December 4, 1998

Does informed consent enhance or hinder the process of psychiatric treatment? Two psychiatrists each took a position assigned to them and debated this question at the annual conference of the American Academy of Psychiatry and the Law in New Orleans in October.

John Beahrs, M.D., a psychiatrist at the V.A. Medical Center in Portland, Ore., argued in favor of informed consent. Beahrs, who is chair of APA's Delayed Recall Committee, said the issue of informed consent has raised difficult questions for psychiatrists. "On the positive side," he noted, "it's forcing us to look at issues I wish we'd dealt with a generation ago."

In taking the position that psychotherapy is a valid medical treatment and defining the process as a procedure, therapists also take on the obligation of all health care providers, Beahrs noted. Among the most important of these, he said, is the duty to provide expert information that patients are not likely to know themselves, so that they can make their own rational choices among many alternatives.

Beahrs presented three arguments to support his endorsement of informed consent. Through well-implemented informed consent, he said, patients become more active participants in their own behalf. Because therapeutic progress correlates very highly with the degree to which patients are actively helping themselves, providing them with information to do so is beneficial.

On another level, informed consent can lessen regressive dependency, continued Beahrs. And when patients become well-informed, active agents in their own behalf, liability is more equally shared by therapist and patient.

Secondly, provision of meaningful informed consent expands patient treatment options beyond particular therapeutic parochialism.

"By parochialism, I refer to the self-reinforcing cultlike illness that is present in most, if not all, therapeutic belief systems and methodologies," said Beahrs. Parochialism involves selective indoctrination, he noted.

The antithesis of parochialism is corrective information gleaned from scientific observation, data gathering, and experimentation, said Beahrs. It includes opportunities for free debate and information, informed decision making, and a more balanced perspective.

Argument three, observed Beahrs, is that informed consent offers a practical antithesis to abusive treatment such as practices that emerged in the late 1980s and early 1990s, when some therapists started encouraging patients to file criminal charges or liability suits against parents for alleged events happening years to decades earlier. They based allegations on memories "recovered" through therapeutic techniques.

This practice, said Beahrs, scared people, and now what happens in the therapeutic consulting room is everybody's business.

"It's up to us collectively to take it like a mensch, accept the consequences, and turn them around," Beahrs noted. Informed consent can be used to serve the best interests of patients, professionals, and society. Where it is problematic, he said, mental health professionals should do everything in their power to make it work.

Thomas Gutheil, M.D., a professor of psychiatry at Harvard Medical School and codirector of the program in Psychiatry and the Law at Massachusetts Mental Health Center and Harvard Medical School, discussed the problems informed consent presents in therapy, noting that because long-term therapy is patient driven and unpredictable, it is not appropriate to provide informed consent within it.

Informed consent is much more suited to a procedure like surgery than the process of psychotherapy, said Gutheil. In psychotherapy, said Gutheil, patients come on time and pay money, and therapist and patient treat each other with respect. Everything else is to be discovered or announced as part of the process, he said.

"Neither the risks nor benefits of psychotherapy can be known at the outset, although uncertainty can and should be shared," he commented.

In recovered memory cases, said Gutheil, critics often focus on the claim that therapy is suggestive. If suggestion is a problem, he noted, and the therapist suggests what might happen in therapy, it can contaminate or distort the therapy. "All forms of therapy direct attention, and attention leads to recall; therefore, all therapy is suggestive and leads to the emergence of memories. I consider that an inescapable issue in treatment."

In addition, said Gutheil, "the kind of process that leads to intellectualization instead of authentic exploration of affect is bad for therapy."

Gutheil went on to examine the trends in psychiatry that have contributed to problems with delayed recall. "We have witnessed a significant decline of dynamic teaching and practice. This means a loss in the psychiatric universe of the notion of the primacy of the self and the patient's responsibility for thoughts and actions," he said.

The concept of primacy of self refers to the idea that issues come from inside a person, Gutheil noted. From the dynamic point of view, he said, a patient's complaints of satanic ritual abuse might stem from his own satanic thoughts and fantasies.

"The modern pressure is not to understand and accept one's own dynamics but to find someone external to the self to blame and to sue," said Gutheil. This leads to the notion of radical victimology in which all trauma is treated as external, he added.

In introducing the debate, moderator Angela M. Hegarty, M.B.B.Ch., a neuropsychiatrist in New York, noted that people from the False Memory Syndrome Association continue to advocate aggressively for formal informed consent for psychotherapy. The aspect of a formal procedure has "raised issues about inhibiting therapists' style or creating an almost litigious atmosphere in the therapy context," she said.

Beahrs said that APA needs to take some action in clarifying the parameters of informed consent. APA has provided guidelines on informed consent in its Annotated Principles of Medical Ethics 1998 and added an addendum on informed consent in 1997.

For more information, see the Annotated Principles of Medical Ethics 1998 on the APA Web page at www.psych.org/apa_members/ethics.cfm.