OPINION

published: 10 August 2016

doi: 10.3389/fpsyg.2016.01170

Evidence-Based Practice and

Psychological Treatments: The
Imperatives of Informed Consent
Charlotte R. Blease 1, 2*, Scott O. Lilienfeld 3 and John M. Kelley 2, 4
1
Centre for Medical Humanities, University of Leeds, Leeds, UK, 2 Program in Placebo Studies, Harvard Medical School,
Boston, MA, USA, 3 Psychology, Emory University, Atlanta, GA, USA, 4 Psychology, Endicott College, Beverly, MA, USA

Keywords: ethics, professional, ethics medical, psychotherapy training, evidence based in clinical psychology,
evidence-based practice, informed consent, paternalism

INTRODUCTION
A decade after physicians (including psychiatrists) endorsed the shift toward evidence-based
medicine, the world’s largest association of psychologists, the American Psychological Association
(APA), belatedly but officially embraced the tenets of evidence-based practice (EBP) [American
Psychological Association (APA), 2006]. Other clinical psychology associations, including the
Canadian Psychological Association, soon followed suit (Canadian Psychological Association,
2012). The interpretation of medical evidence is deeply entwined with ethics; although mainstream
medicine has until recently paid relatively little attention to the ethical repercussions of evidence-
based practice, the neglect in the field of psychological treatments is even more glaring.
Edited by: Why does EBP matter for the ethical practice of psychological treatments? Evidence carries
Tuomas K. Pernu,
ethical imperatives. Both the decision about what is considered to be beneficial in psychotherapy,
King’s College London, UK
and the current paucity of research regarding the potential negative effects of psychological
Reviewed by: treatments, carry ethical implications. We argue that the failure to pay attention to psychotherapy
Luis J. Flores,
research effectively risks undermining key requisites included in professional codes of practice for
King’s College London, UK
clinical psychology, psychiatry, social work, and allied fields. First, EBP bears repercussions for
*Correspondence:
the clinician’s duty of professional competence, or what O’Donohue and Henderson (1999) have
Charlotte R. Blease
collectively termed “epistemic duties”—the responsibility to acquire and apply accurate knowledge.
[email protected]
Second, EBP is relevant to the duty to respect patient autonomy—namely, the patient’s right to
Specialty section:
make informed decisions concerning his or her treatment plans.
This article was submitted to Evidence shows that there are divergent views about the importance, and feasibility, of informed
Theoretical and Philosophical consent among practicing psychotherapists (e.g., Croarkin et al., 2003; Barnett et al., 2007; Goddard
Psychology, et al., 2008). Some of this variation, we argue, probably owes to differences in opinion about what is
a section of the journal materially relevant to patients in deciding to undergo psychotherapy; other omissions of informed
Frontiers in Psychology consent may persist because of continued debate and confusion about what constitutes “evidence”
Received: 06 June 2016 in psychotherapy research and practice. We argue that—despite these challenges—the profession
Accepted: 22 July 2016 of psychotherapy must find ways to meet the moral obligation of providing adequate informed
Published: 10 August 2016 consent to patients.
Citation:
Blease CR, Lilienfeld SO and
Kelley JM (2016) Evidence-Based
EVIDENCE-BASED PRACTICE AND ETHICAL DUTIES
Practice and Psychological
Treatments: The Imperatives of
Professional competence—the ability to accurately assess problems, diagnose psychological
Informed Consent. disorders, recommend an appropriate course of treatment, and successfully carry out that
Front. Psychol. 7:1170. treatment—varies depending on the degree to which the clinician keeps up to date with the latest
doi: 10.3389/fpsyg.2016.01170 research and effectively evaluates the evidence. The APA requires that clinicians be trained in EBP

