- Therapy
- 20 mins
Let's tear down the wall of assumptions when it comes to therapy sessions. In this transcribed episode of The Shrink Think Podcast, Aaron and Nathan explain informed consent—what it is and why it's so important to the client-therapist relationship.
Aaron Potratz:
Hey everyone, welcome to another episode of the Shrink Think podcast. We're going to be talking today about informed consent. I know, I know. Please don't fall asleep. It sounds very boring, but this is actually really important because this is one of the first things that I talk about with clients when they come in, and we're actually going to be speaking at a conference in Georgia later this year about a topic that's very similar to this because it's that important. It's the kind of thing that when you're sitting in the chair as a therapist or if you're a client and you're doing all the hard work, this is all of the behind the scenes stuff that goes into it that you don't necessarily see directly, but if you don't have it, then you feel it. It's the kind of thing that when you're sitting there, you don't know certain things. You're like, "Oh, I'm not sure about this, or I'm uncomfortable," or you have anxiety about, I don't know what to expect.
Those things are likely impacting you and you don't even realize it. We're talking about it because we want to basically, turn on the light and spell out in clear lettering for everyone to see, this is what is going on, this is what we're doing, here's why it's happening. We want to give you all of the information so that you know exactly what you're consenting to, and that doesn't mean that we know everything or see everything, but it means that we know a lot. We can see a lot because we're objective and we've been trained in this and we've had lots of experiences with people, so we can bring those up and put those in front of you as a client, but ultimately, we want to do this as a way of giving you a lot of clarity and setting expectations in therapy.
Let me just kick this off and I'll tell you, as a therapist, when somebody comes in, I will do this little spiel. I've gotten it down to several minutes just to orient people to therapy and orient people to me, and I talk about this is what confidentiality is. You read about it in my paperwork before you came here, but I just want to talk about it verbally and tell you what it is and what it is not. There are some limits to confidentiality as mandatory reporters by the state, and then I'll actually go into, let me talk about informed consent. And then I'll say, "I want to give you as much information as possible as a therapist because..." and this is my value, and I hope all of you therapists out there there will value the same thing, "I think information is powerful," and when clients are coming in, they don't know a whole lot.
Maybe you haven't done therapy before or maybe you have done therapy and you've got an idea of what it's like, but now you're with a new therapist and they do things differently. Either way, there's a lot of information that you, the client, I think need to have in order to feel safe, in order to know what's expected of you, to know your guidelines, your guardrails for how to operate inside this therapeutic relationship with this specific person, and those kinds of things are really helpful for you to make good decisions. I'll talk usually about, "I want to give you information because I want you to feel safe. I want you to feel empowered. I want you to know what I know. I want us to work together collaboratively toward a goal so that we're on the same page, because if we get out of sync, then you'll feel it and we'll feel it, and we might make some bad decisions or we might just have a little bit of conflict that we need to resolve, so if you have the information from the get-go, that will help everything downstream."
From the very beginning I'll talk about things like scheduling and finances even. I'll say, "This is my fee. This is what happens with a cancellation. These are my expectations. Here's how to go about it," and all those things are so important because if we don't clarify those things, what happens when you need to cancel? Maybe you're not feeling well or something came up. You're close to 24 hours notice, if we have a 24-hour cancellation policy. You need to know how to go about things. If you have that information from the get-go, you know how to go about it.
Nathan Hawkins:
Yeah. Part of what you're saying, Aaron, is that, really I want to say maybe a different way or make more applicable, because some of you out there are like, "I've been to therapy before, blah, blah, blah blah." Yeah, but if you switch therapists, you cannot make the assumption that they're doing it the same way. You can't make the assumptions. You may be like, "Well, yeah, I know, they charge a different fee." Uh-huh. They also might do different notices like 24 hours, 48. I know some therapists, actually do, they're okay with 48 or 72 hour notice, meaning that they would prefer that than 24. You look at policies that are different and you don't know that, and you're like, "I gave you 24 hour notice," and they're like, "Yep, I know. Sorry bro. Not doing it that way, and you signed this coming in."
