What does ‘informed consent’ mean? Fundamentally, it relates to the giving of permission (‘consent’) when in possession of sufficient details (‘informed’) to decide whether to participate or not. You will likely already be accustomed to giving informed consent in many aspects of your daily life. When you go to the hairdressers or barbers and have a consultation first, that discussion provides you (hopefully) with enough information so that you can agree to the chosen style or process. When you go to the dentist, doctor or surgeon and they propose an intervention of some sort (e.g. a tooth extraction), they will generally explain the advantages and any disadvantages (or what could go wrong). This enables you to agree to the proposed work, knowing the pros and cons and having come to a decision, based upon the information provided.
At other times, you will seek your own information and use that to reach a decision. When you are searching for a hypnotherapy training school, you may do research on the internet about the school itself, assess the providers accreditations (and check they are real), even conduct a Google search of the trainers (to check they have a relevant profile), as well as explore the views of past students. You will know when you have sufficient information to make a decision that is most relevant to your own best interests.
The giving of consent can be considered to address four key areas: Legal, ethical, interpersonal and administrative compliance. From a legal perspective, consent can protect from assault and can prevent unwanted treatment or interventions. From an ethical perspective, consent supports autonomous decision-making and also supports client-defined goals and desired outcomes. From an interpersonal perspective, the consent process offers an opportunity to build rapport and trust with the client, thus benefiting engagement and enhancing therapeutic interventions. From an administrative compliance perspective, some forms of consent can record or document those involved in the consent process and can form a safeguard to demonstrate meeting ethical and legal requirements.
Within hypnotherapy, there are three types of consent that can arise. That of ‘implied’ consent, ‘explicit’ consent and ‘informed’ consent. We can explore these separately. ‘Implied’ consent is not explicitly stated by the client, rather their actions (or lack of action) indicates their acceptance. For example, shaking hands implies consent to touch. ‘Explicit’ consent is explicit spoken or written permission by the client. For example, asking a client if they are willing to go into hypnosis and they say ‘yes’. ‘Informed’ consent takes explicit consent one stage further. It is when the client gives explicit consent and they are in receipt of sufficient information to make an educated choice.
There may be at least five different aspects of your work where informed consent may be relevant. Firstly, relating to hypnosis and hypnotherapy itself. Secondly, relating to the proposed treatment within the hypnotherapy session, the anticipated benefits of that treatment and any alternatives. Thirdly, relating to any alternatives to the proposed treatment and their benefits and risks. Fourthly, relating to the potential benefits and risks of no action at all (‘declining treatment’) and finally, relating to the proposed self-care (‘homework’) and its benefits and risks.
If we consider the first aspect in more detail, consent for the use of hypnosis and hypnotherapy really does need to be informed consent. There are some conditions (such as some mental health conditions) and situations where the use of hypnosis or hypnotherapy may not be in the best interests of the client. By having a good discussion (e.g. ‘pre-talk’) about what hypnosis is, this can help the client decide whether hypnosis is right for them.
Looking at the second aspect, that of the proposed treatment, provision of information about that treatment is important. Now this doesn’t necessarily mean that you ‘teach’ them how the entire approach works (and thus give some the potential to unpick the work in advance). However, the client knows what is going on in their life in far more detail than they will have shared with you. It may be that they have an important exam the day after, and you are proposing a trauma focused intervention which may have some ongoing processing. By letting the client know (in appropriate terms!), they can make an informed decision whether to go ahead with the proposed treatment or wait until the next session.
This brings us on to our third aspect, that of alternative approaches to the proposed treatment. Some clients may have done their research about hypnotherapy approaches and might want or not want a specific intervention. A client may have strong beliefs about regression, or even past-life regression. They may specifically want this, or even specifically not want it. For example, someone may come with an eating disorder and have previously spent a couple of years in counselling or other talking therapy, going over their childhood in minute detail, without successful insight or change. They may be reluctant to engage with hypnotic regression and may seek information to decide whether an alternative approach (such as behavioural, cognitive or analytical) may be more acceptable.
