FOCUS ON ETHICS

Jeffrey E. Barnett, Editor

Informed Consent: Too Much of a Good Thing or Not Enough?

Jeffrey E. Barnett Erica H. Wise

Arnold, Maryland, and Loyola College in Maryland University of North Carolina at Chapel Hill

Doug Johnson-Greene Steven F. Bucky

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Johns Hopkins University School of Medicine California School of Professional Psychology

Informed consent is an essential aspect of the establishment of every professional relationship in which
psychologists participate. When done effectively, it helps promote other individuals’ autonomy, engages
them in a collaborative process, and helps to reduce the likelihood of exploitation or harm, among a
number of potential benefits. Yet, a number of challenges and dilemmas relevant to informed consent
exist for psychologists. Three invited experts provide commentaries on issues raised, questions asked,
and dilemmas posed that will, the authors hope, fully stimulate further consideration and discussion of
these important issues. The commentaries also broaden the discussion of informed consent in all roles in
which psychologists serve. Specific recommendations are made for practicing psychologists for the
ethical and effective application of informed consent in their work.

Keywords: ethics, ethical practice, informed consent, professional roles

is a shared decision-making process in which the professional

Seeking an Understanding of Informed Consent
Jeffrey E. Barnett
Regardless of the nature of the professional relationship, be it
psychotherapy, assessment, research, clinical supervision, consul-
tation, or some other professional role, psychologists are ethically
and legally bound to begin these relationships only after initiating
a process of informed consent (American Psychological Associa-
tion [APA], 2002; Knapp & VandeCreek, 2006). Informed consent
communicates sufficient information to the other individual so that
she or he may make an informed decision about participation in the
professional relationship. In general, clients, supervisees, research
participants, and others trust psychologists and depend on them to
protect their best interests and to ensure that all risks for harm or
adverse outcomes are minimized. Additionally, this dependence on
the professional is accentuated by the expert status of the psychol-
ogist. Professionals have knowledge, skills, and expertise that
others seek out for assistance. But, as all professional services
bring with them some risk of adverse impact, however small it may

JEFFREY E. BARNETT received his PsyD in clinical psychology from Ye-
shiva University. He maintains an independent practice in Arnold, Mary-
land, and is an affiliate professor in the Department of Psychology at
Loyola College in Maryland. His areas of professional interest include
ethical, legal, and professional practice issues in psychology. He is a
member of the American Psychological Association Ethics Committee.
ERICA H. WISE received her PhD in clinical psychology from Southern
Illinois University at Carbondale after completing her internship in the
Department of Psychiatry at the University of North Carolina at Chapel
Hill. She is a clinical associate professor and directs the training clinic in
the Department of Psychology at the University of North Carolina at
Chapel Hill. Her professional interests include ethical and legal issues in
clinical psychology and clinical training.
DOUG JOHNSON-GREENE received his PhD in clinical psychology from the
University of Mississippi. He is an associate professor in the Department
of Physical Medicine and Rehabilitation, Division of Rehabilitation Psy-
chology and Neuropsychology, Johns Hopkins University School of Med-
icine. He has been an active investigator, teacher, and clinician in a number
of realms of clinical psychology, rehabilitation psychology, and neuropsy-
chology. His primary research interests include cognitive and affective
responses to acquired and developmental brain disorders.
STEVEN F. BUCKY received his PhD in clinical psychology from the
University of Cincinnati. He is the interim systemwide dean for the
California School of Professional Psychology at Alliant International Uni-
versity. His professional interests include the integration of ethical and
legal cases in clinical practices, forensics, substance abuse, and sport
psychology.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Jeffrey
E. Barnett, 1511 Ritchie Highway, Suite 201, Arnold, MD 21012. E-mail:
drjbarnett1@comcast.net

Professional Psychology: Research and Practice, 2007, Vol. 38, No. 2, 179 –186
Copyright 2007 by the American Psychological Association 0735-7028/07/$12.00 DOI: 10.1037/0735-7028.38.2.179

