Issues in Mental Health Nursing
ISSN: 0161-2840 (Print) 1096-4673 (Online) Journal homepage: http://www.tandfonline.com/loi/imhn20
Use of Informed Consent with Therapeutic Paradox Michelle M. Farkas To cite this article: Michelle M. Farkas (1992) Use of Informed Consent with Therapeutic Paradox, Issues in Mental Health Nursing, 13:3, 161-176, DOI: 10.3109/01612849209078771 To link to this article: http://dx.doi.org/10.3109/01612849209078771
Published online: 09 Jul 2009.
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Date: 15 March 2016, At: 20:03
USE OF INFORMED CONSENT WITH THERAPEUTIC PARADOX
Michelle M. Farkas, RN, MSN
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Sinai Hospital, Detroit, Michigan
Debate persists in the literature and among clinicians about the ethical appropriateness of paradoxical interventions. It has been suggested that informed consent with therapeutic paradox would alleviate ethical concerns of deception, manipulation, harm to the client, and withholding of information from the client in therapy. f i e purpose of this study was to explore health care consumer reactions to the benefits and risks of therapeutic paradox as stated in a consent for treatment form. The study explored the responses of 32 medical patients to a hypothetical consent for treatmentform for therapeutic paradox. Data were collected in a brief semistructured interview afer subjects read the hypothetical consent form. Utilizing a case study, the investigator then offered an example of a successful paradoxical intervention and additional subject comments were solicited. Content analysis of the responses was made. Health care consumers had mixed responses to the consent form. Wiiile the consent form served as an obstacle for some consumers, many were willing to sign the consent form and accept treatment even though they had internal reservations and questions. Appropriateness of the consent form format is discussed.
Therapeutic paradox can be seen as “reverse psychology” in which a client is told not to change as a way of getting the client to change. Paradoxical interventions are used commonly by the layman in a variety of everyday situations and represent one of many types of techniques practiced by clinical nurse specialists. However, there are various ethiThe author acknowledges Mark J. Hirschmann, PhD, RN, Professor, Carroll/Columbia College of Nursing, Milwaukee, Wisconsin, for his guidance and support throughout the study and Mary B. Killeen, RNC, MSN, CNAA, Sinai Hospital, for reviewing the article for publication. Address correspondence to Michelle M. Farkas, R.N., M.S.N., Sinai Hospital, ‘+-south,6767 West Outer Drive, Detroit, MI 48235. Issues in Mental Health Nursing, 13:161-176, 1992 Copyright 0 I992 by Hemisphere Publishing Corporation
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cal concerns regarding the use of paradoxical interventions in psychotherapy. Objections often focus around ethical issues of manipulation, harm to the client, and deception. The current debate regarding the practice of therapeutic paradox in psychotherapy focuses on whether a consent form should be utilized by psychotherapists to alleviate these ethical concerns. Cavell, Frentz, and Kelley (1986) believe that the issue of informed consent for paradoxical interventions is an ethical question because psychotherapists need evidence of consumer acceptability. However, there is apprehension by other psychotherapists who believe that clients would fail to develop effective therapeutic relationships if they were aware of the nature of therapeutic paradox. Others feel that the issue of informed consent for therapeutic paradox is no different than for any other type of psychotherapy (weeks & L‘Abate, 1982). The purpose of this study was to explore health care consumer reactions to the benefits and risks of therapeutic paradox as stated in a consent for treatment form.
