You will write an article review, relevant to this weeks learning module and readings You will select the article yourself by searching the UWA Library Databases

Professional Psychology: Research and Practice 1993. Vol. 24. No. 2,160-163

Copyright 1993 by the American Psychological Association. Inc. 0735-7028/93/S3.00

Practical Benefits of an Informed-Consent Procedure: An Empirical Investigation

Therese Sullivan, William L. Martin, Jr., and Mitchell M. Handelsman

Seventy-eight women and 46 men rated a hypothetical therapist described as either a paraprofes- sional (BA in English) or professional (PhD in psychology) with either less than 1 or greater than 9 years of experience. They received either a transcript containing a conversation about informed- consent issues accompanied by a written form or a control transcript with no informed-consent discussion. Participants gave higher ratings to a therapist who used an informed-consent proce- dure and reported more willingness to recommend him to a friend and to go to him themselves. They rated professionals who used informed consent as more expert and trustworthy than those who did not. They rated experienced therapists higher overall and as more expert than inexperi- enced therapists.

Despite growing attention to the ethical and legal issues surrounding informed consent (Haas, 1991), there is no con- sensus on the impact of consent procedures on the relationship between clients and therapists. Some have argued that clients would think highly of therapists who show respect for client rights and that consent procedures would facilitate the thera- peutic relationship (Everstine et al., 1980; Handelsman, 1990; Hare-Mustin, Maracek, Kaplan, & Liss-Levinson, 1979). Others have expressed concern that consent procedures may interfere with the therapeutic relationship and hinder treat- ment (Handelsman, Kemper, Kesson-Craig, McLain, & Johnsrud, 1986; Kimmons, 1980, cited in Muehleman, Pick- ens, & Robinson, 1985).

To test the impact of written consent forms, Handelsman (1990) had participants rate a hypothetical psychologist after being provided with introductory materials, including either no consent form or some combination of forms. Participants rated the psychologist who used written forms more positively on a number of measures. Handelsman and Martin (1992) per- formed two studies to determine whether the positive effects of

THERESE SULLIVAN is a graduate of the University of Colorado at Boulder and is currently pursuing a master's degree at the University of Colorado at Denver. Her interests include ethics and cognitive be- havioral therapy. WILLIAM L. MARTIN, JR., received his MA in clinical psychology from the University of Colorado at Denver in May 1992. He is currently doing therapy with adolescents and their families for the Juvenile Diversion Program of the Eighteenth Judicial District in Colorado. His interests include family therapy and ethics. MITCHELL M. HANDELSMAN holds degrees from Haverford College and the University of Kansas and is currently Associate Professor of psychology at the University of Colorado at Denver. He is a former APA Congressional Science Fellow and has interests in ethics and the teaching of psychology. THE AUTHORS GRATEFULLY ACKNOWLEDGE the assistance of Sheryl Otto and Ellen B. Braaten, who always manage to correlate above .90. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Mitchell M. Handelsman, Department of Psychology, Campus Box 173, University of Colorado at Denver, P.O. Box 173364, Denver, Colo- rado 80217-3364.

a consent form would be maintained when accompanied by more information about a psychologist's actual behavior in a therapy session. They also assessed the effects of readability of the consent form. They found no effects of the consent forms on participants' impressions of therapists. In the second study only, men who received a less readable consent form gave less favorable ratings. With this single exception, it appeared that therapists' actual behavior is a more important influence on client impressions than are written consent forms.

To date, then, there is no empirical support for the notion that written consent forms adversely affect people's first im- pressions as long as the form is readable. The consent process does not end, however, once written material is provided; con- versations between clients and therapists should also occur. Given the evidence that oral interaction has more influence on impressions than does written consent material, oral presenta- tion of informed-consent material in a session may influence first impressions.

The first purpose of the present study was to assess the im- pact of an informed-consent procedure—including both oral and written components—on first impressions of potential clients. Thus, we asked participants to rate a hypothetical thera- pist after receiving either (a) a transcript that was accompanied by a written consent form and that included a conversation about such topics as risks and benefits of treatment, limits of confidentiality, and alternatives to therapy or (b) a therapy tran- script containing no informed-consent material. We hypothe- sized that therapists using an informed-consent procedure would elicit more favorable reactions.