179
 180 FOCUS ON ETHICS
be, prospective participants need adequate information at the out-
set to help them weigh the potential benefits and risks of both
participation and lack of participation.
Unfortunately, informed consent is not uniformly applied, and
confusion appears to exist concerning the specifics of informed
consent. Challenges for psychologists include knowing just which
information to share and in how much detail, deciding in what
form it should be shared, knowing how to ensure the prospective
participant’s understanding of the information, knowing when this
process should occur, and the like. These and other challenges
relevant to the informed-consent process are addressed, questions
for consideration are raised, and recommendations for ethical and
effective practice are made.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Historical Perspective
Informed consent has a long history in the health professions,
beginning in medicine, and has evolved substantially over the
years through case law. Initially, physicians could be seen as
benevolent authoritarians who very paternalistically directed each
patient’s assessment and treatment. Through the 19th and into the
20th century, physicians generally did not first obtain their pa-
tients’ consent prior to providing services to them and were not
seen as under any widely accepted ethical or legal mandate to do
so (Grisso & Applebaum, 1998). This model has been described as
the “doctor-knows-best system,” in which patients were passive
recipients of services (Welfel, 2006). There was little sharing of
information, collaboration, or patient involvement in decision
making, and as a result, patients may be seen as having been more
vulnerable to abuse or harm. Overall, the doctrine of informed
consent changed this practice to require that health professionals
share information about anticipated treatments sufficient to allow
the patient to make an informed decision about participation.
A foundation for informed consent seen in case law is Schloen-
dorf v. Society of New York Hospital (1914), in which Judge
Cardozo stated that “every human being of adult years and sound
mind has a right to determine what shall be done with his own
body” (as cited in Stromberg et al., 1988, p. 446). Then, over a
number of years beginning in the 1950s, a series of malpractice
cases ruled on issues of alleged harm to patients by health care
professionals. In a number of these cases, rulings specifically
addressed issues of harm to patients as a result of how this
evolving process of informed consent was addressed by the pro-
fessional. Each of these legal rulings has contributed to the ac-
cepted professional standards for informed consent. It is interesting
to note and important to emphasize that prior to these legal rulings,
the issue addressed in each had not been part of prevailing pro-
fessional standards.
In Salgo v. Stanford (1957), the California Court of Appeals
ruled that a patient must fully comprehend the information shared
and that risks and benefits associated with participation must be
included in that consent for it to be considered valid. In the
landmark case of Canterbury v. Spence (1972), it was ruled that
merely answering patients’ questions is insufficient and that all
information necessary must be shared that patients need “for an
intelligent decision” (p. 783) regarding participation and that it
must be presented in terms that can be understood by the individ-
ual. This is a significant step forward from the previous standard
of sharing what health professionals determined patients needed to
know to make their decisions. In Truman v. Thomas (1980), the
California Supreme Court ruled that patients must also be in-
formed of the risks associated with refusing treatment, not just the
risks associated with acceptance of the proposed treatment. And,
more recently, the case of Osheroff v. Chestnut Lodge (1985),
although settled out of court, established the precedent that patients
must also be informed of reasonably available alternatives and
their relative risks and benefits as well. Those familiar with
informed-consent standards included in the APA’s Ethical Prin-
ciples of Psychologists and Code of Conduct (referred to as the
APA ethics code; APA, 2002) will see many of the currently
accepted elements of informed consent above in this brief review
of its chronological development.
Goals of Informed Consent
Although informed consent is rooted in the medical field and
originally concerned specific discrete procedures, it has become
widely accepted as an essential aspect of each client’s participation
in the psychotherapy process as well as in all other services
psychologists provide. Authors such as Beahrs and Gutheil (2001)
defined informed consent as “the process of sharing information
with patients that is essential to their ability to make rational
choices among multiple options” (p. 4). But informed consent
brings with it several other important benefits, including “promot-
ing client autonomy and self-determination, minimizing the risk of
exploitation and harm, fostering rational decision-making, and
enhancing the therapeutic alliance” (Snyder & Barnett, 2006, p.
37). Although the psychologist’s theoretical orientation may affect
one’s view of informed consent, in general it can be seen as
consistent with psychologists’ general goal of establishing a col-
laborative relationship that is built on trust, openness, and respect.
Additionally, the provision of information necessary to make an
informed choice also promotes the sharing of decision-making
power in the professional relationship, which enhances the profes-
sional collaboration, reduces risks of exploitation and harm
(Meisel, Roth, & Lidz, 1977), and encourages trust, openness, and
sharing in the relationship (Snyder & Barnett, 2006).
Informed consent should be viewed as a process, not as a single
event that occurs at the outset of treatment (or supervision, re-
search, or any other professional relationship). It is best imple-
mented if integrated into the professional relationship from its
outset through its completion. The APA ethics code (APA, 2002)
states that psychologists should begin the informed-consent pro-
cess “as early as is feasible in the therapeutic relationship” (p.
1072), but psychologists should not consider their obligation met
at that point. It is important to update the informed-consent agree-