A lot of what informed consent is is supposed to tear down the wall of assumption because what we're doing is helping you to know upfront this is how we work, but there's also other sides to that, like you kind of touched on about confidentiality. There are just some legal things that are kind of true across the board, no matter what. I think, too, of lawyers will say, "Cool, cool, cool. You need to tell them this," and we're like, "If we say that, why would anybody go to therapy?" Nope, it has to be black and white, and you're like, so you're saying that therapy's going to do all this damage. Basically, you're going to guarantee sticker it or something.
Aaron Potratz:
You might walk away worse than you started, so why would you come to therapy?
Nathan Hawkins:
How that happens, not to get in into the weeds about it, but it's kind of interesting. I know some of you listen for the behind the scenes, is we hear some therapist gets sued in another state about something like, "You said you were going to help my marriage and then I got a divorce," and then a lawyer gets a hold down and goes, "You need to tell everybody that they're going to get a divorce if they come see you." You're like, what?
Aaron Potratz:
Therapy causes divorce.
Nathan Hawkins:
Right.
Aaron Potratz:
But it's true in the sense that, if you're going to therapy, and this is why you need to have this information, you, the consumer in a sense. You need to go into therapy knowing this could also really help things, and it could also really hurt things. Not that it's therapy itself that's going to hurt things or help things. Of course, if you pick the right therapist, a competent person who's aligned with what you're looking for, that's a part of it, and you can listen to a previous episode where we've talked about how to pick a therapist and that sort of thing, but if our job is to help basically, open the hood, flip up the hood of your car and look at what's really going on in your relationship, these things have already been going on.
They've always been going on. You just haven't maybe seen them or you haven't seen how bad they are. Maybe you're like, "Oh yeah, I haven't changed the oil in forever," and "A timing belt? What's that? Oh yeah, I have 200,000 miles on my car. I've never changed the timing belt." You're like, what? That's twice as long as you need to be driving it before you change it. It's like that kind of stuff. It's not our fault as therapists for pointing that stuff out or helping you see it, but now that we have helped you see it, it can be very destructive or you can interpret that as, wow, this is really bad and I don't know what to do with it or I can't deal with it or whatever, and that might not go the way that you think it's going to go.
Nathan Hawkins:
Yeah, and the feelings that you have, you could feel feelings of betrayal to the therapist. You could fill all these things, and the truth is, I'd say most people don't even read the informed consent coming in. I try to remember every time to do, there's some bullet points myself that I'll do, the financial thing, especially the 24 notice piece, and how that needs to happen because it really is different per therapist. For me, I would rather that you text me for example, then shoot me an email or whatever.
I even have that written down that you're not going to do that, but to be honest with you, if I have something like that go down, I will typically give some slack with that whole thing, but that gets down to, we've talked in the previous two episodes about what a therapist is and is not, and we have bills to pay and we have people that are constantly trying to get in and you don't give notice and we don't have time. "Well, if you would've called me probably an hour ago, I probably could have gotten this time." We're sitting there for an hour doing nothing. Even though we have-
Aaron Potratz:
Well-
Nathan Hawkins:
It's not like we're doing nothing actually.
Aaron Potratz:
We're writing notes and doing productive things for sure.
Nathan Hawkins:
Yeah.
Aaron Potratz:
You might be doing nothing.
Nathan Hawkins:
Yeah, these are just birds chirping and me staring off in the distance. I don't think I could even do that actually. I have a problem doing that while I'm camping, but there's different legal issues. I'll give you another example of informed consent. We want you to know coming in, maybe you have something going on in your life that's legal, and it's not really that big of a deal to you. You're going through a divorce or whatever and you're there to process it and that kind of thing, and there's a custody thing and you get irritated about that. We want you to know upfront with informed consent that we are not going to speak into your legal issues. We are not a lawyer, we are not a mediator, we're not any of those things.
Aaron Potratz:
A custody evaluator. We're not that.