LITERATURE REVIEW Informed Consent in Health Care Within the past three decades, the doctrine of informed consent has shifted the public’s attention to the rights of individuals undergoing health care treatment. The shift that has taken place over the years from the client as a passive receiver of health care to one of an educated, informed consumer has contributed to the current public interest of informed consent for health care services. This age of consumerism has been witness to an increase in malpractice suits and insurance rates for many health care providers. The doctrine of informed consent is composed of three legal elements: competency, knowledgehformation, and voluntariness (Cohen & Mariano, 1982; Lynn, 1983; Mills, 1985; Simon, 1987). The standard requirements of a voluntary informed consent include (1) an explanation of the nature of the recommended therapy, (2) benefits and potential risks, (3) side effects or long-term consequences, and (4) reasonable alternative forms of care (Kolb & Brodie, 1982; Rozovsky, 1984). Through informed consent the individual is encouraged to be an equal partner within the therapeutic relationship by exercising free choice, furthering personal autonomy, and participating actively in treatment. A major health care concern raised by Mariner and McArdle (1985) addresses the effectiveness of informed consent documents in transmitting usable information to clients. Although these documents have become the client’s primary source of information about a proposed ther-
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apy, studies concerned with information-recall reveal that clients are unable to comprehend and recall vital information about informed consent procedures (Mariner & McArdle, 1985; Robinson & Merav, 1976). Unconscious conflicts over helplessness and dependency can produce difficulties in obtaining informed consent, while emotional factors such as anxiety, distortion, and denial can influence understanding and recollection of information (Zeichner, 1985). Other influencing factors include the environment in which the information is received, perceptions about the purpose of the information, amount of time allotted for reading, familiarity with health concepts, care with which a document is read, and attitudes of those administering the form (Mariner & McArdle, 1985). Because of the many aforementioned complexities, health care professionals have an obligation to evaluate the current practice of relying on informed consent documents in transmitting vital information. Informed consent is a process and should not be perceived a a single event. Therefore, a one-time signature on a form may not be ethically sufficient when one considers the array of emotional difficulties inherent to this process. Many psychotherapists (Lewis, 1985; Rozovsky, 1984; Simon, 1987; Zeichner, 1985), cognizant of the influencing factors, have therefore recommended continuous, progressive dialogue between the health care provider and client within a collaborative relationship.
Informed Consent with Psychiatric Procedures There is general agreement that some type of informed consent requirement exists for psychiatric services (Winslade, 1983). Informed consent for psychiatric treatment is generally obtained for psychiatric hospitalization, electroconvulsive therapy, and psychotropic medication administration. Establishing a contractual agreement is also common practice. Through the use of a contract the therapeutic relationship is clarified and defined as a mutual endeavor. The contract encourages goal-setting and can protect both the therapist and client from false expectations (Hare-Mustin, Marecek, Kaplan, & Liss-Levinson, 1979). Difficulties encountered in obtaining valid informed consent within psychiatry are well documented. A study concerned with the amount of understanding 100 mental hospital patients had of a voluntary admission form revealed that only eight patients were rated as completely informed of the voluntary admission contract (Olin & O h , 1975). Similarly, hospitalized patients on both locked and open wards reported that their understanding of informed consent material on antipsychotic medication was good, yet objective ratings did not confirm self-reports (Irwin, Lovitz, Marder, Mintz, Winslade, VanPutten, & Mills, 1985). However
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well intentioned and detailed the format is, many clients, regardless of psychiatric disorder, encounter various difficulties with the process of informed consent.
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Informed Consent with Therapeutic Paradox “Reverse psychology” encompasses a variety of paradoxical interventions, the most common being reframing, symptom prescription, and restraining. Reframing is an intervention that aims at changing the interpretation or meaning of a problem so it is seen from a different point of view. Symptom prescription is an intervention that encourages the deliberate maintenance or exaggeration of a symptomatic problem, while restraining is an intervention that discourages the client or family from changing. These interventions are flexible and have been utilized in different settings dealing with a variety of clinical problems. Clinical areas in which therapeutic paradox has proved successful include school phobia (Bergman, 1983), marital therapy with older adults (Gilewski, Kuppinger, & Zarit, 1985), delinquency in youths (Kolko & Milan, 1983), treatment of children in an inpatient setting (Jessee & L‘Abate, 1980), therapy for the chronically mentally ill and retarded (Bergman, 1980), vocational rehabilitation problems (Daggett, 1978), and treatment of depressed college students (Hills, Gruszkos, & Strong, 1985). There are several indications and contraindications for the use of therapeutic paradox with certain individuals and families. Papp (1981) reserves paradoxical interventions for “covert, longstanding, repetitious patterns of interaction that do not respond to direct interventions such as logical explanation or rational suggestions” (p. 245). Recommended indications for paradoxical interventions include therapy with “therapist killers” and “therapist addicts.” Therapist killers are clients who have a past history of ineffective treatment from a number of therapists, while therapist addicts live for their therapy session. Both are appropriate candidates for paradoxical treatment because they are highly resistant clients who always manage to sabotage their claim for help (Weeks & L‘Abate, 1982, p. 56). Contraindications for paradoxical interventions include crisis situations such as violence, sudden grief, attempted suicide, loss of employment, acute decompensation, unwanted pregnancy, abuse, and homicide (Deschenes & Shepperson, 1983; Jessee & L‘Abate, 1980; Papp, 1981; Weeks & L’Abate, 1982). Paradoxical interventions also are contraindicated for families that are childlike, impulsive, or chaotic with loose, disorganized, and variable structures (Fisher, Anderson, & Jones, 1981).