ment throughout the course of the professional relationship as
circumstances warrant, such as any proposed significant changes
to the treatment to be offered and, thus, changes to the original
informed-consent agreement.
With regard to treatment services, the APA ethics code (APA,
2002) requires psychologists to include in each informed-consent
agreement information about “the nature and anticipated course of
therapy, fees, involvement of third parties, and limits of confiden-
tiality” (p. 1072) as well as reasonable alternatives available, their
relative risks and benefits, and the right to refuse or withdraw from
treatment. Additional requirements are also included for informed
consent to supervision, research, assessment, and other services
 FOCUS ON ETHICS
provided by psychologists. Studies (e.g., Sullivan, Martin, & Han-
delsman, 1993) have found that consumers value having detailed
information provided to them at the outset of the professional
relationship and even rate those psychologists who engage in an
informed-consent process as more expert and trustworthy than
those who do not. But just how that information is provided to
them can significantly affect the specific information they request
(Braaten, Otto, & Handelsman, 1993). Whether informed consent
should be provided through use of written documents, verbally, or
in combination is unclear, yet many professionals suggest a com-
bination approach. The use of an appropriate written consent
agreement can augment all verbal consent discussions. It helps
ensure that clients understand what they are agreeing to, provides
clients with a written document they may refer to and review over
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
the course of the professional relationship, and allows the psychol-
ogist to refer to it as well should there be any confusion or
misunderstandings later.
Is the Consent Truly Informed?
Legally, three conditions must be met for informed consent to be
considered valid. The client must understand the information pre-
sented, the consent must be given voluntarily, and the client must
be competent to give consent (Gross, 2001). It is not sufficient to
just present the information to the client “using appropriate lan-
guage understandable to that person” (APA, 2002, p. 1065). In
addition, psychologists must actively ensure each client’s under-
standing of the information presented and of that to which he or
she is agreeing. Merely asking if clients understand or if they have
any questions would not be seen as meeting this obligation. For
example, having clients explain their understanding of information
shared and of specific agreements would better demonstrate their
understanding than simply asking questions as described above.
Written informed-consent agreements may be seen as useful in
allowing the client to have something to refer to later, and they
provide a tangible record of agreements between both parties. But
even in conjunction with a verbal review, written informed-
consent agreements should be developed with attention to reading
level and ease of comprehension. In one study of informed-consent
forms used in 114 U.S. medical schools, results found the forms to
be written on average at the 10.6 grade level, despite these schools’
own requirements for a readability level of 2.8 grade levels lower
(Paasche-Orlow, Taylor, & Brancati, 2003). In the popular media,
examples of perhaps even greater concern are seen in a review of
the readability of notice of privacy forms from a number of
prominent health care facilities: percentage of patient privacy
forms that in a test were shown to be as easy to read as comics
(0%), percentage as easy to read as J. K. Rowling’s Harry Potter
and the Sorcerer’s Stone (1%), percentage as easy to read as H. G.
Wells’s The War of the Worlds (8%), and percentage as easy to
read as professional medical literature or legal contracts (91%;
“The Numbers Game,” 2005).
Just how much information to include in the informed-consent
process is unclear. Certainly, it is possible to overwhelm a client
with too much information, and this could be inimical to the
previously stated goals of the informed-consent process. Studies of
psychologists’ informed-consent practices have found a wide
range of variability in the breadth and depth of information shared
with clients (e.g., Dsubanko-Obermayr & Baumann, 1998; Otto,
181
Ogloff, & Small, 1991). Certain issues must always be included in
informed consent, as has been described earlier. A careful review
of issues such as limits to confidentiality is essential, because
clients may have very different expectations of the psychologist’s
obligations in this regard. For example, Miller and Thelen (1986)
found that 69% of consumers surveyed believed and expected that
all information shared in psychotherapy would be kept confiden-
tial, and 74% stated that there should be no exception to this rule.
Finally, 96% expressed wanting to know about any possible limits
to confidentiality prior to beginning the psychotherapy relation-
ship. Pomerantz and Handelsman (2004) recommended including
issues such as insurance and managed-care details and psycho-
pharmacology, among others. These authors also made recommen-
dations regarding the format for presenting informed-consent in-
formation. They offered a written question format that includes a
number of questions clients may ask their psychologist to help
gather important information relevant to the informed-consent
process. They did not suggest one set of questions to be addressed
by all clients in all psychotherapy situations. Rather, they offered
this as guidance for what Pope (1991) described as a dynamic
process that can be tailored to best address each individual client’s
needs and circumstances.
Issues to Consider
Informed consent is an important aspect of the psychotherapy
process and psychotherapy relationship as well as for all profes-
sional relationships in which psychologists participate. Whereas
standards exist for the minimal information to be included in the
informed-consent process, no specific standard exists for when to
limit this information and when to know if one is sharing too
much. The extent and specificity of information that should be
included in this process—as well as how to decide what to include
or not to include and how best to present this information—remain
unclear. Dilemmas exist regarding competence, understanding,
