Problems with Forms

Many of us may be so eager to start doing therapy that we try to avoid talking with our clients about consent issues. We try to push all the responsibility off onto a set form, and let the form do the work. Those of us who work within clinics or hospitals may not even handle such forms. The client who shows up for an initial appointment may be handed an imposing-looking form by the receptionist, asked to read it, sign it, and return it before seeing the therapist. The form itself may have been crafted by the clinic or hospital's attorney and may not even have been reviewed by a clinician. The wording may be in intimidating legalese and bureaucratic jargon. Such forms may be intended more to protect the organization against successful lawsuits than to help the client understand the options and make reasonable decisions.

Providing information in written form can be vital in ensuring that clients have the information they need. But the form cannot serve as a substitute for an adequate process of informed consent. At a minimum, the clinician must discuss the information with the client and arrive at a professional judgment that the client has adequate understanding of the relevant information.

Clinicians using consent forms must ensure that their clients have the requisite reading skills. Illiteracy is a major problem in the United States; clinicians cannot simply assume that all of their clients can read. Moreover, some clients may not be well versed in English, perhaps having only rudimentary skills in spoken English as a second or third language.

Not only must the client be able to read, but the form itself must be readable. Grundner (1980, p. 900) noted that great effort has been made to ensure that "consent forms have valid content, but little effort has been made to ensure that the average person can read and understand them." He analyzed five forms with two standardized readability tests and found that "the readability of all five was approximately equivalent to that of material intended for upper division undergraduates or graduate students. Four of the five forms were written at the level of a scientific journal, and the fifth at the level of a specialized academic magazine" (p. 900).

Reading a form does not ensure that the client understands the material or can remember it even a short time later. Robinson and Merav (1976) reinterviewed twenty patients four to six months after they had read and signed a form for informed consent and had undergone treatment. They found that all patients showed poor recall regarding all aspects of the information covered by the form, including the diagnosis, potential complications, and alternate methods of management. Cas-sileth, Zupkis, Sutton-Smith, and March (1980) found that only one day after reading and signing a form for informed consent, only 60 percent of the patients understood the purpose and nature of the procedures. A perfunctory indication from clients that they understand can be unreliable (Irwin et al., 1985). The clinician bears the responsibility for ensuring that the client understands the information

It would be comforting to believe that the identification of problems in these early studies led to effective solutions. Unfortunately, the problems continue to emerge in contemporary research. For example, research by Akkad, Jackson, Kenyon, Dixon-Woods, Taub, and Habiba (2006; see also Commons et al., 2006; Dixon-Woods et al., 2006) found that "even when the consent process satisfies administrative and legal requirements, patients' needs may not be met, and some patients may even consent to [unwanted procedures]. . . . Though patients did identify several important advantages of the consent process, there was substantial uncertainty about the implications of signing or not signing the consent form____Many patients did not see written consent as functioning primarily in their interests nor as a way of making their wishes known. As suggested in previous work, ... many thought the primary function of the form was to protect the hospital These findings are disconcerting for healthcare professionals and patients alike and raise questions about how far current consent processes genuinely fulfil their aim of safeguarding autonomy and protecting patients' rights" (p. 529).

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