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Blease et al. EBP, Psychotherapy and Informed Consent

to be equipped to appraise the range of evidence regarding information about therapy before it started were significantly
the efficacy of different forms of psychotherapy, to recognize more likely to report adverse effects of treatment (Crawford
the strengths and limitations of clinical intuition, and to et al., 2016). This finding, although correlational and open to
understand the importance of patient preferences and values, rival interpretations (e.g., therapists who fail to provide informed
as well as the relevance of the socio-cultural context in treating consent may be less competent in general), supports the notion
clients. In this way, the APA acknowledges that EBP requires that the provision of information about therapy helps demystify
knowledge of controlled clinical trials, but also underlines that the treatment process, may reduce anxiety about treatment, and
trial data have inherent limitations. For example, such trials may increase trust between therapist and patient, contributing to
can be unrepresentative of individual patients given that they better outcomes (Beahrs and Gutheil, 2001; Snyder and Barnett,
can be largely insensitive to such factors as age of patient, 2006). It is also conceivable that negative effects may arise from
and comorbidity [American Psychological Association (APA), failures to provide understandable information to patients, or
2006; cf. Greenhalgh et al., 2014; Sheridan and Julian, 2016]. that negative effects are a consequence of the manner in which
The APA also emphasizes the importance of keeping up to information disclosures are conveyed to patients.
date with the latest process—and not merely outcome—data on It is worth emphasizing that there are ongoing challenges
how psychotherapies work [American Psychological Association associated with providing open and honest disclosures in medical
(APA), 2006]. practice, and perhaps especially in the context of patients
The duty to be professionally competent carries significant with severe mental health problems, which can sometimes
additional implications for the duty to respect patient autonomy. impair judgment, comprehension, or both. At the same time,
Historically, paternalism was the largely unquestioned bedrock of strong arguments are required to justify paternalistic action
healthcare practice. Paternalism is defined as “the interference of in any professional healthcare context. Indeed, even in those
a state or an individual by another person, against their will, and circumstances in which health professionals determine that a
defended or motivated by the claim that the person interfered patient has impaired mental functioning, this does not entail
with will be better off or protected from harm” (Dworkin, that the duty to provide informed consent be overridden. For
2010); it was defended on the grounds that doctors were the example, the UK’s Mental Capacity Act of 2005 states that there
gatekeepers of medical knowledge, as well as the best judges of must be a presumption of capacity for patients to make treatment
how to use that knowledge to serve the interests of patients. decisions; in addition, the burden is on health professionals
Today, healthcare ethics codes (in the West) eschew paternalism: to demonstrate that patients lack any such capacity (UK
professional clinicians are now obliged to be truthful and to Department for Constitutional Affairs, 2005). Notwithstanding
provide adequate disclosure to patients about their diagnosis, these pronouncements, when it comes to informed consent
the risks and benefits of various treatment options, and their there may be practical challenges for psychotherapists who
duration and costs (Trachsel et al., 2015; Blease et al., 2016; are regularly faced with patients who are extremely anxious,
Trachsel and Gaab, 2016). However, the quality of disclosures depressed, or agitated as well as those with pronounced psychotic
to patients depends on practitioner knowledge, illustrating features. The key challenge, then, is to find ways to meet
once again why standards of evidence are enmeshed with the obligation of adequate disclosure while recognizing the
ethics. contextual sensitivities involved in providing comprehensible
information to patients.

EVIDENCE OF FAILURES IN INFORMED

CONSENT EXPLANATIONS FOR PROBLEMS WITH
INFORMED CONSENT
Evidence suggests that psychotherapists may be routinely failing
to provide adequate informed consent to patients (Dsubanko- Why does informed consent to psychotherapy appear to be
Obermayr and Baumann, 1998; Croarkin et al., 2003; Barnett “vastly underestimated by many psychologists?” (Barnett et al.,
et al., 2007; Goddard et al., 2008). Surveys in the US and UK 2007). We propose that there are three main reasons for the
reveal broad variation among psychotherapists, as well as among resistance to informed consent on the part of many practitioners.
psychotherapy schools, in beliefs and practices with respect to
information disclosure (Somberg et al., 1993; Croarkin et al., Informed Consent is a “Process”
2003; Martindale et al., 2009). Psychiatrists and adherents of First, informed consent to therapy is a process, rather than as a
psychodynamic psychotherapy appear to be especially doubtful one-time disclosure of information, such as occurs in biomedical
about the practicability and importance of informed consent contexts. Some psychotherapists may erroneously believe that
(Croarkin et al., 2003; Goddard et al., 2008). Yet even in cases in the procedural nature of understanding how therapy works is
which therapists routinely disclose information about the specific a sufficient reason to dismiss or overlook formal disclosure
techniques of therapy—as we later argue—this information may (Barnett et al., 2007). To overcome any such misconceptions,
be insufficient for adequate informed consent. Barnett et al. propose that a combination of written and verbal
There is evidence that standards of disclosure relate to, disclosure of information be provided to patients prior to
and may influence, outcome in psychotherapy. A recent UK treatment, but that disclosure should additionally be an ongoing,
study found that patients who reported receiving insufficient active exchange of information as therapy ensues.