and voluntariness to include obtaining consent from minors, inpa-
tients, prisoners, those with cognitive impairment, and others and
knowing when to share information, how much information to
share, and when this process may be counterproductive. It is also
important to know how best to present the information, be it
verbally, through a written document, or in combination. Psychol-
ogists should also consider and understand the potential impact of
diversity on this process, such as the role that language, age (and
developmental level), cultural background, and other factors may
play in affecting the informed-consent process. Clinical work with
individuals, couples, families, and groups each presents unique
challenges with regard to informed consent, as do third-party
requests for services, clinical supervision, research, and teaching.
Knowing how best to address these challenges is of great impor-
tance for protecting clients’ rights, promoting their autonomy, and
working to achieve the best possible outcomes in the professional
relationships we form with them.
References
American Psychological Association (APA). (2002). Ethical principles of
psychologists and code of conduct. American Psychologist, 57, 1060 –
1073.
Beahrs, J. O., & Gutheil, T. G. (2001). Informed consent in psychotherapy.
American Journal of Psychiatry, 158, 4 –10.
 182 FOCUS ON ETHICS
Braaten, E. B., Otto, S., & Handelsmann, M. M. (1993). What do people
want to know about psychotherapy? Psychotherapy, 30, 565–570.
Canterbury v. Spence, 464 F.2d 772 (D.C. Cir. 1972).
Dsubanko-Obermayr, K., & Baumann, U. (1998). Informed consent in
psychotherapy: Demands and reality. Psychotherapy Research, 8, 231–
247.
Grisso, T., & Applebaum, P. S. (1998). Assessing competence to consent to
treatment: A guide for physicians and other health professionals. New
York: Oxford University Press.
Gross, B. H. (2001). Informed consent. Annals of the American Psycho-
therapy Association, 4, 24.
Knapp, S. J., & VandeCreek, L. D. (2006). Practical ethics for psycholo-
gists: A positive approach. Washington, DC: American Psychological
Association.
Meisel, A., Roth, L. H., & Lidz, C. W. (1977). Toward a model of the legal
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
doctrine of informed consent. American Journal of Psychiatry, 134,
This document is copyrighted by the American Psychological Association or one of its allied publishers.
285–289.
Miller, D. J., & Thelen, M. H. (1986). Knowledge and beliefs about
confidentiality in psychotherapy. Professional Psychology: Research
and Practice, 17, 15–19.
Osheroff v. Chestnut Lodge, 490 A.2d 720 (Md. App. 1985).
Otto, R. K., Ogloff, J. R., & Small, M. A. (1991). Confidentiality and
informed consent in psychotherapy: Clinicians’ knowledge and practices
in Florida and Nebraska. Forensic Reports, 4, 379 –389.
Paasche-Orlow, M. K., Taylor, H. A., & Brancati, F. L. (2003). Readability
standards for informed-consent forms as compared with actual readabil-
ity. New England Journal of Medicine, 348, 721–726.
Pomerantz, A. M., & Handelsman, M. M. (2004). Informed consent revis-
ited: An updated written question format. Professional Psychology:
Research and Practice, 35, 201–205.
Pope, K. S. (1991). Informed consent: Clinical and legal considerations.
Independent Practitioner, 11, 36 – 41.
Salgo v. Leland Stanford Jr. Univ. Bd. of Trustees, 154 Cal. App. 2d 560,
317 P.2d 170 (1957).
Schloendorf v. Society of New York Hospital, 211 N.Y. 125, 105 N.E. 92
(1914).
Snyder, T. A., & Barnett, J. E. (2006). Informed consent and the process of
psychotherapy. Psychotherapy Bulletin, 41, 37– 42.
Stromberg, C. D., Haggarty, D. J., Leibenluft, R. F., McMillian, M. H.,
Mishkin, B., Rubin, B. L., & Trilling, H. R. (1988). The psychologist’s
legal handbook. Washington, DC: Council for the National Register of
Health Service Providers in Psychology.
Sullivan, T., Martin, W. L., & Handelsman, M. M. (1993). Practical
benefits of an informed-consent procedure: An empirical investigation.
Professional Psychology: Research and Practice, 24, 160 –163.
The numbers game. (April 12, 2005). The Washington Post, p. F3.
Truman v. Thomas, 611 P.2d 902 (Cal. 1980).
Welfel, E. R. (2006). Ethics in counseling and psychotherapy: Standards,
research, and emerging issues. Belmont, CA: Thomson Brooks/Cole.
Commentaries
Informed Consent: Complexities and Meanings
Erica H. Wise
Through his review of relevant case law, Barnett documents a
paradigm shift from one in which the client is viewed by health
professionals as a passive recipient of health care to one in which
the client is expected to be an active and fully informed collabo-
rator in the health care process. Although there are clear benefits
to engaging in informed consent in terms of communicating re-
spect for the client, fostering client autonomy, and promoting the
therapeutic relationship, there is conversely an inherent dilemma
for health care providers that is associated with the effective
discharge of this duty. This commentary will bring a linguistic
perspective to a consideration of this dilemma.
The APA ethics code (APA, 2002) strongly and unambiguously
endorses the notion of informed consent. General Principles C
(Integrity) and E (Respect for People’s Rights and Dignity) form
the ethical foundation for this duty. In the enforceable portion of
the APA ethics code, Sections 10.01, 3.10, 8.02, and 9.03 outline
our duties regarding informed consent related to psychotherapy,
human relations, research, and assessment, respectively. As
Behnke (2004) pointed out, other sections of the code, including
3.07, 3.11, and 10.02, do not have the term informed consent in the
title but similarly promote autonomy and advance notice as ethical
duties for psychologists.
Given the clear legal mandate and ethical duty to engage in
informed consent, how might we best gain insight into the inherent
dilemmas that Barnett and others have identified? Is the very
notion of informed consent somehow paradoxical or contradic-
tory? A careful consideration of the etymology of the term in-
formed consent sheds light on these questions. The term inform is
from the Latin informare: “in ⫽ causative preposition ⫹ for-
mare ⫽ to make or to form; to form an idea” (American Heritage
Dictionary, 1970, p. 674). Thus, to inform someone, in an etymo-
logical sense, is to cause him or her to form an idea. The origin of