Nathan Hawkins:
It's not a good assumption for you to have, which is what informed consent is supposed to let you know. We are giving you the information that you cannot think to yourself... Well, you can I guess, but it's not going to matter because you're saying-
Aaron Potratz:
We'll pat you on the back and be like, I'm glad you have that thought.
Nathan Hawkins:
Right. That we're going to be able to be your, somehow advocate with the court, or we're going to do you a solid and say, "Yep, they're a good parent," because that's an expert that says that they do it. That's an entirely different field that does it. They're called custody evaluators because all we know is you. We'll get into the weed just a little bit because you might be thinking, why not? This is stupid. Let's say you're like, "Nope, I really want you to be involved," and we're going to try to avoid that all day long, but let's say that you convince your attorney to do it, and we go, "Okay, well, here's the notes."
Aaron Potratz:
From your sessions.
Nathan Hawkins:
From your sessions. Now, your notes are out there, and you know who else has those notes? The other attorney and they get to play therapist in front of everyone out there. Well, it says right here that he's never liked her and he even cheated on her once and she doesn't know that or whatever. Couldn't it be true that also this thing, as a therapist, you're sitting there with the facts going like, yep, that could be true.
Aaron Potratz:
Our job is not to be an expert, not to give our opinion, not to share what we think about it, but just to simply declare, yes, this is what happened in the session. It's just to give the information.
Nathan Hawkins:
That whole thing, you don't want that. You don't want that at all. This is also true with, you're coming in and you've got some kid issues and you're trying to deal with custody. I mentioned that a little earlier. The custody evaluator, what they do is they meet with literally everyone. They meet with the therapist on both sides. They meet with both of the partners involved with the kids. They meet with all the kids. They also do psychometrics, which is these tests that they give everybody quite frankly, and then they stand back in their expert thing sitting room. I picture them in a little smoking jacket or whatever. "This is what I think is the best situation. This person is going to be the parent," and they've looked at all that and the judge will take that seriously and go, "Okay," and the judge still might not even rule in that favor.
The judge might still pick their own way, but as our episode is focused on informed consent, circling back, because I don't want a tributary too much. We want you to know these things up front. And I'm saying these examples because these are the reasons why we need you to know this up front. You can ask questions on things. I even have to have in my informed consent if legal stuff does happen and we have to print stuff out and send it in, there's a place in there that says you're going to pay 25 cents a page for all that stuff because it's not me as a therapist. I'm not the only one involved. We've got our admin manager and having to deal with it, so it's not as simple as, oh, we're just going to do XYZ. By the way, that's going to be pretty expensive for me to be at that and deal with the whole court thing for that day because I'm going to have to not see potentially, five people. This is all stuff to know up front.
Aaron Potratz:
You said earlier, you may have certain thoughts in your head about what it's going to be and that's fine. We don't want you to not have those thoughts, but the information that we give you is meant to, I guess, expose those thoughts that you might have or those assumptions that you didn't even realize you were making, so that you can bring those to the table and say, "Oh wait, so this is how you do things or this is what I should expect. Oh, I guess I was thinking it was something else." No, no, it's not that. So now, with this information, we've helped you to clarify some of what you were thinking, didn't even realize you were thinking or assuming about us or about the process that can help you get more in alignment with who we are, how we do things, and what the actual therapeutic process is like.
That's really helpful because then that's a potential avoidance of a conflict, and I always encourage my supervisees, my staff, and other therapists as I do speaking and consulting, I want to teach people that this kind of information from the very get-go is so important. It's good to talk about in the very first session. I even say about confidentiality, I'll tell people that, that extends out into the community, and it's funny to say now with this whole COVID thing going on, but I'll usually tell people, "Confidentiality extends in the community. If I happen to see you out in public, I probably won't recognize you because you have a mask on, but in a normal world, if I see you, I'm not going to come up and talk to you, and it's not because I don't like you or I don't want to talk to you. It's because I don't want to break your confidentiality. I don't want to come up and say hi, and then you have to explain to the people that you're with or me to the people that I'm with, hey, how do you know each other?"
