Integrative Research Review Essay
Psychiatric professionals must comply with strict legal, professional, and ethical standards guiding practices and decisions. More essentially, they should understand the power that lies in professional practice. According to Manderius et al. (2023), situations arise in psychiatric inpatient care settings where healthcare professionals use coercive measures that restrict individual autonomy and conflict with other bioethical principles. For instance, the bioethical principles of autonomy, beneficence, non-maleficence, and justice require healthcare professionals to benefit patients, prevent harm, and safeguard the right to self-determination and individual capacity to make informed decisions. Client’s rights and informed consent are profound legal, ethical, and professional aspects of psychology since they align with the overarching need to ensure transparent information disclosure and the obligation to uphold justice and fairness.
The current scholarly literature explores the rationale for protecting clients’ rights and obtaining informed consent in psychotherapy. Although some studies reveal inconsistent findings regarding the importance of informed consent, consistent associations exist between obtaining informed consent, quality care delivery, and improved patient satisfaction. Consequently, this paper provides an integrative research review of clients’ rights and informed consent in psychotherapy. It offers a comprehensive analysis of current literature on clients’ rights, the process of obtaining informed consent, its components, and the rationale for safeguarding clients’ rights and obtaining informed consent.
Clients’ Rights in Psychiatry
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Often, psychiatric healthcare professionals face multiple challenges when assessing health needs and providing quality care to patients grappling with mental health conditions. Notably, mental and emotional changes associated with mental health conditions complicate care delivery practices. According to Ventura et al. (2020), psychiatric patients are susceptible to stigma, discrimination, and limitations in exercising political, civil, and social rights. To explore the human rights issues affecting psychiatric patients, Ventura et al. (2020) conducted a comprehensive review of empirical literature from various electronic sources, including PubMed, Scopus, Hein, and CINAHL. This scoping review aimed to examine the available evidence regarding human rights and ethical issues prevalent when providing nursing care to patients with mental illnesses (Ventura et al., 2020). The researchers reviewed 26 eligible studies that fulfilled inclusion and exclusion criteria.
Based on the scoping review of 26 studies, the study revealed the unexplained and unaddressed differential decisions on imposing compulsory psychiatric treatments on patients of different ethnic and socio-economic diversities. Further, the study unearthed issues surrounding individual rights in psychiatry. According to Ventura et al. (2020), limitation of autonomy, violation of individual rights, the value of dignity, ethics of nursing care, confidentiality and privacy concerns, and informed consent are profound human rights concerns in psychiatry. In this case, patients deserve respect, especially their right to self-determination and legal protection from coercive or restrictive interventions that do not benefit patients (Ventura et al., 2020). Equally, patients have the right to transparent and timely access to information regarding treatment strategies. Consequently, effective communication between healthcare professionals and patients can promote meaningful relationships and enable all-concerted efforts to address different mental health issues.
The International Code of Ethics for Nursing, adopted by the International Council of Nurses (ICN), protects individual psychiatry rights. According to Ventura et al. (2018), the ICN states that nurses respect human rights, including cultural rights, dignity, life, choice, and respectful treatment. Consistent with this professional and ethical responsibility, healthcare professionals should embrace various values and principles, including trustworthiness, integrity, respectfulness, compassion, and responsiveness. The American Psychological Association (APA) provides updated ethical principles and codes of conduct for psychologists in the United States. According to the American Psychological Association [APA] (2017), the general ethical principles and standards that guide psychiatric practices include beneficence and non-maleficence, fidelity and responsibility, integrity, justice, and respect for people’s rights.
Beneficence and non-maleficence
The American Psychological Association [APA] (2017) states that psychologists should strive to provide quality care to patients grappling with mental health issues. In this case, they seek to safeguard the welfare, prevent harm, and address issues affecting individual health and wellness. They should professionally interact with patients, incorporate ethical considerations when conducting research, and apply scientific and professional judgments to improve health outcomes. Further, the American Psychological Association (2017) indicates the professional responsibility to be aware of and protect patients against personal, financial, social, political, and organizational factors that can compromise patient safety and well-being. Finally, psychiatric healthcare professionals can safeguard beneficence and non-maleficence by solving conflicts through strategies for minimizing harm and avoiding misusing their professional influence and power.