the term consent is particularly germane to this discussion. The
Latin term is comsentire: “com ⫽ with ⫹ sentire ⫽ to feel or to
sense; to feel together; to feel with; to be of one mind” (American
Heritage Dictionary, 1970, p. 283). I would argue that the etymo-
logical origin of the term informed consent suggests that we are
striving for the client to be of the same mind or to agree with what
is presented. Both the terms inform and consent in fact share this
underlying or root meaning. It is interesting that the term choice
(sometimes used interchangeably with the term consent, as in
Barnett’s section) has a different meaning: “to select freely”
(American Heritage Dictionary, 1970, p. 237). Similarly, the term
decision implies a more active role on the part of the client. So,
although we tend to consider the notion of informed consent to be
in support of client autonomy and active involvement in the
treatment process, the use of terms such as choice and decision
implies a more active engagement and agency on the part of the
client.
This exploration of the etymology of these terms is relevant to
the tensions that even well-intentioned health professionals may
experience in endeavoring to effectively engage in the process of
informed consent. Most often it is not realistic to fully inform
potential clients in a manner that allows them total autonomy or
equality in making treatment decisions. The APA ethics code
(APA, 2002) uses the term reasonably understandable to describe
the level of complexity and completeness that is expected of
psychologists. Barnett summarizes research suggesting that
informed-consent documents may not actually be reasonably un-
derstandable to the general population. How might we best deter-
mine the precise risks of seeking or failing to seek treatment? Is it
realistic for us to fully articulate all reasonable treatment alterna-
tives and risks to clients? Can we truly ensure that potential clients
have adequately understood what we have attempted to commu-
nicate to them? If the purpose of informed consent is to elicit
 FOCUS ON ETHICS
agreement with our proposed treatment plan, then we are arguably
engaging in risk management rather than truly meeting the aspi-
rational goal of informed consent. Although few psychologists
would question the value of seeking informed consent, it is, in fact,
a surprisingly complex ethical duty to implement effectively.
Among many examples, acutely distressed individuals seeking
psychological treatment may have little interest in attempting to
comprehend the nuances of a long or technically complex
informed-consent statement. In addition, clients from differing
cultural backgrounds may not feel personally empowered to ask
questions of a professional or may actually perceive it to be
disrespectful.
Although the profession is in wide agreement with the move
toward greater autonomy of those whom we serve, it is not always
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
clear how to most effectively include clients in the process of
making active decisions about their treatment. I very much agree
with Barnett’s suggestion to provide informed consent both ver-
bally (to foster discussion) and in writing (for later review). Asking
ourselves what we would want to know if either we or a loved one
were contemplating the proposed course of treatment enables us to
more meaningfully take the perspective of the client. Ethical
discharge of this duty would also suggest that we take extra time
with clients who, for example, are acutely distressed or whose
cultural background might make it difficult for them to question a
professional. This exercise in perspective-taking enhances the ef-
fective discharge of this duty in line with aspirational rather than
purely risk-management goals and intentions. We also might want
to consider integrating terms such as choice and decision into our
ethical discourse to more effectively and accurately portray our
commitment to empowering our clients.
References
American heritage dictionary of the English language. (1970). New York:
American Heritage.
American Psychological Association (APA). (2002). Ethical principles of
psychologists and code of conduct. American Psychologist, 57, 1060 –
1073.
Behnke, S. (2004). Informed consent and APA’s new ethics code: Enhanc-
ing client autonomy, improving client care. Monitor on Psychology,
35(6), 80.
Evolving Standards for Informed Consent: Is It
Time for an Individualized and Flexible
Approach?
Doug Johnson-Greene
The importance of informed consent is probably vastly under-
estimated by many psychologists, and I suspect that some may
tend to view it more cynically as an initial onetime legal hurdle for
psychotherapy and research activities. There also appears to be an
overemphasis on content issues (i.e., what do I need to include to
make this a valid consent?) and comparatively little attention paid
to process issues (i.e., what does a specific patient need to know to
have a full appreciation for the parameters of this professional
relationship?). Barnett’s thought-provoking article raises some im-
portant questions about the nature of informed consent and how
183
best to convey the parameters of the professional relationships we
have with our patients.
Rationale for Informed Consent
There is considerable case law relating to informed consent in
medicine for situations that have predominantly involved surgical
procedures, which is understandable given the invasive nature of
the surgical profession, the litigious nature of our society, and an
evolving understanding of medical ethics over the past century.
Early case law described nonconsented surgery as assault and
emphasized the right to govern the integrity of one’s own body
(Schloendorff v. Society of New York Hospital, 1914), which in
later cases evolved into the “reasonable man standard,” in which
there was a right to pertinent information in order to make an
informed opinion before consenting to a procedure (Mitchell v.
Robinson, 1960/1962; Natason v. Klein, 1960). It should be noted
that the right to informed consent is not absolute and has excep-
tions even in medicine, such as the special police powers granted
to states so that they can address public health concerns deemed to
be in the interest of the greater good or when life-threatening
emergencies dictate the need for immediacy of action.
Despite informed consent’s legal history in medicine, I find no