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Contrary to the beliefs that paradoxical interventions be used discriminately is Fraser’s (1984) viewpoint on the usage of paradoxical interventions:
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Not to choose such therapeutic actions as a first resort, on the grounds that they appear contradictory when reasoning from some conventional orthodoxy, may not only be ineffective, but also irresponsible to our therapeutic contracts to most efficiently and effectively help facilitate change. (P. 364)
Although therapeutic paradox has attracted many clinicians it has been met with resistance from others. Weeks and L‘Abate (1982) attribute this resistance to changing work habits and threatening of confidence and security: “Clinicians may feel more threatened with paradoxical therapy than other methods because it does not make sense within traditional views of therapy” (p. 239). The therapist’s behavior may be perceived as illogical (Fisch, Weakland, & Segal, 1986) and manipulative. Some critics believe that paradoxical therapy is manipulative because it is an “insightless” form of therapy; yet Haley (1976) claims that it is “out of fashion” to be a therapist using an insight approach (p. 206). This issue of manipulation also has raised concerns of coercion and deception in therapy resulting in harm to the client. Not surprising is the fact that some psychotherapists have raised the issue of the use of informed consent with therapeutic paradox: “Future endeavors in the area of paradoxical intervention must begin to address pragmatic issues regarding their implementation, their social validity, and the ethics surrounding the absence of informed consent that is inherent in paradoxical procedures” (Kolko & Milan, 1983, p. 660).
METHODOLOGY Design
This exploratory study examined the responses of 34 medical clients and/or significant others to a hypothetical consent form for therapeutic paradox. Sample Obstetrical-gynecological clients and/or significant others awaiting treatment in the waiting room of an urban, midwestern obstetriciangynecologist’s private office comprised the sample. The nonprobability sample size of 34 represented 74% of 46 individuals approached to
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participate in the study. Medical patients rather than psychiatric patients were selected so that an initial, general reaction to the consent form could be obtained without jeopardizing the possible use of paradoxical interventions in a psychiatric or mental health setting. The sample is characteristic of that found in an obstetriciangynecologist’s office, with the overwhelming majority being female (88%). The mean age of the sample was 30 years, with 85% being 34 years of age or younger. The majority of the sample was Caucasian (84%)and married (56%);41%were never married. Nearly 13% of the sample completed high school, while 25% had earned a graduate degree. One-half stated that they experienced therapeutic paradox in everyday life, usually in situations that dealt with disciplining of children (3 1 %). Thirty-one percent experienced therapeutic paradox at the workplace. The majority (66%) had never sought mental health counseling. Of those who had experience with mental health counseling, 73% had sought counseling in the past. lkenty-seven percent were currently seeking counseling.
Procedure The research study was discussed with an interested physician who gave approval for data collection to be conducted in the waiting room of his private office. A formal letter was sent with the instrument to the physician prior to data collection. During each visit to the physician’s office, the researcher began collecting data by inviting the last client on the waiting list to participate in the study while everyone thereafter was approached. This format was instituted so that ample time was given to record and complete responses. Verbal explanation was given to all subjects regarding their informed consent to participate in the study. Subjects were informed that completing the paperwork was evidence of their informed consent to participate. Before comments were recorded on the instrument, a hypothetical situation about going to a mental health professional for counseling was read aloud. Hypothetical Situation Pretend that you are going to a mental health professional for a persistent personal problem that restricts you from engaging in important activities of daily living. You have learned that the therapist is respected by your physician. As part of registration with the therapist, you are asked to read and sign the following consent form. As with all consents, your decision to receive therapy is made voluntarily and freely and there
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has been no guarantee made regarding the outcome of therapy. Any questions regarding your therapy have been answered to your satisfaction. The following is a one-page consent form broken into parts. This allows for the record of your comments and opinions. After the hypothetical situation was read, subjects began completing the instrument by writing their reactions to each of the four sections of the consent form. Following instrument completion, the researcher read a condensed version of a case study described by Papp (1977) entitled “The Family That Had All the Answers.” This case study was chosen to give subjects a reliable and valid account of therapeutic paradox as it is practiced in therapy. Case Study