Fidelity and Responsibility
Psychologists can promote fidelity and responsiveness in their practices and decisions by establishing meaningful relationships with patients and ensuring mutual trust. According to the American Psychological Association [APA] (2017), healthcare professionals should understand their professional and scientific responsibilities to society and uphold professional standards of conduct. Other obligations consistent with fidelity and responsibility include accepting the consequences and outcomes of their decisions and practices, clarification on their roles, and operating to the best of their clients (American Psychological Association, 2017). Finally, psychiatric healthcare professionals should collaborate with other professionals and institutions to ensure care coordination and improve care outcomes.
Patients with mental health conditions have the right to professional services guided by integrity, honesty, and truthfulness. The American Psychological Association [APA] (2017) requires psychologists to promote accuracy, honesty, and truthfulness by avoiding fraudulent activities or intentional misrepresenting of clinical or procedural facts. More essentially, professionals must strive to fulfill their promises, avoid unclear commitments, and consider the need for and consequences of any decision or practice resulting from mistrust. (American Psychological Association, 2017). The principle of integrity is consistent with other bioethical principles, including beneficence and non-maleficence.
Respect for People’s Rights and Dignity
This principle underpins all client’s rights and entitlements while receiving care from psychiatric healthcare professionals. The American Psychological Association (2017) states that patients have the right to dignity, self-worth, privacy, confidentiality, and self-determination. In this case, psychologists should strive to uphold the individual entitlement to autonomous decisions and be aware of cultural, individual, and role differences. In psychiatric contexts, patients exhibit differences in age, gender, race, ethnicity, disability, language, socioeconomic status, and other primary and secondary dimensions of diversity (American Psychological Association, 2017). Therefore, psychologists should eliminate implicit biases, prejudicial stereotypes, and other elements of deficit thinking that can contribute to structural discrimination based on these elements of diversity. Finally, they should provide culturally responsive and sensitive care to address conflicts and promote client satisfaction.
Consistent with other bioethical principles that inform psychiatric decisions and practices, recognizing fairness and justice is equally an essential aspect of psychiatry. According to the American Psychological Association (2017), psychiatric patients have the right to access and benefit from psychological interventions regardless of their individual, cultural, and ethnic differences. As a result, psychologists should avoid potential biases and make reasonable judgments that recognize the boundaries of their competence (American Psychological Association, 2017). Finally, they should set limitations to ensure their expertise and professional powers do not condone unjust practices.
Informed Consent in Psychiatry/Counseling
Informed consent extends to the professional and legal standards of patient-centered and dignified psychiatric care. Although psychologists should strive to uphold clients’ rights and the four bioethical principles, this obligation may not be achievable without the commitment to transparent and honest information disclosure. Many scientific studies explore the process of obtaining informed consent, the professional approach to disclosing information, the problems prevalent when obtaining informed consent, and the rationale for obtaining informed consent.
What is informed consent?
Trachsel & Holtforth (2019) present informed consent as a profound legal and moral legitimation for physical and psychological interventions, including psychotherapeutic practices in inpatient, outpatient, individual, and group therapy settings. Similarly, Eberle et al. (2021) argue that informed consent (IC) is an ethical and legal obligation that forms an essential component of psychotherapy. Although informed consent is a well-spelled element of quality and patient-centered psychiatric care, healthcare professionals may have different perspectives or opinions regarding obtaining informed consent. Eberle et al. (2021) conducted an online survey of 155 psychotherapists in Switzerland to explore and assess the attitudes regarding informed consent.
Components of Informed Consent
Informed consent in counseling practices represents a moral duty for counselors since it reflects the client’s right to self-determination. According to Trachsel & Holtforth (2019), informed consent should include various vital aspects/components: decision-making capacity, voluntariness, the statement of consent, and disclosure of relevant. Firstly, the patient’s decision-making capacity entails the ability to understand relevant information regarding therapeutic interventions, the competence to appreciate the disorder and the consequences of the underlying situation, awareness of treatment choices, and the patient’s ability to communicate decisions, preferences, and choices (Trachsel & Holtforth, 2019). In care delivery contexts, Libby et al. (2022) present capacity as “a functional determination that an individual is or is not capable of making a medical within a given situation.” In psychiatry, healthcare professionals should understand the intricacies and challenges associated with clients’ decision-making capacity, considering the cognitive limitations associated with multiple behavioral and mental conditions. Consequently, obtaining informed consent is a profound strategy for assessing the patient’s ability to comprehend information, communicate perspectives, and make independent decisions.
Determining the client’s decision-making capacity involves an interplay between various bioethical principles. According to Libby et al. (2022), obtaining informed consent builds on respect for individual autonomy by allowing them to make appropriate decisions. Also, this process strengthens the role of the beneficence principle in patient-centered care delivery. In this case, informed consent seeks to prevent patients’ coercion into the course of action and limits healthcare professionals’ potential misuse of power and influence (Libby et al., 2022). These aspects are central to preventing harm and discomfort that may compromise patient safety and well-being during therapeutic sessions.