case law pertaining to inadequate informed consent and provision
of clinical psychological services, which implies that if there have
been any torts in this area, they likely settled prior to judgment
(Johnson-Greene, Hardy-Morais, Adams, Hardy, & Bergloff,
1997). It could be argued, though, that informed consent may be a
contributing factor to some malpractice suits and complaints to
state licensing boards insomuch as misunderstandings between
psychologists and their patients are likely to give rise to more
formal remedies. However, when such misunderstandings occur, it
is unlikely that they are attributed to inadequate informed consent.
Does the level of intrusiveness associated with psychological
services justify informed consent? The answer to that question
depends on your definition of intrusiveness. Although psychother-
apy does not have the same type of intrusiveness as medicine, in
which there is the alteration of the physiology or structure of one’s
body, there is a highly intrusive quality associated with sharing and
altering thoughts and beliefs, assessing mental capabilities and
capacities, and providing closely guarded information that would
otherwise be kept from the closest of relatives. Also, psychological
services are increasingly used as the basis for loss of various
freedoms such as the ability to drive, to make financial or medical
decisions, to have employment opportunities, and to complete
educational programs. They are also used as the basis for deter-
mining competency to stand trial and eligibility for imposition of
death sentences for convicted criminals. These outcomes are
clearly not from the same domain as complications from invasive
surgery, but there should be little doubt that they are highly
intrusive in their own right.
Content and Conveyance of Informed Consent
Although there are now several ongoing National Institutes of
Health-funded studies examining the content and conveyance of
informed consent for specific types of research participants (e.g.,
persons with Alzheimer’s disease and multiple sclerosis), there is
an appalling lack of empirical investigations of informed consent
 184 FOCUS ON ETHICS
for clinical services. Thus, recommendations about informed con-
sent are a matter of ethical statements made by professional guilds
or based on legal advice, personal beliefs and morals, clinical lore,
and educated guesses.
The content of informed consent for research has been well
mapped, and several specialties within psychology have addressed
this issue (Caplan, 1988; Johnson-Greene, 2005). The latest iter-
ation of the APA ethics code (APA, 2002) described in Standard
10.01 that informed consent for psychotherapy has several com-
ponents, including “the nature and anticipated course of therapy,
fees, involvement of third parties, and limits of confidentiality” (p.
1072). Despite these recommendations, our profession lacks a
consensus about informed consent for psychotherapy patients.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
I would argue that informed consent for psychotherapy should
This document is copyrighted by the American Psychological Association or one of its allied publishers.
include at a minimum all basic parameters such as fees, expected
duration, potential consequences that could be reasonably ex-
pected, limits to confidentiality, objectives of treatment, and alter-
natives to the proposed treatment. In addition, there needs to be
flexibility in the content and conveyance of informed consent for
issues of diversity as described by Barnett, but also flexibility
related to the situation and purpose of the treatment. Informed
consent would be expected to look much different for psychother-
apy services provided to a cognitively impaired patient in a hos-
pital setting being evaluated for capacity to make decisions com-
pared with those provided to a reasonably intact outpatient seeking
psychotherapy.
The APA ethics code (APA, 2002) describes in Standard 3.1
that written or oral informed consent needs to be documented,
which implies that it may be permissible to obtain an oral consent
in some circumstances. Use of a written informed-consent docu-
ment ensures that important items are not inadvertently omitted by
in essence standardizing the process. Thus, important areas are
always covered, and it leaves less doubt about whether a specific
aspect had been covered should questions about a patient’s consent
arise later. Perhaps more important, Barnett’s paper suggests that
informed consent is not a onetime document signing but rather a
process that necessitates an ongoing exchange of information, and
one should document that an exchange of information occurred
and its content. Barnett suggests that psychologists should “ac-
tively ensure” that patients understand the information presented to
them, and I wholeheartedly agree. Clinicians may wish to ask
questions after providing information to ensure understanding and
to increase the opportunity for patients to ask questions. Such
techniques will ensure that the informed-consent process is not
passive; rather, it is an active interchange of information between
psychologists and their patients.
Concluding Remarks
In summary, informed consent is vitally important for promot-
ing our patients’ autonomy and self-determination. It must be
viewed as a flexible entity whose content is partly dependent on
the particular set of circumstances associated with a specific pa-
tient and his or her unique situation. What constitutes full disclo-
sure in informed consent is a matter of some debate, but the
process of providing ongoing, up-to-date information to our pa-
tients that is relevant to their situation is the critical aspect of
informed consent to which we must adhere.
References
American Psychological Association (APA). (2002). Ethical principles of
psychologists and code of conduct. American Psychologist, 57, 1060 –
1073.
Caplan, A. (1988). Informed consent and patient–provider relationships in
rehabilitation medicine. Archives of Physical Medicine and Rehabilita-
tion, 69, 2–7.
Johnson-Greene, D. (2005). Informed consent procedures for neuropsy-
chology: Official Statement of the National Academy of Neuropsychol-
ogy. Archives of Clinical Neuropsychology, 20, 335–340.
Johnson-Greene, D., Hardy-Morais, C., Adams, K., Hardy, C., & Bergloff,
P. (1997). Informed consent and neuropsychological assessment: Ethical