Many therapists are paraprofessionals who do not have grad- uate degrees in a mental health field (Windle, Poppen, Thomp- son, & Marvelle, 1988). The general ethical reasons for obtain- ing informed consent from clients of paraprofessionals are no different from those cited for professionals. There are no data, however, on the impact of informed-consent procedures on first impressions toward paraprofessional therapists. The sec- ond purpose of this study was to assess the impact of an in- formed-consent procedure on paraprofessionals as well as pro- fessionals. Does a consent procedure influence client percep- tions differently depending on the status of the therapist?

160

PRACTICAL BENEFITS OF INFORMED CONSENT 161

The above question could also be applied to experience level; thus, the third purpose of this study was to assess the impact of therapist experience on the impact of an informed-consent procedure.

The influence of therapist status and experience on client perceptions has not been well established. The research has consistently confounded the effects of status and experience. Although some studies have shown that therapists with more experience and high status are seen as more expert (Angle & Goodyear, 1984; McKee & Smouse, 1983), the confounded vari- ables make these results difficult to interpret. Separating these two variables would help establish their individual influences.

Only three studies have varied therapist status (PhD vs. BA) with experience held constant (Corcoran, 1985; McCarthy, 1982; Simonson & Bahr, 1974). Only two of these analogue studies reported significant main effects for status. McCarthy (1982) found that paraprofessionals were rated as more trust- worthy and attractive than were professionals. Corcoran (1985) found participants more willing to discuss interpersonal prob- lems with a paraprofessional student than with a PhD psycholo- gist. On the basis of these findings, we expected paraprofes- sionals to be favored in the present study.

In a study of the effects of introductory material on first impressions, Handelsman (1990, Study 2) manipulated thera- pist experience and held status constant. He found that moder- ate and high levels of therapist experience (9 and 19 years) elic- ited more positive reactions and more willingness to see and recommend the psychologist than did a low level of experience (less than 1 year). We hypothesized that highly experienced ther- apists would elicit more positive ratings than would less experi- enced therapists.

Method

Participants

Participants were 124 students (78 women and 46 men) in an Intro- ductory Psychology class at the University of Colorado at Denver, who received extra credit for their participation. The mean age was 22.7 years, with a range of 17-53. They were randomly assigned to one of the eight conditions, with 13-17 participants per condition.

Design

The design was a 2 X 2 X 2 factorial, with the between-subjects independent variables of Informed Consent Procedure (absent vs. pres- ent), Status (paraprofessional vs. professional), and Experience (low vs. high).

Transcripts

Two therapy transcripts were used in this study: a control transcript and an informed-consent transcript. The control transcript was based on one first used by McCarthy and Betz (1978) in their study of thera- pist self-referent responses; we omitted the self-referent responses. The therapist was identified as a man, John Doe, and the client was identi- fied as a woman, Karen.

The informed-consent transcript was created by adding dialogue to the control transcript. Early in the session, the therapist says, "At the end of the session, I want to save a few minutes to talk with you about the process of therapy." At the end of the session, the therapist reintro-

duces this theme and asks the client if she has received the consent form (Handelsman & Galvin, 1988) that was given to participants in this condition. The client asks about risks; the therapist explains that some clients do not improve, and if the client feels she is not progress- ing, they can discuss it and arrange a referral if necessary. The client asks about alternative treatments, confidentiality and its limits, and the length of treatment, and the therapist responds to each of these questions. At the end of the session, the therapist says, "We will discuss these issues further as we get to know each other and as they come up again. At some point later on, we'll discuss this sheet again.. . ."Both transcripts ended with the therapist inviting the client to come back next week. Adding dialogue made the transcript longer, but it was judged that holding the content of the therapy session constant was more important than holding length constant.

Procedure

After agreeing to participate, participants were given a packet of materials that included a description of a therapist, the control or informed-consent transcript, and several dependent measures. Partici- pants in the informed-consent condition also received the written con- sent form, purportedly used by the therapist. Participants were in- structed to read through the materials and answer the questions as if they were the client in the transcript.

