Informed consent and client rights

Transcript

RyanA man drops into the chair across from a psychologist, arms folded. A judge ordered him to be here. Before she can say a word, he says, Let's skip the small talk. Whatever I tell you goes straight to the judge anyway, right?

SoheeAnd honestly? It's a fair question. He's asking exactly what the Code says he deserves to know before anything starts.

RyanWelcome to EPPP Prep, the podcast. I'm Ryan.

SoheeI'm Sohee. Today is informed consent and client rights. What people must be told, when they must be told it, and who gives permission when someone can't legally consent. Plus two federal privacy rights that don't get enough airtime.

RyanLet's answer our court-ordered client first. Standard 3.10, part c. When psychological services are court ordered or otherwise mandated, psychologists inform the person of the nature of the anticipated services, including whether the services are court ordered or mandated, and any limits of confidentiality, before proceeding.

SoheeBefore proceeding. So the honest answer to his question comes at the start. What the services are, that they're court ordered, and what will and won't be shared.

RyanNow the general rule, 3.10 part a. When psychologists conduct research or provide assessment, therapy, counseling, or consulting, in person or via electronic transmission, they obtain informed consent, using language that is reasonably understandable to the person.

SoheeWith an exception: when doing the activity without consent is mandated by law or governmental regulation, or as otherwise provided in the Code.

RyanThen Standard 10.01 tells you what consent to therapy has to cover. As early as is feasible in the therapeutic relationship, psychologists inform clients about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of confidentiality.

SoheeAnd they provide sufficient opportunity for the client to ask questions and receive answers. That part's easy to forget, but it's in the standard.

RyanSo four topics: the nature and course of therapy, fees, third parties, and limits of confidentiality. Plus questions. As early as is feasible.

SoheeThird parties sounds abstract, so let's make it concrete. The study notes for our practice questions give examples: an insurer, an employer paying for sessions, or a consulting psychiatrist.

RyanAnd here's where the exam sets its traps. Practice questions offer answers like, delay the consent discussion for a few sessions so talk of fees doesn't interfere with rapport.

SoheeWrong. Rapport isn't a reason to delay. Another trap: explain fees now, and raise limits of confidentiality only if a situation requiring disclosure comes up. Wrong again.

RyanAnd one more: cover therapy and confidentiality, but discuss fees and third-party involvement only if the client asks. All of those leave something out. The right answer covers every topic, early, with time for questions.

SoheePart b of 10.01 covers newer treatments. When generally recognized techniques and procedures haven't been established, psychologists inform clients of the developing nature of the treatment, the potential risks, alternative treatments that may be available, and the voluntary nature of their participation.

RyanAnd part c is about trainees. When the therapist is a trainee and legal responsibility rests with the supervisor, the client is told the therapist is in training and being supervised, and is given the supervisor's name.

SoheeNow, what about people who can't legally consent? Children, or adults under guardianship. Standard 3.10 part b.

RyanFor persons legally incapable of giving informed consent, psychologists nevertheless do four things. One, provide an appropriate explanation. Two, seek the individual's assent. Three, consider the person's preferences and best interests. Four, obtain appropriate permission from a legally authorized person, if that substitute consent is permitted or required by law.

SoheeI love the word nevertheless. Even though the person can't legally consent, they still get an explanation and a chance to agree. Assent means their own agreement.

RyanAnd when consent by a legally authorized person isn't permitted or required by law, psychologists take reasonable steps to protect the individual's rights and welfare.

SoheePause and think. An eight-year-old is brought in by her parents for anxiety. Her parents sign the consent forms. Is the psychologist done?

RyanNo. The psychologist also explains therapy in terms the child can understand, seeks her assent, and considers her preferences and best interests, alongside the parents' permission. All four steps.

SoheeAnd the traps for 3.10b come in three flavors. Skip the person: the guardian's permission alone is enough because the person can't consent. Skip the guardian: the child agreed, so go ahead without the parents. Or delay: postpone services until the person can consent.

