Beyond Informed Consent: Talking to Patients About Therapeutic Action

In other areas of psychiatry and medicine, discussions of treatment options are often accompanied by a statement of how each is expected to work. For example, an anxious patient may be presented with two medication options—benzodiazepines and selective serotonin reuptake inhibitors—and the different ways in which each pharmacological agent would be expected to work. This information is invaluable for helping patients select treatments and understand their hypothesized mechanism of action. However, even when consent procedures for psychotherapy are carried out to a T, they generally do not include a discussion of therapeutic action, that is, ideas about how the treatment works.

Of course, when psychoanalysis was the only form of treatment available, there was less need to discuss alternative therapies, length of proposed treatment, or theories of therapeutic action. This changed, however, as alternative forms of psychotherapy became available, and other types of psychotherapists began treatments with extensive discussions about treatment frame, roles of the therapist and patient, and ideas about therapeutic action. For example, in cognitive-behavioral therapy, therapists discuss with patients their ideas about how the treatment will work in the first session (14). Far from conceptualizing this discussion as potentially interfering with the therapeutic process or promoting resistance, discussing therapeutic action at the outset of treatment is thought to be a vital component of the therapy, aimed at enhancing patient motivation and active participation (14). However, psychodynamically oriented psychotherapists remained hesitant to have similar conversations with their patients, continuing to cite concerns that doing so might corrupt or contaminate the therapeutic relationship (15).

Our experience, though, is that patients are interested in how psychodynamic psychotherapy works and that discussing this at the beginning of treatment may enhance the induction process and foster the therapeutic alliance. One of us (DC), after writing a textbook on psychodynamic psychotherapy for the purpose of educating current and future providers of psychodynamic psychotherapy (16), had numerous experiences in which patients and other non–mental health professionals remarked that they wished that they had read the book before starting psychotherapy. In particular, these people highlighted their interest in ideas about how the treatment is thought to work. This made us wonder whether other patients would also be interested in having targeted information about psychodynamic psychotherapy at the outset of treatment, including ideas about therapeutic action. Although ideas about therapeutic action are not within the minimal criteria for informed consent as discussed earlier, we feel this additional information is vital for helping patients understand the nature of the proposed treatment. Given our experience with patients’ interest in information about therapeutic action and our belief that this uniquely augments patients’ understanding of the proposed treatment, we started to provide them with targeted information.

After our search for extant patient information materials that included information about therapeutic action in psychodynamic psychotherapy came up empty, we decided to create our own. While creating the materials, we kept in mind the difficulties discussed earlier, namely, that psychiatry residents conducting psychotherapy are still not presenting the basic information necessary to obtain informed consent and that even complete informed consent conversations in psychodynamic psychotherapy do not necessarily include a discussion of therapeutic action.

On the basis of information included in Psychodynamic Psychotherapy: A Clinical Manual (16), we created a two-sided document called the PEPPER (Post-Evaluation Psychodynamic Psychotherapy Educational Resource), included in the online supplement. The PEPPER includes basic information about the general frame of and expectations for psychodynamic psychotherapy, information about the therapeutic action of psychodynamic psychotherapy, and frequently asked questions.

The PEPPER is oriented toward the patient as the audience and is intended to be given during the informed consent process after patients starting psychodynamic psychotherapy have been evaluated and determined to be appropriate for this form of treatment. We informally vetted the instrument with nonclinician peers to determine whether it was easy to understand and contained the information they would want before beginning a treatment.

Given the previous finding that psychiatry residents did not provide adequate information to obtain informed consent for psychotherapy, we felt that this group of trainees could benefit from having access to this resource. At our institution, we began to use the PEPPER with patients beginning psychodynamic psychotherapy in our resident long-term therapy clinic. We created standardized training for clinicians in how to use the PEPPER, which involved watching a video of the PEPPER being discussed in a mock session with a patient, engaging in a role-play exercise using a standard script (online supplement), and taking a three-item quiz. We then began to train residents (postgraduate years [PGY] 2–4) in how to administer the PEPPER to their patients during the informed consent process for psychodynamic psychotherapy. We gave them copies of the PEPPER to give to their patients and encouraged them to follow the standard script while discussing it during the informed consent process.

Typically, the informed consent process was expected to take place after the initial patient evaluation was complete and the resident was proposing psychodynamic psychotherapy as the recommended treatment (generally after three to five sessions). Residents who evaluated patients deemed to be appropriate for psychodynamic psychotherapy gave their patients a copy of the PEPPER along with standard consent forms during the informed consent process and, according to the standard script, asked them to bring the PEPPER home and read it before the next session. In the next session, residents prompted their patients to bring up any questions they had about what they read in the PEPPER and to discuss their understanding of it. The discussion aspect of the PEPPER is key, because it ensures that patients have thought about the information presented to them and implicitly suggests that they take an active role in the treatment process. If the patient had not read the PEPPER at home, the resident was expected to read it with the patient in session and engage the patient in a discussion thereafter.

