informed consent to the retention of organs. The Bristol Royal Infirmary Inquiry which examined these practices drafted codes of practice to govern future post-mortem activities. It is argued that these codes of practice may be onerous to some parents, yet effectively disbar them from dissenting to their application whilst they might otherwise agree to the post-mortem removal and retention of organs for purposes of medical audit, research or training. This consequence arises from employing an over-rigorous concept of informed consent in the immediate circumstances of bereavement. That concept is discussed in detail. An alternative proposal is canvassed which improves on the status quo but does not impose a practice of consent which may be burdensome and distressing to many.     

Parents' estimations of their own intelligence and that of their children: a comparison between English and Icelandic parents

In this study, 158 parents (79 fathers and 79 mothers) with a mean age of 38.3 yrs (SD = 8.2), estimated their own, and their children's, overall intelligence as well as their children's score on the 12 intelligence scales from the Wechsler's Intelligence Scale for Children (WISC-III). The sample included English (n = 122) and Icelandic parents (n = 36), and a comparison between them showed few differences except that Icelandic parents' estimates were lower than English parents' estimates. The results showed fathers estimated their own overall intelligence higher than mothers estimated theirs and sons were estimated higher than daughters on overall intelligence. Two factors (verbal, performance) of intelligence were identified through factor analysis of the ratings of the 12 WISC subscale score estimates. A hierarchical regression showed that these two factors explained most of the variance in the estimation of the child's overall intelligence; however, gender of child and parents' self-estimated own overall intelligence added incremental variance.     

Parents' teaching strategies with their children: The effects of parental and child status variables

The intent of the study was to examine the effects of parental (mother and father) and child (gender and communicative status) status variables on the teaching strategies used by parents in a paper-folding task. The linguistic and nonverbal strategies of 120 parent-child groupings were analyzed during paper-folding tasks. Parents' strategies were coded according cognitive demand and directiveness. Results indicated that strategies varied as a function of children's communicative status. Parents were less directive and more demanding of nonhandicapped children compared to handicapped children. Parents' strategies seemed to be determined by children's ability to sustain discourse. Results are discussed in terms of Vygotsky's notion of the zone of proximal development.This research was partially supported by a grant from the U.S. Office of Education, Office of Special Education (Grant No. G007902000) to I. Sigel and A. McGillicuddy-DeLisi at Educational Testing Service, Princeton, and from the Biomedical Research Support Grant Program, Division of Research Resources, N.I.H. (Grant No. BRSG 507RR07025-17) to the first two authors. We acknowledge the helpful comments of two anonymous reviewers.     

Participants' understanding of the process of psychological research: informed consent

Sixty-five undergraduates participating in a wide range of psychological research experiments were interviewed in depth about their research experiences and their views on the process of informed consent. Overall, 32% of research experiences were characterized positively and 41% were characterized negatively. One major theme of the negative experiences was that experiments were perceived as too invasive, suggesting incomplete explication of negative aspects of research during the informed consent process. Informed consent experiences were viewed positively 80% of the time. However, most of the participants had a limited view of the purpose of informed consent: less than 20% viewed the process as a decision point. Results suggest a number of common pitfalls to standard informed consent practices that have not generally been recognized. Results are discussed in terms of both ethical and methodological implications. Suggestions for improving the informed consent process are also provided.