A middle-class family consisting of a mother and father and two children, Debbie, aged 15, and John, aged 12, are seeking counseling at a family therapy clinic. Mother is interested in solving John’s behavior problems of being disruptive in class, smoking pot, kicking holes in the walls at home, and taking pleasure in annoying his parents. John and his sister also fight frequently. Disciplining of both children is done by the father as the mother has no backbone for this. Counseling in the past has failed. Therapist’s Hypothesis
After getting to know the family and establishing a good relationship, the therapist believed that John’s behavior problems were due in part to the unshared job of discipline between the parents. Knowing that previous counselors had unsuccessfully advised father to assume less and mother to assume more disciplinary activities, the therapist decided to avoid making the same suggestion. Furthermore, the therapist expected the parents to defy most therapeutic recommendations. Therefore, the father was told to continue being the bad guy because the children are accustomed to finding protection and companionship from their mother. A change would be upsetting to the entire family and may even threaten their marriage. Following this intervention the parents did defy the therapist by sharing the activities of discipline. John’s behavior problems decreased and the marriage remained intact. Following the reading of the case study with the therapist’s hypothesis, subjects were then asked in writing whether they would allow their family to be treated by competent therapists who use this type of psychotherapy (paradoxical) and more conventional types of interventions. A demographic data sheet was then completed. Each demographic data sheet and instrument was coded with a number to protect and maintain confidentiality. To establish anonymity, no
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names or addresses were recorded. Data collection was completed in 11 hours during five visits to the physician’s office.
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Instrument A consent form for therapeutic paradox was developed by the investigator and a nursing research advisor. The form was labeled “Consent for Treatment” and was divided into four sections: Introductory Paragraph, Basic Conditions for Treatment, Benefits of the Treatment, and Possible Risks of the Treatment. From recommendations in the literature, the visual format of the consent form was prepared with concise statements using simple language and was proofread for spelling and grammatical errors (Lewis, 1985; Mariner & McArdle, 1985). Wording of the consent form was in the second person, as advised by Lewis (1985). Subjects wrote their reactions to each of the four sections of the consent form and responded to a seven-point Likert scale (with a range of strongly agree to strongly disagree) as to whether they would sign the consent form and accept treatment. Responses were condensed into three categories: (1) agreement (strongly agree, slightly agree, agree), (2) undecided, and (3) disagreement (slightly disagree, disagree, strongly disagree). The one-page consent form was divided into seven pages. Each page represented one of the four sections of the consent form previously mentioned. This format encouraged concentration on each individual issue within the consent form and gave ample space for written responses. After the consent form was developed, it was pretested on five people (mental health professionals and lay persons). They were asked to complete the instrument and make recommendations regarding format, clarity, and readability. Recommendations were incorporated into the consent form based on their comments. The consent form was judged to have content validity by a clinical nurse specialist who was trained and experienced in strategic therapy. Introductory Paragraph The initial section of the consent form relayed information about one’s right to be informed of the conditions, benefits, and possible risks of therapeutic paradox. Statements explained that some of the directions from the therapist might seem to be out of the ordinary as emphasis was given to new ways of relating to oneself and others. The goal of treatment was defined as finding answers to the problems identified in therapy. A brief statement was incorporated into this section explaining that
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a referral to other types of psychotherapy would be made available if desired.
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Basic Conditions for Treatment This section included neutral statements applicable to most types of psychotherapy. The style of therapy required (1) a description of the problem as a new observer would see it even if most of the difficulty is internal, (2) a therapeutic contract expressed in observable terms between the client and therapist regarding the goal of therapy, and (3) the client’s openness to following instructions given by the therapist.
Benefits of Treatment Promoting the goals of therapy by alerting clients to uncommon solutions found in the paradoxical nature of the everyday world was identified as a benefit of treatment. A statement was made regarding possibly meeting therapeutic goals within a few sessions even if previous treatments had failed.
Possible Risks of the Treatment The last section of the consent form incorporated the risk areas identified in the literature such as manipulation, harm to the client, deception, and withholding of information.