And that's helpful because when people have that in their mind, they're like, oh yeah, that makes sense because inevitably, when I do see you in public and then you're like, "Why didn't you come talk to me?" or "Why didn't you come up and say hi? It felt weird. I was like, did you not want to say hi?" And then you remember, oh yeah, there's this reason why. I don't need to be hurt about this or offended by it. It's because you told me this is what you're going to do and here's why, and then we can come back to the next session and be like, "Oh, I saw you, and then I was like, why aren't you talking to me? But then I remembered," and then we can laugh about it together, whatever, and revisit that issue, but that information can help avoid lots of problems.
Nathan Hawkins:
The other thing, too, is in that particular example, I will actually give examples because what I've found is sometimes people will go, "Okay," but then they think, no big deal. I'll just say hi to you anyways, whatever, because it'll still be fine. This is a true story. I had that happen. Good connection with this kiddo. Well, he is not a kid. In my mind, he's like 19, and he's there with his buddies at Safeway, and I'm there to get milk. I cruise in. I see him and what I tell people is, if I see you first, I'm out of there. You won't know that I'm there. It's my goal because I don't want to put you in that position, but we see each other at the same time, basically. He comes over, "Hey Nate, man." He says some stuff. I haven't said anything by the way. Not a word.
And his buddies go, "Oh my gosh, you're his therapist? Okay, you need to totally work with this and this. He's basically jacked up, man. I can't believe he's finally seeing somebody because he's so crazy or whatever," and still haven't said a word. I'm like, "oh, nice to meet you guys," and his face gets beat red, and the reason why is because he just told me the previous session this important thing, and they just told me in that moment that he should be working on it, and he did not know anyone would've observed that about him. So now, he's totally embarrassed about this whole situation, and I'm sitting there like, "I'm going to get some milk now. See you guys later." I haven't said anything, not done anything at all, and he's in the next session. He's like, "You know that whole thing where we don't talk? I get it now."
Aaron Potratz:
Right.
Nathan Hawkins:
Oh, that's what you mean.
Aaron Potratz:
Right.
Nathan Hawkins:
There are just things that over the years of therapy that people have compiled, therapists, lawyers, whatever, that we realized, man, you guys don't do this every day. We need you to know upfront that this is just a different relationship. We've talked about in the previous episodes what a therapist is and is not, and we need to highlight some of that right off the bat up front, and what you can do then is edit. You can edit what you say because you know how we're going to use the information if we get it. One of the biggest pieces of that is directly in couples therapy, and we were talking in the last episode about secrets. It's like, if you know that you're, we're not going to hold that secret, you probably won't say it. You just won't. You'll be like, I know where this is going to go. I'm not saying that. And then what you're encouraged to do is make a determined decision at some point to let that secret out with everybody there.
Aaron Potratz:
Yeah. One example of this is, if you got one partner that you do the back and forth. You meet with one of them individually, and then maybe 30 minutes, and the other one for 30 minutes, and you just get a gauge of what's been going on or how are you feeling? Is there anything that you want to share without your partner present, so you can be more open about it? Maybe one person decides to say, "Yeah, I gambled and lost $20,000 and didn't tell them," or whatever, and there's this trust issue that you're working on in the relationship. Building trust or being honest with each other, that's where that informed consent can be really helpful.
I know maybe it's a bad example because that's a big deal, but you want to talk about that in terms of, okay, if we don't share about that, then here's what's going to happen. We move forward, we build trust, we talk about honesty or honest about everything else that's going on, but not about that. Well, what happens when you partner finds out about this? Then all of that trust work that we've done was kind of built on a flimsy foundation. It's all false because this information comes out about your gambling habit and it breaks that down. Now on the other side, if we do share, here's what that's going to be like. You're probably going to have to deal with this reaction. Maybe you're going to be in a position where you're not in charge of the finances anymore.
You've got some open book policy with your spending or whatever, so that you have an idea of what you're walking into or what kinds of reactions or responses do people give in these kinds of scenarios. That's not to say we know all of them, but because we're not a part of them, we can kind of see a little bit more objectively, and because we've been doing this for a while, we get a sense of how many people would respond or lots of different responses people generally give. We can give you that information so that you can decide, what do I want to do? What do I want? Do I want that short term gain, but the long term problem, or do I want to deal with this and have some short term problem, but in the long run it's going to be better for me?