RyanNone of those match the standard. Assent alone isn't enough when a guardian's permission is required, and 3.10b doesn't call for putting services on hold.

SoheeAnd part d. Psychologists appropriately document written or oral consent, permission, and assent.

RyanNow, consent gets more complicated when there's more than one person in the room. Standard 10.02. When psychologists agree to serve several people who have a relationship, like spouses or parents and children, they take reasonable steps to clarify at the outset which of them are clients, and the relationship the psychologist will have with each.

SoheeAnd that clarification includes the psychologist's role and the probable uses of the services or the information.

RyanGroups have their own rule, Standard 10.03. In a group setting, psychologists describe at the outset the roles and responsibilities of all parties, and the limits of confidentiality.

SoheeAnd Standard 10.04 covers someone who's already seeing another provider. Psychologists carefully consider the treatment issues and the person's welfare, discuss these issues with the client to minimize confusion and conflict, consult the other provider when appropriate, and proceed with caution.

RyanOne more Code right that's easy to miss. Standard 4.03, Recording. Before recording the voices or images of people they serve, psychologists obtain permission from all such persons or their legal representatives.

SoheeOkay, now the federal side. In our confidentiality episode we covered the right to see and copy your own records under HIPAA, the Health Insurance Portability and Accountability Act. Today, two other rights in the federal privacy rule.

RyanFirst, the right to amend. An individual has the right to have a covered entity amend health information or a record about them in the designated record set, for as long as it's kept there.

SoheeBut the practice can deny the request in specific situations. If the information wasn't created by that practice, unless the person gives a reasonable basis to believe the originator is no longer available. If it isn't part of the designated record set. If it wouldn't be available for inspection. Or if it is accurate and complete.

RyanAnd the timeline. The practice must act on the request no later than 60 days after receiving it. It may extend once, by no more than 30 days, with a written statement of the reasons for the delay.

SoheeIf it denies the request, the denial must be written, in plain language, give the basis, and tell the person they have the right to submit a written statement disagreeing with the denial.

RyanPause and think, round two. A client reads her record and says, That diagnosis is wrong, change it. Her psychologist reviews it and believes the record is accurate and complete. What happens?

SoheeAccurate and complete is a permitted ground for denial. So the psychologist can deny it, in a timely written denial that explains why, and the client can submit a written statement of disagreement. The decision still comes within 60 days.

RyanThe second right is an accounting of disclosures. An individual can receive an accounting of disclosures of their health information made in the six years before the request.

SoheeWith a long list of exceptions. Notably, disclosures for treatment, payment, and health care operations, disclosures to the individual themselves, and disclosures made under the individual's own authorization aren't included.

RyanAnd the timing echoes the amendment rule. Act within 60 days, with one possible extension of no more than 30 days and a written statement of the reasons. The first accounting in any twelve-month period is free.

SoheeSo, two numbers to hold. Access, from our confidentiality episode, is 30 days. Amendment and accounting are 60 days. Each allows one extension of up to 30 days.

RyanLet's recap.

Sohee10.01: as early as is feasible, explain the nature and course of therapy, fees, third parties, and limits of confidentiality, and leave room for questions. Don't wait for rapport, for a reportable event, or for the client to ask.

Ryan3.10b: for someone who can't legally consent, explain, seek assent, weigh preferences and best interests, and get permission from the legally authorized person.

Sohee3.10c: for court-ordered or mandated services, tell the person the nature of the services, that they're mandated, and the limits of confidentiality, before proceeding. And document consent, permission, and assent.

RyanWith couples, families, and groups, clarify at the outset who the clients are and how confidentiality works. Get permission before recording.

SoheeAnd under the federal privacy rule, clients can ask to amend their record and can get an accounting of disclosures, each with a 60-day clock.

RyanConsent is really about respect. The client deserves to know what they're walking into. And you deserve the same patience with yourself as you learn these details. You've just covered a lot of ground.

SoheeGo try a few consent questions and listen for the word early. Thanks for listening to EPPP Prep.

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