To get a better sense of how this new intervention was received by both therapists and patients, we decided to administer a qualitative survey to residents who had received training in the use of the PEPPER. We were interested in their experience in using it, whether they found it useful, and whether their patients had had any response to it.

In January 2016, we sent out a 12-item anonymous electronic survey via Qualtrics software to the 23 residents (12 PGY2, six PGY3, five PGY4) who were trained to administer the PEPPER. This survey was designed to assess attitudes about the use of this document during the informed consent process. This survey asked for PGY level and then asked for opinions about the training, the PEPPER itself, and its use during the informed consent process. The survey included both yes-no and open-ended questions to which participants could write in answers. Reminders to complete the survey were sent weekly for a total of three weeks, including the initial correspondence. Instructions were given to not duplicate responses.

This study was reviewed by the institutional review board of our institution and was exempt from full review because it was determined to not constitute human subjects research.

Nineteen residents completed the survey (11 PGY2, three PGY3, five PGY4). Of those residents, only 10 (53%) had already administered the PEPPER to their patients. Two reasons for not administering the PEPPER were given: Four PGY2s had not yet been assigned an outpatient for psychodynamic psychotherapy but had already received the training, and five PGY3 and PGY4 residents voluntarily sought out training but had already completed the informed consent process with their patient in the past and opted not to discuss the PEPPER with their current patient.

All survey participants agreed that the PEPPER is a useful resource for patients. Some sample responses after the initial yes-no question included “It makes them more active participants,” “It helps them understand what this treatment entails,” “It uses easy-to-understand language,” and “It sets expectations and promotes shared decision making.”

All survey participants also agreed that the PEPPER is a useful resource for providers. Some sample qualifying responses after the initial yes-no question included “It gave me good language for describing the treatment without using jargon,” “It makes providers more aware of the process,” “It helps align expectations,” “It helps us tackle common questions,” “It reminds providers of the ethical issues in the consent process,” and “It gave us a clear and concise list of psychodynamic topics to discuss with the patient.”

One question asked participants to describe how they thought the PEPPER affected the informed consent process. Select answers to this included “I think it helped my patient have a more informed understanding of the form of therapy he was consenting to,” “It made the process go more smoothly,” and “It made it easier to make sure all important points were covered and discussed.”

Some responses from PGY2 residents suggested that the PEPPER also helped them to understand more about psychodynamic psychotherapy. These types of responses were not given by residents at other PGY levels. Sample responses included “As a resident with little experience providing psychodynamic psychotherapy, it helped [me] orient myself to the treatment I would be providing” and “The PEPPER helped me understand psychodynamic psychotherapy as an intervention.”

Of the 10 residents who reported they had used the PEPPER with a patient by the time of the survey, seven wrote an answer describing the patient’s reaction to the intervention. Five responses were judged to be positive (“My patient really liked it” and “They referenced countertransference in the next session”), and two responses were judged to be neutral (“They were indifferent” and “passive acceptance”). No patients refused to consent to treatment after they were given the PEPPER.

The results of this survey clearly demonstrate that residents in our program viewed the PEPPER as a useful addition to the informed consent process for both patients and providers. Common themes that emerged from the qualitative responses included that the PEPPER promotes shared decision making and makes the patient and provider more active during the consent process and that it is a simple way to present information to patients. PGY2 residents also felt that the PEPPER helped them to learn more about psychodynamic psychotherapy as a treatment, particularly with respect to therapeutic action, which is developmentally appropriate because the intervention was introduced at the end of their psychodynamic psychotherapy didactic course and may have served to consolidate knowledge. No responses indicated concern about the PEPPER interfering with the therapeutic process.

Although our intention was to assess resident attitudes, future work may focus on asking patients for their perspective on the PEPPER, particularly their thoughts on receiving information about therapeutic action. Moreover, we did not actually assess whether residents took all steps to meet minimal criteria for informed consent, nor was this the intention of our intervention. Nevertheless, we feel that the results show that residents overwhelmingly found the PEPPER to be a useful resource that can have a positive impact on the informed consent process, whether or not they had experience using it.

The proposed benefits of an informed consent discussion have included empowering patients to take a more active role and providing them with valuable information. Our hope in providing additional information about therapeutic action was that it would also serve to strengthen the relationship through clear and honest communication. It is encouraging that this simple intervention was felt to have these effects. Future work will focus on connecting this intervention to therapeutic outcomes.

The overwhelmingly positive response to the PEPPER in this limited sample suggests that, far from perceiving it as promoting resistance, residents feel that educating patients about psychodynamic psychotherapy demystifies the treatment. We believe that providing this information at the beginning of treatment will foster mutual understanding and trust while also modeling the active and honest role we hope our patients will take. Combining the principles of informed consent and the theory of therapeutic action helps modify the fundamental rule to bring it into the new millennium. Allowing a therapist to explore one’s unconscious can now be an informed and conscious decision.