Client investment. This risk involved investing time and money without achieving desired therapeutic goals. It was specified that the success of psychotherapy reflected the amount of work invested by both therapist and client. Miscommunication: Harm or embarrassment. Because miscommunication could result in embarrassing or harmful situations, a statement was included encouraging clients to ask questions to clear up any possible confusion. Emphasis was made on communication being a two-way responsibility, with the therapist making efforts to keep instructions clear and understandable. Withholding interpretations. The therapist’s sharing of the most helpful ideas while not sharing less helpful ideas was the focus of this identified risk. The consent form explained that because the therapist interprets situations from many points of view, it is impossible to share all ideas. Denying beliefs. Information was given regarding the therapist denying his or her own beliefs about a client’s situation during the course of treatment in an effort to achieve the therapeutic goal. Denial of beliefs was explained to be necessary at times to prevent a block in progress to the therapeutic goal.
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RESULTS Handwritten responses to each section of the consent form were duplicated on index cards. Using Q sort technique, the investigator sorted the cards into categories according to the theme expressed. The cards were then sorted by a graduate nursing student. The number of agreements for each section of the consent form was divided by the total number of agreements and disagreements. The percentage of agreement ranged from 80 to 94% ,with a mean of 89 % . Comments obtained about willingness for family treatment elicited 78 % agreement. An evaluation of the written responses on the instrument led the investigator to eliminate 2 of the 34 subjects. These subjects exhibited a set response in their attitude. They were the only ones that answered “strongly disagree” to the items in the Basic Conditions for Treatment section of the consent form, which includes neutral statements applicable to most types of psychotherapy. Both subjects were identified as outliers and their responses were eliminated from the study. There was overwhelming acceptance to two sections of the consent form, with 94% and 97% of the sample exhibiting agreement to the Introduction and Basic Conditions for Treatment sections, respectively. Differences were noted in the remaining areas, as seen in Fig. 1 . Analysis revealed differences between the structured questionnaire items on the scale and handwritten responses.
Benefits of the Treatment Seventy-eight percent agreed to the Benefits section of the consent form. Two subjects (6%) disagreed and 16% were undecided. Upon content analysis, 58% of written responses were positive statements that reflected the major theme of therapeutic paradox “opening doors to ideas” that might not have been thought of regarding one’s personal situation. The issue of meeting therapeutic goals within a few sessions was perceived as positive treatment because brief psychotherapy would alleviate the prolonging of problems. The content analysis of responses that were in disagreement (13%) addressed the unrealistic expectation of solving problems in a few sessions. There was a feeling of being wary and suspect of such success (6%)while questioning how the therapist would have solutions that the client had not considered (3%). Two subjects (6%)exercised caution in their written responses, stating they would try therapeutic paradox only after other therapies had failed.
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Possible Risks of the Treatment
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Client Investment Sixty-nine percent of the subjects were willing to invest time and money without achieving desired therapeutic goals. ”kenty-five percent were undecided, while 6% disagreed. Upon content analysis, 37% of written responses were positive statements. There was agreement that a possible risk of therapy was investing time and money without achieving therapeutic goals. This risk would probably have to be taken if there was a chance in solving a problem. The theme of “nothing ventured, nothing gained’ was apparent in these responses. The content analysis of responses that were in disagreement were divided into two themes. Thirty-three percent of written responses emphasized the expectation of benefitting from therapy. If time and money were invested without achieving goals, other therapy would be needed. The second theme, representing 10% of the written responses, addressed the need for statistical information such as estimate of time needed to reach goals, percentage of people who failed this type of therapy, and the odds of a patient helping himself without therapy.
Miscommunication: Harm or Embarrassment Over 80% were willing to accept the risk of miscommunication in therapy. Those who disagreed numbered two (6%), with 12% being undecided. Content analysis revealed that 35 % were openly accepting of this risk because it was understandable and made sense. An additional 32% emphasized the importance of the client taking responsibility in being honest in expressing feelings and asking questions. The theme that emerged from 21 % of written responses addressed the two-way responsibility in communication between the therapist and client. There was an expectation that the client should not have to talk all of the time without feedback from the therapist. In addition, the therapist may not always communicate clearly and the client may not ask enough questions to understand the information discussed.
Wdhholding Interpretations Responses on the seven-point scale to this third risk were divided, with 44% of the sample in agreement and 40% in disagreement. Content analysis revealed that 40% wanted the therapist to share all ideas. Three themes were identified from these responses:
1. The therapist should share all ideas because those that are viewed as less helpful may actually be most beneficial to the client. 2. Because therapy is expensive, all ideas should be shared.