The therapist was described as working at a fictitious mental health center. Status was manipulated by describing the paraprofessional ther- apist as having a BA in English and the professional as having a PhD in psychology. Experience was manipulated by describing the therapist as having either less than 1 year or greater than 9 years of experience. The status and experience information was reiterated at the top of the therapy transcript.

The first dependent measures checked the status and experience manipulations, as follows:

In the transcript you read, how many years of experience did the therapist have? . . . In the transcript you read, what was the high- est degree earned by the therapist? (check one answer).

BA MA PhD

Participants then completed the Counselor Rating Form—Short Version (CRF-S; Corrigan & Schmidt, 1983). The CRF-S asks partici- pants to rate a therapist on 12 characteristics, each on a 7-point Likert- ty pe scale. The CRF-S yields a total score as well as subscale scores for trustworthiness, expertness, and attractiveness.

Participants then answered three questions on a 7-point scale (1 = disagree completely; 4 = neither agree nor disagree; 7 = agree com- pletely): (a) "I would recommend Dr. [Mr.] Doe to a friend"; (b) "If I were experiencing problems, I would go see Dr. [Mr.] Doe"; and (c) "My overall reaction to Dr. [Mr] Doe is very positive." Finally, participants responded to several demographic questions, including one that asked if they had ever been in therapy.

Results

The four CRF-S scores (Total, Trustworthiness, Expertness, Attractiveness) and the three additional attitude questions were each analyzed in a 2 X 2 X 2 analysis of variance (ANOVA), with the between-subjects factors of Informed-Consent Procedure (absent vs. present), Status (paraprofessional vs. professional), and Experience (low vs. high). Sex of participant was not used as an independent variable due to the low number of men in some cells.

To help determine the generalizability of these data to people with experience in psychotherapy, all analyses were performed

162 T. SULLIVAN, W MARTIN, JR., AND M. HANDELSMAN

with Therapy Experience (no vs. yes) as a fourth independent factor. There were no differences due to this factor on the re- sults; thus, results from only the three-way ANOVAs are re- ported.

Manipulation Checks

The two manipulation checks revealed that participants at- tended to the status and experience manipulations. Fifty-three (88.3%) of the participants in the paraprofessional status condi- tion accurately identified the status of the therapist; 59 (92.2%) of those in the professional status condition did so. An ANOVA showed that participants reported significantly more years of experience in the high-experience condition (M = 8.79) than did those in the low-experience condition (M = 1.10), F(l, 111) = 1995.54, p < .001. It is interesting that participants in the professional condition reported more experience (M= 5.24) than did those in the paraprofessional condition (M = 4.28), F(l, 111) = 4.58, p = .035. It appears that part of participants' perception of professionals is that they have about 1 year more experience.

Informed Consent and Status

The informed-consent manipulation yielded several signifi- cant effects. Analysis of the total CRF-S score revealed a main effect, F(, 116) = 5.78, p = .018, such that participants gave higher ratings to therapists who used the informed-consent procedure (M = 56.69) than to therapists who did not (M = 51.52).

Analysis of the CRF-S Trustworthiness scale yielded a main effect favoring the informed-consent procedure, F(l, 116) = 11.01, p = .001. This main effect was qualified by a trend for the Informed Consent X Status interaction, F(l, 116)= 3.57, p = .061. Means and standard deviations are shown in Table 1. Sub- sequent Duncan's multiple range tests revealed that partici- pants rated professionals who used the consent procedure as more trustworthy than did professionals who did not ( p < .01); there were no differences between paraprofessionals. Profes- sionals received higher ratings than paraprofessionals only when the informed-consent procedure was present (p < .05).