Like the patient’s decision-making capacity, valid informed consent should emphasize the client’s voluntariness. Hug (2020) presents voluntariness as a crucial element of valid consent since it entails various elements, including the capacity to give consent, information disclosure, and the ability to understand information necessary for decision-making. Consistent with the need to ensure clients’ voluntariness, the Council for International Organizations of Medical Sciences (CIOMS) states that “researchers must provide potential research participants with the information and the opportunity to give their free and informed consent to participate in research, or to decline to do so” (Hug, 2020, p. 1). The primary requirements for clients’ voluntariness are the dependent relationship between patients and clinicians and freedom from external influence. In this case, meaningful relationships between patients and healthcare professionals can promote honest, timely, and transparent information disclosure, enabling patients to understand all elements of therapeutic interventions. Freedom from external influence capitalizes on intrinsic motivation to participate in therapies. It eliminates coercion or unfair influence that may affect an individual capacity to make informed decisions and participate in care interventions (Hug, 2020). Consequently, ensuring patient voluntariness can safeguard their autonomy and self-determination.
Disclosure of relevant information
Arguably, disclosing relevant information on therapeutic processes represents the primary objective of obtaining valid consent. Patients in psychiatric care settings have the right to transparent and honest access to information regarding care processes and decisions. According to Drisko (2020), the Joint Commission requires formal documentation of the five core elements of informed consent in patients’ health records. These elements include the disclosure of information on; the risks and benefits of care procedures, explanations of available alternative treatment options, a comprehensive assessment of the patient’s understanding of the components of the consent process, and the nature of the intervention. Other elements of information disclosure include the duration of interventions and the estimated/expected costs of treatment options (Trachsel & Holtforth, 2020). A holistic and genuine disclosure of relevant information can improve the client’s decision-making capacity and enhance voluntariness.
Statement of consent
Although healthcare professionals in psychiatry have a legal and ethical obligation to disclose information about therapies, clients have the final decision regarding their understanding of the disclosed information and willingness to participate in therapies. A patient consent statement is a written or oral confirmation that they have read and understood all elements of informed consent, including the cost, duration, benefits, potential risks of interventions, confidentiality, privacy policies, and available, viable treatment alternatives (Pietrzykowski & Smilowska, 2021). By providing a consent statement, patients can effectively communicate their intentions to participate in care interventions and confirm the voluntariness of the informed consent process. Consequently, it is a profound aspect of valid informed consent in psychiatry.
Challenges in Obtaining Informed Consent
While informed consent aligns with the overarching objective of upholding clients’ rights and the subsequent compliance with the four bioethical principles, healthcare professionals in psychiatry may face unique challenges when obtaining informed consent. Dalal (2020) presents cognitive impairment and deficits in mental abilities associated with mental and behavioral conditions as the primary challenges that compromise informed consent processes in psychiatry. In this case, patients may encounter impairments in reasoning, mood, attention, and understanding, affecting their decision-making capacity and limiting their ability to comprehend information regarding therapeutic interventions’ benefits, risks, costs, durations, and available alternatives (Dalal, 2020). Consequently, these patients may require input from caregivers and family members to make informed decisions on their participation in therapeutic sessions.
Secondly, healthcare professionals may face the problem of compelling and competing ethical reasons when obtaining informed consent. According to Darby & Weinstock (2018), clinicians may have the autonomy and flexibility to withhold therapy information when determining severe risks associated with therapeutic interventions. The decision to conceal some relevant information about treatment options compromises the principles of autonomy, self-determination, justice, and non-maleficence. Therefore, healthcare professionals must consider options and make ethically informed decisions when obtaining informed consent.
Thirdly, healthcare professionals may encounter the challenge of the patient’s “subjective impression” that they understand all elements of care processes (Pietrzykowski & Smilowska, 2021). This limitation creates a false impression and may lead to the belief that the informed consent process will lead to patients’ complete comprehension of information. Further, disclosing information on the potential consequences or risks of the intervention may lead to nocebo effects. According to Gelfand (2020), the nocebo effect is a phenomenon where disclosing information about the possible side effects of medical intervention may increase the likelihood of participants suffering from these side effects. It is possible to minimize the likelihood of the nocebo effects by reducing patients’ anxiety about treatment and discussing the potential adverse effects in the context of treatment options’ benefits.