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3. If the client is to be honest and open with information, the same should be expected from the therapist. The view expressed by 20% of written responses indicated that withholding interpretations by the therapist was understandable. Sharing only the most helpful ideas would not only be easier for the client to interpret, but would also not waste time. The theme emerging from 17% of written responses focused on the issue of a therapist’s skill in deciphering which ideas would be most helpful. These responses indicated that less helpful ideas added together could be more beneficial.
Denying Beliefs This risk was the least acceptable, with 34% agreeing to have the therapist deny beliefs during the course of treatment. Twenty-five percent were undecided, while 40% were in disagreement. Content analysis revealed that 30% of written responses were in agreement to accept this risk. The therapist was supported in denying beliefs during the course of treatment so as not to slow or block progress to the therapeutic goal. The reason the client is seeking therapy is to make progress. From those responses that were in disagreement with this risk, several themes were apparent:
1. The therapist should disclose all beliefs whether or not doing so blocks progress (23 %). 2. Therapy is a two-way responsibility of communication and both therapist and client should be open with beliefs (10%). 3. The therapist should remain objective and not let his or her beliefs interfere with a client’s therapy (7%).
Willingness for Family Treatment Upon hearing an example of therapeutic paradox from the case study, 81 % of the subjects agreed that they would consent to treatment for their family members. Content analysis revealed a general willingness to give therapeutic paradox a try in an attempt to solve a problem (30%). Experiencing a feeling of well-being with an end result of being “cured” was valued. Two other themes emerged in addition to the general willingness to undergo therapeutic paradox in therapy: 1. The objective of treatment is more important than the process and the risks seem no greater than for other types of therapy (15%). 2. If other alternatives were tried and did not produce results, then therapeutic paradox would be attempted as a last resort (1 1%).
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Four subjects would not consent for their family members to experience therapeutic paradox in therapy for the following reasons:
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1. Therapists are not needed to solve,problems. The family should take responsibility to solve their own problems. 2. Both parents (in the case study) were not encouraged by the therapist to be actively involved in the family therapy session because each parent was given different information.
DISCUSSION The number of objections to the components of the consent form and general willingness to permit treatment is noteworthy. Although many were willing to sign the consent form and allow their family to be treated with therapeutic paradox, written responses revealed internal reservations. Circled responses on the seven-point scale differed from written responses to several sections of the consent form. This discrepancy may be attributed to several factors. One explanation could be that signing a consent form is considered by most to be a “normal procedure.” After all, without a signature on a consent form it is understood that treatment will not be rendered. Others may feel helpless in making health care decisions and succumb to signing the form. In addition, by placing the case study between the last component of the consent form and the final question (regarding family treatment), subjects may have had their decision influenced by the successful case study, thus overriding possible earlier objections to the components of the form. The use of a consent form with therapeutic paradox would likely prevent a small but important percentage of people from receiving treatment. Four subjects (13%) would not allow their families to receive psychotherapy involving therapeutic paradox. Although 4 out of 32 is relatively small, these subjects displayed a critical attitude about therapy with the general belief that problems can be solved individually without third-party intervention. Therapeutic paradox, when conducted in the context of a therapeutic relationship, is known to be effective with clients who are critical of the therapeutic process and who have had previous treatment failures. By using a consent form, it is feared that discussion of treatment with these clients would block participation of those for whom therapeutic paradox could be most helpful. Informed consent is one of several methods of involving clients in treatment decisions. The process of informed consent is ongoing and is connected to a therapeutic alliance in which the client is encouraged to make choices and decisions responsibly. Ideally, informed consent with therapeutic paradox can occur as a process over time and not only at the
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beginning of treatment. Therapists often invite clients to share and explore concerns about treatment as questions arise. In this way, clients remain informed as needed while the therapist avoids the abrupt and overwhelming presentation of complicated risks inherent to the consent form format. Clients remain free to discuss the style of treatment gradually as they experience the process. Although client autonomy in making health care decisions is valued in psychotherapy, there are times when clients surrender autonomy to health care professionals such as leaving certain decisions to a surgeon while under anesthesia. It may be appropriate for nurse clinicians who use paradoxical interventions to assume a paternalistic position as a means of providing the most effective treatment for clients. However, this does not rule out the need to pursue methods of describing paradox to clients in the context of a progressive dialogue. Because this study consisted of a nonprobability sample of 32 obstetric-gynecological patients and/or significant others, further research should be conducted with a larger, preferably random, representative sample of clients who have direct contact with psychiatric-mental health treatment. Future investigation of this topic should solicit subjects’ judgments after responses to the consent form are completed and before the case study is presented. The influence of the case study could be ascertained by asking for a second judgment from the subjects after the case study is read. In addition, efforts to establish content validity for the instrument could be determined more firmly by knowledgeable psychotherapists. Some measure of test-retest reliability could be established by repeating the instrument over a moderate length of time.