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Blease et al. EBP, Psychotherapy and Informed Consent

The Complexities of Psychotherapy of attention to potential harms of psychotherapy may perpetuate

Research the erroneous assumption that psychotherapy carries negligible
Second, psychotherapy research is highly contentious. Compared risk.
with the evaluation of psychopharmacological treatments,
psychotherapy research is even more difficult to interpret.
Debate focuses largely on what constitutes “evidence” in
FUTURE DIRECTIONS: WHAT AND HOW
psychotherapy research (Tanenbaum, 2006; Stuart and Lilienfeld, TO DISCLOSE INFORMATION TO
2007; Goldfried, 2013). Although there is not the space to PATIENTS?
evaluate and appraise the extensive, ongoing debate about
the nature of EBP, we highlight two salient points that we EBP—in its broadest sense—requires therapists to attempt to put
believe transcend this debate, and that are relevant to informed aside or find ways to compensate for their biases, and to approach
consent to psychotherapy. First, subjective impressions of efficacy psychotherapy research systematically. Although there is ongoing
based largely or entirely on personal clinical observations can debate about how to interpret process and outcome research
be misleading. A robust body of research strongly suggests evidence in psychotherapy, there is a duty among therapists not
that such impressions are frequently inaccurate (Lilienfeld only keep up to date with findings about specific treatments,
et al., 2014; Casarett, 2016). Second, although there is still but to be well-informed about broader debates regarding the
disagreement regarding the effectiveness of specific techniques potential mechanisms and mediators of therapeutic outcomes. As
in therapy (e.g., insight-techniques in psychodynamic therapies, noted, a wide range of research suggests that explanations for the
or cognitive restructuring techniques in cognitive-behavioral techniques involved in psychological treatments cannot be taken
therapy) a large body of research suggests that non-specific at face value. For example, given the evidence for the importance
factors, such as therapist empathy and the working alliance, of the common factors across different forms of psychotherapy,
should be taken into account when it comes to assessments of such as the working alliance, therapist empathy, and the patients’
psychotherapeutic efficacy. For example, therapist characteristics expectations about treatment effectiveness, a strong case can be
appear to be important predictors of outcome and in some made for their inclusion in initial information disclosures (Gaab
cases—for example, major depressive disorder—it has been et al., 2015; Blease et al., 2016). It is also likely that there are
argued that such factors may be more predictive than the ways of disclosing the importance of the therapeutic relationship
specific therapeutic modality (Cuijpers et al., 2008; Wampold to patients, for example, without undermining that relationship
and Imel, 2015). Although, this research is controversial, there (Blease, 2015a,b; Trachsel and Gaab, 2016), and we strongly
is widespread consensus among psychotherapy researchers and encourage research on this issue.
psychotherapists that—whatever the role of specific factors—the Clients also have a right to be fully informed about the
so-called common factors in therapy—are significant mediators efficacy and effectiveness of specific techniques in therapy. For
of change in treatment (Lambert and Barley, 2002; Huppert et al., example, patients with obsessive-compulsive disorder (OCD)
2006; Marcus et al., 2014; Cuijpers, 2016). have a right to know that exposure and response prevention is
the best-supported intervention for their condition—and hence
a first-line treatment (Olatunji et al., 2013). Additionally, when
Neglect of Research on Negative Effects it comes to overall efficacy claims, treatment specificity tends to
Finally, unlike in pharmacology, evidence of possible negative be considerably higher for certain conditions than for others; for
effects of psychological treatments is both under-researched example, in contrast to OCD, for which behavioral interventions
and largely underappreciated in clinical psychology and allied are the clear treatment of choice, major depression tends to
fields. The routine failure to consider the possible harms of respond to a broad range of psychological treatments (e.g.,
psychotherapy may stem, in part, from intuitive ontological behavioral, cognitive, interpersonal; see Hollon et al., 2002).
considerations: namely, in psychotherapy the treatment Moreover, because certain conditions, major depression again
modality involves “talking” rather than the administration of a being a prime example, appear to be etiologically heterogeneous,
“physical” treatment such as a drug or surgery (Blease, 2015b). it unlikely that even a highly efficacious intervention will work
Findings indicate that approximately 10% of patients experience for virtually all clients. Therefore, clients need to be informed
worsening of symptoms following long term treatment in that, depending on their diagnosis, therapeutic interventions may
psychotherapy—although it is unclear what proportion of work well for most patients but not all. The point is that research
these deterioration effects is due to the treatment, as opposed must percolate into disclosure procedures: patients have a right
to a naturally-occurring worsening of symptoms, negative to be furnished with adequate, understandable information about
life events outside of therapy, or other influences (Lilienfeld, treatment techniques, the importance of common therapeutic
2007). In their UK study, Crawford et al. (2016) reported that factors as well as specific therapeutic techniques, and the risks of
1 in 20 patients who enter into psychological therapies report harm from a minority of psychological treatments (see Lilienfeld,
long-lasting negative effects of treatment. At an institutional 2007).
level, unlike drug treatments in which the FDA requires adverse Finally, we recommend that informed consent to
risks of medications to be investigated and listed, there are no psychotherapy is best conceived as a process—initial disclosures
comparable requirements for psychological treatments (Duggan of information will require active, ongoing refinement as
et al., 2014; Markowitz and Milrod, 2015). The longstanding lack therapy ensues. Research suggests that including ongoing patient