The Rationale for Obtaining Informed Consent
Although obtaining informed consent in psychotherapy is daunting, the rationale for engaging in this complex endeavor is justifiable by the current scholarly literature. According to Trachsel & Holtforth (2021), informed consent strengthens the individual’s right to self-determination and improves autonomy, voluntariness, and clients’ decision-making capacity. Besides strengthening clinicians’ compliance with ethical and legal standards that guide practices, informed consent is a crucial element of patient-centered care (PCC) since it allows patients and healthcare professionals to collaborate in a shared decision-making process and disclose relevant information (Shah et al., 2022). Also, it allows healthcare professionals to consider and account for clients’ unique preferences, priorities, and needs. Further, obtaining informed consent is ideal for regulating clinicians’ powers and influence to ensure they do not manipulate clients, engage in fraudulent activities, and coarse patients to participate in therapeutic interventions (Shah et al., 2022). Consequently, it promotes patient safety and well-being and bolsters individual satisfaction with care interventions.
Patients in psychiatric care settings have various rights and entitlements, including the right to self-determination, dignified care, life, autonomy, privacy, and confidentiality. Healthcare professionals should safeguard these rights by adhering to the four bioethical principles and professional standards underpinning the ethical code of conduct. Obtaining Informed consent in psychiatry is a profound strategy for complying with ethical and legal standards that guide practices and protecting clients’ rights. A valid consent should include information regarding the nature of procedures, risks, and benefits, reasonable alternatives, risks and benefits of these alternatives, and an assessment of the client’s understanding of various elements of informed consent. Although clinicians may encounter multiple challenges when obtaining informed consent in psychotherapy, this process is crucial in promoting the client’s self-determination, protecting patients from coercive interventions, and enhancing patient-centered care by emphasizing collaboration between healthcare professionals and patients and preventing fraudulent activities that may compromise patient safety and wellbeing.
American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (pp. 1–20). https://www.apa.org/ethics/code/ethics-code-2017.pdf
Dalal, P. (2020). Consent in psychiatry – concept, application & implications. Indian Journal of Medical Research, 151(1), 6. https://doi.org/10.4103/ijmr.ijmr_1518_19
Darby, W. C., & Weinstock, R. (2018). The limits of confidentiality: Informed consent and psychotherapy. FOCUS, 16(4), 395–401. https://doi.org/10.1176/appi.focus.20180020
Drisko, J. W. (2020). Incorporating evidence-based practice into informed consent practice. Families in Society: The Journal of Contemporary Social Services, 102(1), 67–77. https://doi.org/10.1177/1044389420929625
Eberle, K., grosse Holtforth, M., Inderbinen, M., Gaab, J., Nestoriuc, Y., & Trachsel, M. (2021). Informed consent in psychotherapy: A survey on attitudes among psychotherapists in Switzerland. BMC Medical Ethics, 22(1). https://doi.org/10.1186/s12910-021-00718-z
Gelfand, S. (2020). The nocebo effect and informed consent—taking autonomy seriously. Cambridge Quarterly of Healthcare Ethics, 29(2), 223–235. https://doi.org/10.1017/s0963180119001026
Hug, K. (2020). Understanding voluntariness of consent in first-in-human cell therapy trials. Regenerative Medicine, 15(5), 1647–1660. https://doi.org/10.2217/rme-2019-0126
Libby, C., Gillette, G., Wojahn, A., & Nicolini, J. R. (2022). Competency and capacity. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532862/
Manderius, C., Clintståhl, K., Sjöström, K., & Örmon, K. (2023). The psychiatric mental health nurse’s ethical considerations regarding the use of coercive measures – a qualitative interview study. BMC Nursing, 22(1). https://doi.org/10.1186/s12912-023-01186-z
Pietrzykowski, T., & Smilowska, K. (2021). The reality of informed consent: Empirical studies on patient comprehension—systematic review. Trials, 22(1). https://doi.org/10.1186/s13063-020-04969-w
Shah, P., Thornton, I., Turrin, D., & Hipskind, J. E. (2022). Informed consent. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430827/#
Trachsel, M., & Holtforth, M. (2019). How to strengthen patients’ meaning response by an ethical informed consent in psychotherapy. Frontiers in Psychology, 10(1747). https://doi.org/10.3389/fpsyg.2019.01747
Ventura, C. A. A., Austin, W., Carrara, B. S., & de Brito, E. S. (2020). Nursing care in mental health: Human rights and ethical issues. Nursing Ethics, 28(4), 1–18. https://doi.org/10.1177/0969733020952102
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