For hypnotherapists, addressing the impact of ‘no action at all’ is not commonly offered as an option. After all, the client has booked a session with a view to seeking therapy. It may be though that the outcomes they want or the goals that they have are not realistic or achievable. For example, someone might be seeking hypnotherapy for weight loss, yet they are of a normal weight or even a low weight. Here, taking no action towards their requested outcome may be most appropriate.
Finally, the consent process really does also apply to the proposed self-care. Although it might be optimal to have a ‘contract for action’ or specific homework task to support or reinforce the work conducted in the session, if the client is not committed to that process, it can actually weaken the gains of the therapy. If you are working with a client who has a fear of escalators and ‘tell’ them to spend a day on the London Underground going up and down some of the very long escalators, on their own, they might initially be compliant and then get scared and it have a negative impact on the positive work previously done. Whereas, if the potential for them feeling ‘concerned’ at any point was discussed as a potential outcome and measures established to address it, the client is likely to engage in the task from a more informed and consenting perspective.
There are also four key elements that contribute to the consent process. Firstly, that the client has sufficient capacity to make decisions. For example, you may be working with a child (and thus both parent and child will consent) or a vulnerable adult (where a guardian and the client may consent). Secondly, that sufficient information is provided for an informed choice to be made. Thirdly, that the client (and any other person also making the decision) has a way to demonstrate their understanding of that provided information and finally that the consent was freely made. There could be considered to be a fifth consideration, which is a means of recording that they have given consent.
Generally, it is good for information to be provided within a discussion. Some studies, albeit in medical settings, indicate that clients may retain little of the information provided to them during the consent process. Furthermore, that their level of understanding can be over-estimated. How much information is the right amount? A good starting point when assessing how much information to provide is what a ‘reasonable person’ would want to know in a similar situation. Whilst being sensitive to the individual differences and needs of each particular client. You may have a client who wants you to ‘just get on with it’ and only wants the briefest amount of information. Alternatively, you may have a highly critical, analytical or detail-oriented client who wants a far greater depth of information.
Moreover, that information is best provided in a format and manner which takes into consideration the individuality of the client. In addition to their general personality, their locus of control can be a factor as can their age and life experience, as well as their present emotional state. For example, anxiety can impair their ability to focus on detail. So, it is important to use language and concepts the client is likely to understand and also checking for understanding.
There are clear advantages of providing information for consent. By supporting client autonomy, it helps demonstrate that the treatment is directed towards the client’s chosen outcomes, shifting some aspects of the decision-making away from the therapist and towards the client, this self-determination thus enhancing client-centred models of therapy. Furthermore, by the client giving consent, they are also giving a commitment to the treatment process and thus can enhance their level of engagement.
As talking therapists, can we do better than physicians/doctors at providing informed consent? A study of 2553 clinical decisions found only 9% met the criteria for completely informed decision-making. Are they missing out on an awesome opportunity to build rapport and trust? Perhaps. Yet, could giving the client autonomy in the decision-making process go too far? Surely shared decision-making is stronger. The client may know themselves better than anyone else. Yet the therapist is likely to know the therapeutic processes more than the client. Thus, the concept of hypnotherapy being a collaborative approach may start at the very beginning of the therapeutic process.
Something that is generally discussed from a collaborative perspective is that of the client’s goals. Is consent related to the client’s goals? To ensure that clients have a realistic understanding of what they can expect from hypnotherapy and the potential outcomes, and their part in the process, then it could be said that the consent process is very much aligned to the formulation of effective goals. As part of the ‘goals discussion’, it can be useful to manage expectations, and this links back to the consent process and provision of sufficient information. Furthermore, you may find it helpful to have an understanding of the client’s core values, so that you can focus your discussion even more accurately.
Beyond the discussion in the therapy room, what other options do you have for providing information for informed consent purposes? The medical field may offer some guidance here on the benefits of engaging with information technology. For example, there is some research that indicates the use of an information video can be helpful, whilst another study found that an interactive video was superior in its information provision to that of just a booklet.
Finally, how can you record the giving of information and receiving consent? It may be that you have a standard list of topics that you cover (or even a standard list for each type of condition / approach) and simply make a note of using that as well as noting any additional information (‘narrative notes’) you provide on your intake form, perhaps alongside the client’s goals for therapy. It might be that you have a separate consent form. Either way, the client can sign to indicate that they have been provided with sufficient information.