considerations and proposed guidelines. Clinical Neuropsychologist, 11,
454 – 460.
Mitchell v. Robinson, 334 S.W.2d 11 (Mo. 1960), reh’g denied. 360
S.W.2d 673 (Mo. 1962).
Natason v. Klein, 186 Kan. 393, 350 P.2d 1093 (1960).
Schloendorff v. Society of New York Hospital, 211 N.Y. 125, 105 N.E. 92
(1914).
Informed Consent: A Brief Attempt to Clarify
Some of the Ambiguities
Steven F. Bucky
Barnett’s article on informed consent is brief and to the point. It
was interesting and focused on major issues relevant to the clinical
process and raises many other interesting, though at times ambig-
uous, issues.
The primary points of the Barnett article are as follows:
1. Informed consent is not simply a form—it is a process.
2. The issue is controversial.
3. The way in which informed consent is handled by psy-
chologists is highly variable.
4. It is an important process that should be initiated early in
the therapeutic process.
The focus of the Barnett article is clearly on informed consent and
its relevance to clinical or therapeutic activities. It is worth men-
tioning, however, that informed consent has relevance in a number
of other psychological activities including, though not limited to,
(a) research, (b) assessment, and (c) supervision.
In the article, Barnett indicates, on a number of occasions, that
informed-consent “guidelines are unclear.” The following re-
sponse is an attempt to add some clarity where ambiguity prevails.
Research
It is my impression that psychologists do a relatively good job
of providing informed consent to research participants, with the
focus being on (a) risk, (b) benefits, (c) choice in agreeing to
participate, (d) choice in terminating the process at any time.
Assessment
Informed consent as it relates to assessment tends to be less
clear and more variable. It is important to note that according to the
 FOCUS ON ETHICS
informed-consent procedure (3.10) from the APA ethics code
(APA, 2002), psychologists should
1. Use “language that is reasonably understandable”
(3.10a);
2. When necessary or appropriate, “seek permission from a
legally authorized person” (3.10b);
3. Have appropriate “documentation of the informed-
consent procedure” (3.10b);
4. Provide assessments about “individuals only after they
have conducted an examination of the individuals ade-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
quate to support their conclusions” (9.01b).
This document is copyrighted by the American Psychological Association or one of its allied publishers.
The lack of informed-consent clarity in assessment, particularly in
custody evaluations, is much too common and, with some regu-
larity, leads to disciplinary action and significant levels of stress
for psychologists that can last for years (Gold, 2007).
Consistent with the guidance provided by the APA ethics
code (APA, 2002), I recommend that in the assessment process
(e.g., custody evaluation is the most common source of com-
plaint against psychologists in the State of California), the
following components be included in the informed-consent
process:
1. Client,
2. Person responsible for paying the bill,
3. Timing of the payment,
4. Relationship between paying the bill and completion of
the report,
5. Person who is going to be assessed (individually and
potentially with others),
6. Role of the child(ren),
7. Records that are going to be reviewed,
8. Purpose of the assessment,
9. Questions that are going to be asked,
10. Psychologist’s availability for discussion after the as-
sessment is completed,
11. Person(s) who will receive the report,
12. Sensitivity to language and culture (on a side note,
because of lawsuits and Board of Psychologists’ com-
plaints filed against psychologists and other mental
health professionals, it is recommended that psychol-
ogists be cautious about using the most recently pub-
lished tests with established reliability and validity;
also, it is recommended that psychologists avoid de-
rogatory, inflammatory use of language; O’Connor,
2007).
185
Supervision
Another professional activity about which psychologists have
been found to be relatively weak is informed consent in supervi-
sion (Falender & Shafranske, 2004). Supervisees (ideally) should
be provided with an informed-consent form and should participate
in an ongoing informed-consent process that focuses on the devel-
opment of the supervisory relationship (particularly in the early
weeks of the process or, preferably, prior to the initiating of
supervision) and that includes the following:
1. Start and stop dates,
2. Specifics of supervision (individual or group),
3. Responsibilities of the supervisor,
4. Responsibilities of the supervisee,
5. Resources available to the supervisee,
6. Pay,
7. Importance of confidentiality,
8. Limits of confidentiality,
9. Information on how to handle disagreements between
supervisor and supervisee,
10. Termination or transfer of clients,
11. Evaluations: criteria and timing,
12. Development of goals,
13. Role of theory in the therapeutic and supervisory pro-
cess,
14. Procedure for rescheduling supervision time.
(Note that 8, 9, and 11 are particularly important components of
the informed-consent process in supervision that are frequently
overlooked.) The informed-consent process is an important com-
ponent of developing the supervisory relationship and helps to
establish a safe environment for supervisees who frequently feel
more anxious, insecure, and intimidated than is apparent.
Some other areas in which informed-consent processes are
worth pursuing in more detail (though in another forum because of
the limited space for this article) are academic processes (e.g.,
outcome, effectiveness data, cost, time-to-completion data, and
information about internships), classes in which personal informa-
tion may be shared publicly, and consultation with organizations.
In conclusion, informed consent is an important process for
numerous professional activities and processes. It is important for
psychologists to be open and honest within a wide variety of
professional roles with diverse sets of clients (e.g., clients, stu-
dents, supervisees, and organizations). I suggest that psychologists
stay vigilant, with an open mind to new, potentially beneficial
ways in which to implement informed-consent processes that are
consistent with the APA ethics code (APA, 2002), relevant state
laws, and sound professional practice. The focus needs to be on the
 186 FOCUS ON ETHICS