Nathan Hawkins:
Yeah, the thing of it is, like in your example, Aaron, when you have been given good informed consent as a client, you will know when you're sitting there with this therapist for the 30 minutes individually that he's not or she's not going to hold your confidence, meaning the goal of that therapist in that moment is not to keep everything that you're saying totally close to the vest. As we mentioned in the previous episode, we will hold your privacy, which is by the way, the entire intent of seeing somebody individually because in high example of high conflictual couples where there's a lot of conflict, what I'm trying to say, with my mouth is conflicting with myself.
You oftentimes can't get your words out. You can't get everything out because everything's just a fight, so it can be helpful to be like, "Okay, as a therapist, I need to understand what your point is. We are never getting to where you need to go. I don't even know what you are trying to do." As a therapist, I need the space to understand what your heart is about what's going on, but that doesn't mean that, that information you're sharing is not necessarily going to get used in the session. My goal is not to, "Can you believe it? He said, and then she said, and he, what do you guys think?"
Because it's not about me, it's about what's helpful for you guys, but also, if you've been having an affair, you need to know up front that if you tell me that when you're in there, that information is now game. Also though, I want to be honest with this, my goal's not going to be to expose you when the other person, "Yep, he just told me he's having an affair, so don't know what we're going to do now. Remember that conflict thing? It's about to get real." That's not what I would do. I have been in that situation actually, and what you want to do is you want to help the person get that information out over a course of time when both the person can actually say it to the full measure and the other partner can hear it all the way.
Aaron Potratz:
Without things breaking down, because there are many situations where if you're talking about this high conflict situation, the other person, the receiving partner, is not in a position where they can really receive it and respond well to it and in a very productive way. That doesn't mean that they have no feelings about it, no reactions to it, but maybe if they've got a rage issue or they're abusive or something, that's not helpful. That's not safe to share when you know that it's going to be used against you. All we're trying to say is, we want to give you the information and we might hold some of that confidence for a while until we can get you to a place where it's like, okay, why aren't we going to deal with... Another quick example before we close up was with trauma stuff. People will talk about, "I want to come in and I want to deal with this incident or this abuse that happened in my childhood," or whatever.
It's like, well, if we do deal with this, here's how it's going to impact your life. You are already drinking or you've got these coping mechanisms and it's probably going to make those things worse. So before we do that, I think if you're not really ready, if you don't have the coping skills for it, it might impact you more than you realize and make your life sort of fall apart, but if you're really like, I need to know, I need do this right now, then that's up to you. You can make that decision, or if you'd rather work on some of these strengthening some of these coping skills, we can do that, and then when you've got those abilities, then we can go and deal with that. We're not saying one is better than the other. We're saying, here's what's going to happen if we do this, and we want you to be informed about it, so that you know what you're walking into.
Nathan Hawkins:
Right. Informed consent is just that. It's you getting an information, and then essentially being able to consent to it. As therapists, you want to do a good job helping your people understand essentially, you. There are some generalities that we've been talking about as well, like the whole legal thing earlier, but you are consenting to therapy when you sit in there. You are doing it, and some of you out there are like, I wonder where that document was that I signed? What exactly did I sign?
Aaron Potratz:
Now would be the time to read it.
Nathan Hawkins:
The cool thing about this is, I hope that we've made something that is extremely boring, not boring, and maybe actually helpful to you, and I hope we can figure out a good title of this episode. Hey, thanks for listening and have a great day.
Aaron Potratz:
Thanks for listening to our show. Don't forget to head over to Apple Podcasts, Spotify, Stitcher, or wherever you get your podcast, to leave us a review and subscribe to our podcast, so you never miss an episode. You can also sign up for our free email course, Nine Ways to Overcome Fear and self-Doubt. You'll get nine weeks worth of customized, practical strategies you can use to get past the fear that's holding you back in your life. Thanks again for listening.