A similar pattern emerged in the analysis of CRF-S Expert-

Table 1 Cell Means and Standard Deviations of CRF-S Trustworthiness and Expert ness Subscale Scores by Experimental Conditions

CRF-S Subscale

Trustworthiness Expertness

Procedure M SD n M SD n

No informed consent Paraprofessional 18.37 4.10 30 16.40 5.23 30 Professional 18.06 3.66 32 16.78 4.31 32

Informed consent Paraprofessional 19.33 4.53 30 16.37 5.25 30 Professional 21.81 3.48 32 19.66 4.38 32

Note. CRF-S = Counselor Rating Form-Short Version.

ness scores. There was a trend for an Informed-Consent X Sta- tus interaction, F(, 116) = 3.44, p = .066, which qualified a main effect for Status, F(l, 116) = 4.39, p = .038. Table 1 shows the means and standard deviations. Duncan's tests revealed that participants rated professionals who used the consent pro- cedure as more expert than professionals who did not ( p < .05). There were no differences between paraprofessionals who did and did not use the consent procedure. Once again, profes- sionals were rated as more expert than paraprofessionals only when the consent procedure was present (p < .05).

Analysis of participants' willingness to recommend the thera- pist to a friend yielded a main effect, F(l, 116) = 8.45, p = .004, favoring therapists who used the consent procedure (M= 4.42) over therapists who did not (M = 3.69).

There was also a main effect for the consent procedure on participants' willingness to see the therapist, F(l, 116) = 12.24, p= .001. Participants were more willing to go to the therapist when he used the consent procedure (M =4.13) than when he did not (M= 3.08).

Analysis of participants' overall positive reactions revealed a main effect, F(l, 116)= 7.24, p = .008, such that ratings were more positive when the consent procedure was present (M = 4.19) than when it was absent (M = 3.47).

The status manipulation yielded no effects other than those on the CRF-S Trustworthiness and Expertness scales, dis- cussed above.

Experience

There were two main effects for level of experience. Analysis of the total CRF-S scores yielded a main effect for Experience, F(, 116) = 6.29, p= .014, such that more experienced thera- pists received higher ratings (M = 56.92) than did less experi- enced therapists (M = 51.38). There was also a main effect for experience on the CRF-S Expertness ratings, F(l, 116) = 28.75, p < .001. Participants gave higher Expertness ratings to more experienced therapists (M = 19.52) than to less experienced therapists (M = 15.21).

Discussion

Our first hypothesis, regarding the effects of the consent pro- cedure, was confirmed: When oral and written consent mate- rials are presented together, there is a positive impact on peo- ple's first impressions toward therapists. Two interactions indi- cated that not all of the positive effects of the consent procedure were consistent across levels of status. The consent procedure increased ratings of expertness and trustworthiness for profes- sional therapists but not for paraprofessional therapists.

These results provide evidence that an informed-consent procedure, when done well, can be used to provide ethical treatment to clients without risking damage at the beginning of the therapeutic relationship. Indeed, clients may be more favor- ably disposed to therapists who take the time and effort to provide information. For professional therapists, this consent procedure also seems to enhance impressions of trustworthi- ness and expertness.

It could be argued that the positive effects of the consent discussion were not because of the content of the discussion but

PRACTICAL BENEFITS OF INFORMED CONSENT 163

because it portrayed a more highly skilled therapist. We do not know the mechanism behind the positive effect we found. It could be that the informed-consent portion of the transcript was better written than the rest of the transcript or that the provision of any information may itself be seen as an indication of competence.

It may also be argued that there is other information relevant to informed consent that could damage a therapeutic relation- ship. The present transcript incorporated several important and relevant topics, including confidentiality, alternative treat- ments, and risks. More research is needed to test the limits of the positive eifects of this study. On the basis of the existing empirical literature, we believe that therapists can meet their ethical requirements and provide benefit to clients without reaching those limits.

Our second hypothesis, that paraprofessionals would be rated more favorably than professionals, was not confirmed. The only status differences found favored professionals on rat- ings of trustworthiness and expertness and were present only in the informed-consent condition. Thus, status differences seemed to reflect only an absence of the positive effects of the consent procedure for paraprofessionals rather than a general preference for professionals. It is unclear why paraprofessionals would not also be rated more expert and trustworthy when using informed consent. Perhaps people expect paraprofes- sionals to interact with clients as partners on their level, willing to provide information, whereas they expect professionals to interact with clients in a more traditional doctor-patient rela- tionship in which the doctor is not expected to welcome too many questions. These participants may have been pleasantly surprised to find the professional so willing to initiate and en- gage in this type of discussion.