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Blease et al. EBP, Psychotherapy and Informed Consent

feedback during therapy is one important means of monitoring treatments. Legally and morally, licensed clinical and counseling
progress, thereby helping therapists to enhance patient outcomes psychologists, psychiatrists, and other psychotherapists are duty-
(Lambert et al., 2001; Sapyta et al., 2005; Shimokawa et al., 2010; bound to eschew healthcare paternalism. Patients deserve to
Beidas et al., 2015). The bidirectional flow of information about be fully informed if they are to make autonomous choices
how therapy works, as well as how patients believe therapy is regarding psychological treatment modalities. Psychotherapy
progressing, should be built into the therapeutic process (Barnett must incorporate best evidence into training and practice if it
et al., 2007). is to establish and maintain high ethical standards of care. The
discussion about how best to accomplish this crucial goal must
now begin in earnest.
CONCLUSIONS
Therapists should decisively disavow the pervasive assumption AUTHOR CONTRIBUTIONS
that psychotherapies—although generally effective—carry no risk
of harm, and that disclosure (or its omission) somehow carries CB devised and structured the paper. CB, SL and JK jointly
a different moral valence for psychotherapy than for biomedical co-authored the content.

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psychotherapy. Psychother. Bull. 41, 37–42. be construed as a potential conflict of interest.
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Therapists’ beliefs and practices. Prof. Psychol. 24, 153–159. doi: 10.1037/0735- The reviewer LF and handling Editor declared their shared affiliation, and
7028.24.2.153 the handling Editor states that the process nevertheless met the standards of a fair
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practice and public policy,” in Evidence-Based Psychotherapy: Where Practice distributed under the terms of the Creative Commons Attribution License (CC BY).
and Research Meet, eds C. D. Goodheart, A. E. Kazdin, and R. J. Sternberg The use, distribution or reproduction in other forums is permitted, provided the
(Washington, DC: American Psychological Association), 239–259. original author(s) or licensor are credited and that the original publication in this
Trachsel, M., and Gaab, J. (2016). Disclosure of incidental constituents journal is cited, in accordance with accepted academic practice. No use, distribution
of psychotherapy as a moral obligation for psychiatrists and or reproduction is permitted which does not comply with these terms.

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