Technical comment
Comment on: Novosel D. Setting as informed consent in psychotherapy. Swiss Med Wkly.2019;149:w20028
Institut für Bio- und Medizinethik, Universität Basel, Switzerland
Informed consent to (psychodynamic) psychotherapy needs disclosure of uncertainty
In a recent viewpoint article, Dragutin Novosel argued that “informed consent has been a crucial element in psychotherapy since its beginnings, but under another name: the setting” [1]. In response, Trachsel and Biller-Andorno have rightly pointed out that informed consent extends beyond disclosure of the setting of psychotherapy [2].
Novosel acknowledges that unwanted effects and alternative treatments should be disclosed, but he reiterates the argument that this might deter patients from treatment and “increase their anxiety” [1]. As the author references psychoanalytic psychotherapy frequently, it is noteworthy this is a common view among psychoanalysts [3]. Indeed, Freud famously warned against lengthy discussions at the outset of psychoanalysis [4], because these might unduly influence the transference relationship. Furthermore, the importance of disclosing the setting is an original psychoanalytic idea. In Freud’s words, “time and money” [4] are the most important constituents to be disclosed.
Nonetheless, the issue of informed consent to psychodynamic psychotherapy is particularly complicated. Informed consent is notoriously difficult for this form of psychotherapy because the positive and negative consequences for the patient are hard to foresee. In line with this, Beahrs and Gutheil state that “[i]nforming of uncertainty is particularly relevant in exploratory psychotherapeutic approaches in which therapists play a less directive role and uncertainty is intrinsically greater than in procedure-based treatment” [5]. Informed consent to psychodynamic psychotherapy, as an exploratory psychotherapeutic approach, thus has to account for this uncertainty.
As a solution to this problem, some authors have recommended adopting a procedural approach to informed consent, where informed consent is seen not as a single event, but as a continuous process [3, 6, 7]. In this view, consequences and constituents of psychotherapy are only disclosed after some psychotherapy has transpired, for example, if they are clinically relevant.
How this procedural informed consent would work and whether it is a better fit for psychodynamic psychotherapies still needs to be discussed. Nevertheless, informed consent to psychodynamic psychotherapies demands special attention in research and training because of the intrinsic procedural uncertainty, alongside disclosure of the setting.
Disclosure statement
No financial support and no potential conflict of interest relevant to this article was reported.
Correspondence
Christopher Poppe, MSc, Assistent, Institut für Bio- und Medizinethik, Universität Basel, Bernoullistrasse 28, CH-4056 Basel, christopher.poppe[at]unibas.ch
References
1 Novosel D. Setting as informed consent in psychotherapy. Swiss Med Wkly. 2019;149:w20028. doi:. http://dx.doi.org/10.4414/smw.2019.20028 PubMed
2 Trachsel M, Biller-Andorno N. Informed consent for psychotherapy includes much more than the setting. Swiss Med Wkly. 2019;149:w20030. doi:. http://dx.doi.org/10.4414/smw.2019.20030 PubMed
3 Saks ER, Golshan S. Informed consent to psychoanalysis: the law, the theory, and the data. Bronx, NY, US: Fordham; 2013.
4 Freud S. Zur Einleitung der Behandlung. Weitere Ratschläge zur Technik der Psychoanalyse. 1913;I:454–78. German.
5 Beahrs JO, Gutheil TG. Informed consent in psychotherapy. Am J Psychiatry. 2001;158(1):4–10. doi:. http://dx.doi.org/10.1176/appi.ajp.158.1.4 PubMed
6 Pomerantz AM. Increasingly informed consent: discussing distinct aspects of psychotherapy at different points in time. Ethics Behav. 2005;15(4):351–60. doi:. http://dx.doi.org/10.1207/s15327019eb1504_6 PubMed
7 Eich H, Reiter L, Reiter-Theil S. Informierte Zustimmung in der Psychotherapie. Psychotherapeut. 1997;42(6):369–75. German. doi: http://dx.doi.org/10.1007/s002780050089
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