Resident’s Column

Lisa McMurray, MD
Director-in-Training, McGill University, Montreal QC.

Informed Consent and Psychotherapy Training: Do We Know What We’re Getting Ourselves Into?

The doctrine of informed consent to treatment was originally developed for invasive medical procedures and required physicians to disclose to the patient the nature of the illness and of the proposed intervention, the probable risks and benefits of the treatment, and of alternative treatments. More recently it has become clear that less invasive therapies, such as medications, require informed consent as well. Some efforts have been made to apply the doctrine of informed consent to the psychotherapies; these have been met with a rather lukewarm reception—partly because therapists fear and resent their legal implications and partly because of concerns that such a reality-oriented discussion might interfere with the evolution of the therapy (1).

Proponents of informed consent argue that patients are autonomous beings who have a right to information about available treatments before making a decision about which treatment to pursue; they believe that such disclosure can actually improve the therapy by creating an atmosphere of trust and integrity in the relationship. Interestingly, both camps are concerned with the vulnerability of patients: those who value beneficence worry that patients might not be able to handle premature disclosure of information and those who value respect of autonomy worry that patients do not know enough about therapy to make decisions that are right for them (2). Residents beginning their training may be in a similar position: they may be interested in psychotherapy but know relatively little about what types of therapy are available to be learned. Misperceptions based on personal experience or media portrayals of psychotherapeutic work may exist. Residents may also be prone to influence by a charismatic teacher or by the therapeutic culture of their training program.

Wenning (2), speaking about long-term psychotherapy, says that “both therapists and patients are vulnerable to initiating and maintaining protracted therapy experiences that patients may not want, need, or know how to question.” Residents share this vulnerablity, especially if one particular therapeutic approach is emphasized as being “therapy” and other approaches are seen as interesting but optional alternatives.

Psychodynamic therapy continues to be the cornerstone of our psychotherapy training, and many would argue that this should continue to be so as the psychodynamic understanding of patients is seen as one of the key skills of a psychiatrist; certainly our profession is deeply rooted in the psychoanalytic and psychodynamic tradition (3). Some residents embrace this ideology from the beginning and continue to deepen their understanding of it, others are disillusioned and look for alternate models, while still others incorporate alternate modalities and end by identifying themselves as eclectic in their orientation. For some residents, particularly those who draw more heavily upon nondynamic schools of thought that are not routinely emphasized in residency training, the path to their eventual therapeutic identity can be a difficult one. Also, those who have strongly identified with any one type of therapy may be biased in their approach to treating patients.

Some readers may perceive this article as an attack on psychodynamic therapy, which it is not intended to be; rather, it is an appeal for balance and for the sharing of information. If we were informed about the different types of therapy at the beginning of our training, and if we had practical training opportunities in more modalities, many benefits could be had: our choices of training experiences and our pursuit of a therapeutic identity would be facilitated, we would be able to inform our patients more thoroughly and in a less biased way, and we would have more therapeutic options at our disposal.

Our current state of knowledge does not permit us to say that any one type of therapy is better than another. If residency training programs were to approach psychotherapy education in a broader and more inclusive manner, however, we might also be a step closer to discovering what works and to developing a more integrated approach to psychotherapy.

– L McMurray

References

1. Applebaum PS. Informed consent to psychotherapy: recent developments. Psychiatric Services 1997;48:445–6.

2. Wenning K. Long-term psychotherapy and informed consent. Hospital and Community Psychiatry 1993;44:364–7.

3. Tasman A. The future of residency training in psychiatry. Bull Menninger Clin 1994;58(4):474–85.