Our third hypothesis received partial support: More experi- enced therapists received higher ratings than did less experi- enced therapists. Therapists with more than 9 years of experi- ence were rated higher on the total CRF-S score and on the Expertness subscale than were therapists with less than 1 year of experience. These results are consistent with those of Han- delsman (1990) and—given that status and experience manipu- lations both worked—suggest that experience may be a more salient variable than status.

The consent material presented in this study represented only one possible method of presentation; different informa- tion or different ways of presenting it may have a different impact (Andrews, 1984). In addition, client and therapist char- acteristics, such as gender and ethnicity, may interact with con- sent procedures. The generalizability of the results to a current clinical population is limited, even though participants came from an atypical student population with a mean age of 22.7 years and many had experience as therapy clients. In no in- stance in the present study did the presence of a consent proce- dure lead to more negative impressions of therapists. Our tenta- tive conclusion is that doing ethical practice and doing good therapy are not mutually exclusive.

References

Andrews, L. B. (1984). Informed consent statutes and the decision- making process. Journal of Legal Medicine, 5, 163-217.

Angle, S. S., & Goodyear, R. K. (1984). Perceptions of counselor quali- ties: Impact of subjects' self-concepts, counselor gender, and coun- selor introductions. Journal of Counseling Psychology, 31, 576-579.

Corcoran, K. J. (1985). Unraveling subjects' perceptions of paraprofes- sionals and professionals: piotsludy.PerceptualandMotorSkills, 60,111-114.

Corrigan, J. D., & Schmidt, L. D. (1983). Development and validation of revisions in the Counselor Rating Form. Journal of Counseling Psychology, 30, 64-75.

Everstine, L., Everstine, D. S., Heymann, G. M., True, R. M., Johnson, H. G., & Seiden, R. H. (1980). Privacy and confidentiality in psycho- therapy. American Psychologist, 35, 828-840.

Haas, L. J. (1991). Hide-and-seek or show-and-tell? Emerging issues of informed consent. Ethics & Behavior, 1, 175-189.

Handelsman, M. M. (1990). Do written consent forms influence clients' first impressions of therapists? Professional Psychology: Re- search and Practice, 21, 451-454.

Handelsman, M. M., & Galvin, M. D. (1988). Facilitating informed consent for outpatient psychotherapy: A suggested written format. Professional Psychology: Research and Practice, 19, 223-225.

Handelsman, M. M., Kemper, M. B., Kesson-Craig, P., McLain, J., & Johnsrud, C. (1986). Use, content, and readability of written in- formed consent forms for treatment. Professional Psychology: Re- search and Practice, 17,514-518.

Handelsman, M. M., & Martin, W L., Jr. (1992). Effects of readability on the impact and recall of written informed consent material. Pro- fessional Psychology: Research and Practice, 23, 500-503.

Hare-Mustin, R. T., Maracek, J., Kaplan, A. G., & Liss-Levinson, N. (1979). Rights of clients, responsibilities of therapists. American Psy- chologist, 34, 3-16.

Kimmons, C. (1980). A survey of attitudes towards confidentiality. Un- published master's thesis, Murray State University, Murray, KY.

McCarthy, P. R. (1982). Differential effects of counselor self-referent responses and counselor status. Journal of Counseling Psychology, 29,125-131.

McCarthy, P. R., & Betz, N. E. (1978). Differential effects of self-dis- closing versus self-involving counselor statements. Journal of Coun- seling Psychology, 25, 251-256.

McKee, K., & Smouse, A. D. (1983). Clients' perceptions of counselor expertness, attractiveness, and trustworthiness: Initial impact of counselor status and weight. Journal of Counseling Psychology, 30, 332-338.

Muehleman, T

Collepals.com Plagiarism Free Papers

Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.

Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS

Why Hire Collepals.com writers to do your paper?

Quality- We are experienced and have access to ample research materials.

We write plagiarism Free Content

Confidential- We never share or sell your personal information to third parties.

Support-Chat with us today! We are always waiting to answer all your questions.