Informed consent lays the foundation for the psychotherapy relationship and treatment to come in respecting the client’s legal rights and offering her or him the opportunity to make an informed decision about participating in the treatment to be offered. Barnett, Wise, Johnson-Greene, & Bucky (2007) have highlighted the potential benefits of an appropriately implemented informed consent process:
The informed consent process also is required by the ethics code and in the licensing laws and regulations of each of the mental health professions. Licensing laws and regulations make clear the legal requirements and obligations for informed consent.
One such requirement is the age of majority for that jurisdiction and the various circumstances under which minors have the same rights as adults to give their own consent. In each jurisdiction’s licensing law and regulations there are multiple exceptions to the requirement to be legally an adult to give consent to treatment. Each of these must be known and understood prior to beginning clinical work with minors.
Snyder and Barnett (2006) assert that for informed consent to be valid, four criteria must be met:
The first three of these criteria are of special significance when seeking to obtain informed consent in the treatment of minors.
Children and adolescents may come to treatment under a number of circumstances. They may be brought to treatment by their parent(s), they may be brought to treatment by a guardian (an individual or a representative of an agency such as Child Protective Services or Department of Social Services, for example), or they may seek out treatment on their own. An important first step is to determine what obligations the psychotherapist owes to each party (Fisher, 2009). Who we typically consider the client is the individual receiving the psychotherapy. But, this is not always the case. The Ethical Principles of Psychologists and Code of Conduct (APA Ethics Code; APA, 2010) addresses this issue in Standard 3.07, Third Party Requests for Services. As is stated in this standard “psychologists attempt to clarify at the outset of the service the nature of the relationship with all individuals or organizations involved” (p. 6).
In these situations “the client” may in fact be an organization or individual other than the child or adolescent who is to receive the treatment. Thus, the informed consent process is of great importance for clarifying roles, responsibilities, and expectations with agreements being reached at the outset, before treatment is provided. These agreements would include decisions on confidentiality and its limits, the role third parties may play in the child or adolescent’s treatment, if any; who will participate in setting treatment goals, and who will agree to the treatment plan.
Except in situations consistent with certain exceptions allowed under the laws in one’s jurisdiction (e.g., when the minor is married or in the military, an emancipated minor) minors are not typically allowed to consent to their own treatment. But, that does not mean they should not play any role in the informed consent process. Depending on the minor’s age and developmental level, minors may have varied levels of participation in the informed consent process.
Even in situations where the parent or guardian legally is “the client” it is important for clinical and ethical reasons to include the minor (the direct recipient of our services) in this information sharing and decision-making process. For very young children it will be important to obtain their assent to treatment.
Assent is different from informed consent in that assent involves sharing information to the child so that she or he will understand the services to be provided, the nature of the process, the psychotherapist’s role and the child’s role, and other relevant information. The goal is to share basic information with the child at a level that she or he may understand. Doing so may help encourage the minor’s participation in the proposed course of treatment and to promote a more collaborative and effective treatment relationship.
As the minors’ age and developmental level increase their ability to comprehend the nature and vicissitudes of the psychotherapy process and each party’s role, responsibilities, and obligations typically increases as well. Thus, as McCabe (2006) illustrates, it is helpful to think of assent and informed consent as being on a continuum. As the minor develops an increased ability to participate in the information sharing and decision-making process, with the parents’ agreement, she or he should be afforded an increased role in this process.
Even when they do not yet have the legal right to give their own consent to treatment, research has demonstrated that many minors possess the cognitive and emotional abilities to understand the consequences of their decisions, to include health care decisions. In fact, minors as young as 12 years of age frequently possess this ability (Redding, 1993). While they may not have the legal right to provide informed consent to their own treatment, many minors may be able to be active partners in the decision-making process. Further, as their developmental level increases over time, the information sharing and decision-making processes should be revisited to afford minor clients the opportunity to participate in this process as fully as is feasible.
Further, there are a host of clinical reasons for including the more developmentally advanced minor in this process:
Parents or guardians have the legal right to consent to their minor child’s or adolescent’s treatment, to decide on the parameters of the course of treatment and potentially have complete access to all information from the psychotherapy process; however, one must consider the appropriateness of this on a practical level.
Psychotherapists should consider if clinically, this is a viable way to proceed with psychotherapy.
Psychotherapists should carefully consider the minor’s wishes and preferences in light of the presenting clinical situation. Additionally, we should consider what would be most appropriate for achieving the goals of psychotherapy. For example, how effective would psychotherapy be with a 15 year-old if she or he knows that everything shared and discussed in treatment is disclosed in detail to her or his parents each week? What impact would this arrangement have on the degree of sharing that takes place as well as on the level of trust the minor has for the psychotherapist?
Thus, while parents and guardians do have certain legal rights with regard to their minor children, these rights can be negotiated during the informed consent process. A parent could be informed that for treatment to be effective, the minor must be afforded some degree of confidentiality. As Koocher explains: “Parents can often be persuaded to agree to respect the privacy of the treatment relationship, particularly if they feel that the psychotherapist shares their interest and values with respect to their child’s safety” (In Barnett, Behnke, Rosenthal, & Koocher, 2007, p. 12).
It can be explained to all parties that certain topics and issues will be addressed within the confines of the psychotherapy relationship and that only if certain thresholds are crossed will this confidential information be shared with the parent or guardian. Examples of these circumstances can be shared to illustrate when this will happen, such as a significant risk to the safety of the minor or to others.