REFERENCES Bergman, J . S. (1980). The use of paradox in a community home for the chronically disturbed and retarded. Family Process, 19, 65-71. Bergman, J. S. (1983). Prescribing family criticism as a paradoxical intervention. Family Process, 22, 517-522. Cavell, T. A , , Frentz, C. E . , & Kelley, M. L. (1986). Acceptability of paradoxical interventions: some nonparadoxical findings. Professional Psychology: Research and Practice, 17(6), 519-523. Cohen, R., & Mariano, W. (1982). LRgal guidebook in mental health. New York: The Free Press. Daggett, S. R. (1978). Rapid problem resolution: an “uncommon-sense” approach to rehabilitation. Journal of Applied Rehabilitation Counseling, 9(2), 13- 16. Deschenes, P., & Shepperson, V. L. (1983). The ethics of paradox. Journal of Psychology and Zheology, 11(2), 92-98. Fisch, R., Weakland, J . , & Segal, L. (1986). The tactics of change: doing therapy briefly. San Francisco: Jossey-Bass.
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Fisher, L., Anderson, A., &Jones, J. A. (1981). Types of paradoxical intervention and indicationsfcontraindicationsfor use in clinical practice. Family Process, 20, 25-35. Fraser, J. (1984). Paradox and orthodox: Folie a deux. Journal of Marital and Family Iherapy, 10(4), 361-372. Gilewski, M. J., Kuppinger, J., & Zarit, S. H. (1985). The aging marital system: a case study in life changes and paradoxical intervention. Clinical Gerontologist, 3(3), 3-15. Haley, J. (1976). Problem-solving therapy: New strategies for @embe f m ’ l y therapy. New York: Harper & Row. Hare-Mustin, R. T., Marecek, J., Kaplan, A. G., & Liss-Levinson, N. (1979). Rights of clients, responsibilities of therapists. American Psychologist, 34(1), 3-16. Hills, H. I., Gruszkos, J. R., & Strong, S. R. (1985). Attribution and the double bind in paradoxical interventions. Psychotherapy, 22(4), 779-785. Irwin, M., Lovitz, A., Marder, S., Mintz, J., Wmlade, W.,VanPutten, T., & Mills, M. (1985). Psychotic patient’s understanding of informed consent. American J o u m l of Psychdry, I42( 1 l), 1351- 1354. Jessee, E., & L‘Abate, L. (1980). The use of paradox with children in an inpatient treatment setting. Family Process, 19, 59-64. Kolb, L., & Brodie, H. (1982). Modern clinicdpsychiatry. Philadelphia: W. B. Saunders. Kolko, D., & Milan, A. (1983). Reframing and paradoxical instruction to overcome “resistance” in the treatment of delinquent youths: A multiple baseline analysis. Journal of Consulting and Clinical Psychology, 51(5), 655-660. Lewis, M. (1985). Organ transplants, research, and children. In D. Schetky & E. Benedek (Eds.), Emerging issues in child psychiatry and the law @p. 48-54). New York: BrunnerfMazel. LYM, J. (1983). Informed consent: An overview. Behavioral Sciences & the Law, 1(4), 2945. Mariner, W.K., & McArdle, P. A. (1985). Consent forms, readability, and comprehension: The need for new assessment tools. Law,Medicine & Health Care, 13(2), 68-74. Mills, M. J. (1985). Legal issues in psychiatric treatment. Psychiatric Medicine, 2(3), 245-261. O h , G. B., & Olin, H. S. (1975). Informed consent in voluntary mental hospital admissions. American Journal of Psychiatry, 132(9), 938-941. Papp, P. (1977). The family that had all the answers. In P. Papp (Ed.), Family therapy: Full length case studies @p. 143-165). New York Gardner. Papp, P. (1981). Paradoxes. In S. Minuchin & H. C . Fishman (Eds.), Family therapy techniques (pp. 244-261). Cambridge, MA: Harvard University Press. Robinson, G., & Merav, A. (1976). Informed consent: Recall by patients tested postoperatively. Zhe Annals of Zkracic Surgery, 22(3), 209-212. Rozovsky, F. A. (1984). Consent to treatment: A practical guide. Boston: Little, Brown & co.. Simon, R. I. (1987). Clinical psychiatry and the law. Washington, Dc:American Psychiatric Press, Inc. Weeks,G., & L‘Abate, L. (1982). Paradonical psychotherapy: Zheory and practice with individuals, couples, and families. New York BrunnerfMazel. Wmlade, W. (1983). Informed consent in psychiatric practice: The primary of ethics over law. Behavioral Sciences & Ihe Law, 1(4), 47-56. Zeichner, B. (1985). The role of unconscious contlict in informed consent. Bulletin of the American A~ademyOf Psychiatry and the Law, 13(3), 283-290.