For further information on this topic, check out the extensive ‘further reading’ list below…
We hope that this blog on wellbeing at work for hypnotherapists has been helpful to you. If you have any more questions about this topic or anything else for that matter, do please get in touch, because we’re always happy to help!
Informed consent – Further reading
Bowden MT, Church CA, Chiu AG, et al. (2004) Informed consent in functional endoscopic sinus surgery: the patient’s perspective. Otolaryngology Head and Neck Surgery 131:126–32
Braddock CH, III, Edwards KA, Hasenberg NM, et al. (1999) Informed decision making in outpatient practice: time to get back to basics. Journal of the American Medical Association 282:2313–20
Chan EC, Sulmasy DP. (1998) What should men know about prostate-specific antigen screening before giving informed consent? The American Journal of Medicine 105:266–74
Courtney MJ. (2001) Information about surgery: What does the public want to know? ANZ Journal of Surgery 71:24–6
Dawes PJ, Davison P. (1994) Informed consent: What do patients want to know? Journal of the Royal Society of Medicine 87:149–52
Dawes PJ, O’Keefe L, Adcock S. (1993) Informed consent: using a structured interview changes patients’ attitudes towards informed consent. Journal of Laryngology and Otology 107:775–9
Deyo RA, Cherkin DC, Weinstein J, et al. (2000) Involving patients in clinical decisions: impact of an interactive video program on use of back surgery. Medical Care 38:959–69
Hutson MM, Blaha JD. (1991) Patients’ recall of preoperative instruction for informed consent for an operation. Journal of Bone and Joint Surgery. American Volume 73:160–2
Lashley M, Talley W, Lands LC, et al. (2000) Informed proxy consent: communication between pediatric surgeons and surrogates about surgery. Pediatrics 105:591–7
Lavelle-Jones C, Byrne DJ, Rice P, et al. (1993) Factors affecting quality of informed consent. British Medical Journal 306:885–90
Leeb D, Bowers DG, Jr, Lynch JB. (1976) Observations on the myth of “informed consent.” Plastic and Reconstructive Surgery 58:280–2
Leeper-Majors K, Veale JR, Westbrook TS, et al. (2003) The effect of standardized patient feedback in teaching surgical residents informed consent: results of a pilot study. Current Surgery 60:615–22
Lloyd A, Hayes P, Bell P. (2001) The role of risk and benefit perception in informed consent for surgery. Medical Decision Making 21: 141–9
Marshall M, Bibby J. (2011) Supporting patients to make the best decisions. British Medical Journal 342:d2117.
McKneally MF, Ignagni E, Martin DK, et al. (2004) The leap to trust: perspective of cholecystectomy patients on informed decision making and consent. Journal of the American College of Surgeons 199:51–7
McKneally MF, Martin DK. (2000) An entrustment model of consent for surgical treatment of life-threatening illness: perspective of patients requiring esophagectomy. Journal of Thoracic and Cardiovascular Surgery 120:264–9
Morgan LW, Schwab IR. (1986) Informed consent in senile cataract extraction. Archives of Ophthalmology 104:42–5
Newton-Howes PAG, Dobbs B, Frizelle F. (1998) Informed consent: What do patients want to know? The New Zealand Medical Journal 111:340–2
Sulmasy DP, Lehmann LS, Levine DM, et al. (1994) Patients’ perceptions of the quality of informed consent for common medical procedures. Journal of Clinical Ethics 5:189–94
Tait AR, Voepel-Lewis T, Malviya S. (2003) Do they understand? (part II): assent of children participating in clinical anesthesia and surgery research. Anesthesiology 98:609–14
Weston J, Hannah M, Downes J. (1997) Evaluating the benefits of a patient information video during the informed consent process. Patient Education and Counselling 30:239–45
Wisselo TL, Stuart C, Muris P. (2004) Providing parents with information before anaesthesia: What do they really want to know? Paediatric Anaesthesia 14:299–307
– written by Dr Kate Beaven-Marks