welfare of the wide array of clients with whom psychologists taining objectivity. In S. Bucky, J. Callan, & G. Stricker (Eds.), Ethical
work. and legal issues for mental health professionals: In forensic settings.
New York: Haworth Press.
O’Connor, T. (2007). Due process, ethics and licensing boards. In S.
References Bucky, J. Callan, & G. Stricker (Eds.), Ethical and legal issues for
American Psychological Association (APA). (2002). Ethical principles of mental health professionals: In forensic settings. New York: Haworth
psychologists and code of conduct. American Psychologist, 57, 1060 – Press.
1073.
Falender, C. A., & Shafranske, E. P. (2004). Clinical supervision: A
competency-based approach. Washington, DC: American Psychological Received July 7, 2006
Association. Revision received October 19, 2006
Gold, R. (2007). Evaluating child custody cases: Techniques and main- Accepted October 26, 2006 䡲
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Members of Underrepresented Groups:

Reviewers for Journal Manuscripts Wanted
If you are interested in reviewing manuscripts for APA journals, the APA Publications and
Communications Board would like to invite your participation. Manuscript reviewers are vital to the
publications process. As a reviewer, you would gain valuable experience in publishing. The P&C
Board is particularly interested in encouraging members of underrepresented groups to participate
more in this process.

If you are interested in reviewing manuscripts, please write to the address below. Please note the
following important points:

• To be selected as a reviewer, you must have published articles in peer-reviewed journals. The
experience of publishing provides a reviewer with the basis for preparing a thorough, objective
review.

• To be selected, it is critical to be a regular reader of the five to six empirical journals that are most
central to the area or journal for which you would like to review. Current knowledge of recently
published research provides a reviewer with the knowledge base to evaluate a new submission
within the context of existing research.

• To select the appropriate reviewers for each manuscript, the editor needs detailed information.
Please include with your letter your vita. In the letter, please identify which APA journal(s) you
are interested in, and describe your area of expertise. Be as specific as possible. For example,
“social psychology” is not sufficient—you would need to specify “social cognition” or “attitude
change” as well.

• Reviewing a manuscript takes time (1– 4 hours per manuscript reviewed). If you are selected to
review a manuscript, be prepared to invest the necessary time to evaluate the manuscript
thoroughly.

Write to Journals Office, American Psychological Association, 750 First Street, NE, Washington,
DC 20002-4242.