ISSN: 0161-2840 (Print) 1096-4673 (Online) Journal homepage: http://www.tandfonline.com/loi/imhn20
Use of Informed Consent with Therapeutic Paradox Michelle M. Farkas To cite this article: Michelle M. Farkas (1992) Use of Informed Consent with Therapeutic Paradox, Issues in Mental Health Nursing, 13:3, 161-176, DOI: 10.3109/01612849209078771 To link to this article: http://dx.doi.org/10.3109/01612849209078771
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Date: 15 March 2016, At: 20:03
USE OF INFORMED CONSENT WITH THERAPEUTIC PARADOX
Michelle M. Farkas, RN, MSN
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Sinai Hospital, Detroit, Michigan
Debate persists in the literature and among clinicians about the ethical appropriateness of paradoxical interventions. It has been suggested that informed consent with therapeutic paradox would alleviate ethical concerns of deception, manipulation, harm to the client, and withholding of information from the client in therapy. f i e purpose of this study was to explore health care consumer reactions to the benefits and risks of therapeutic paradox as stated in a consent for treatment form. The study explored the responses of 32 medical patients to a hypothetical consent for treatmentform for therapeutic paradox. Data were collected in a brief semistructured interview afer subjects read the hypothetical consent form. Utilizing a case study, the investigator then offered an example of a successful paradoxical intervention and additional subject comments were solicited. Content analysis of the responses was made. Health care consumers had mixed responses to the consent form. Wiiile the consent form served as an obstacle for some consumers, many were willing to sign the consent form and accept treatment even though they had internal reservations and questions. Appropriateness of the consent form format is discussed.
Therapeutic paradox can be seen as “reverse psychology” in which a client is told not to change as a way of getting the client to change. Paradoxical interventions are used commonly by the layman in a variety of everyday situations and represent one of many types of techniques practiced by clinical nurse specialists. However, there are various ethiThe author acknowledges Mark J. Hirschmann, PhD, RN, Professor, Carroll/Columbia College of Nursing, Milwaukee, Wisconsin, for his guidance and support throughout the study and Mary B. Killeen, RNC, MSN, CNAA, Sinai Hospital, for reviewing the article for publication. Address correspondence to Michelle M. Farkas, R.N., M.S.N., Sinai Hospital, ‘+-south,6767 West Outer Drive, Detroit, MI 48235. Issues in Mental Health Nursing, 13:161-176, 1992 Copyright 0 I992 by Hemisphere Publishing Corporation
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cal concerns regarding the use of paradoxical interventions in psychotherapy. Objections often focus around ethical issues of manipulation, harm to the client, and deception. The current debate regarding the practice of therapeutic paradox in psychotherapy focuses on whether a consent form should be utilized by psychotherapists to alleviate these ethical concerns. Cavell, Frentz, and Kelley (1986) believe that the issue of informed consent for paradoxical interventions is an ethical question because psychotherapists need evidence of consumer acceptability. However, there is apprehension by other psychotherapists who believe that clients would fail to develop effective therapeutic relationships if they were aware of the nature of therapeutic paradox. Others feel that the issue of informed consent for therapeutic paradox is no different than for any other type of psychotherapy (weeks & L‘Abate, 1982). The purpose of this study was to explore health care consumer reactions to the benefits and risks of therapeutic paradox as stated in a consent for treatment form.
LITERATURE REVIEW Informed Consent in Health Care Within the past three decades, the doctrine of informed consent has shifted the public’s attention to the rights of individuals undergoing health care treatment. The shift that has taken place over the years from the client as a passive receiver of health care to one of an educated, informed consumer has contributed to the current public interest of informed consent for health care services. This age of consumerism has been witness to an increase in malpractice suits and insurance rates for many health care providers. The doctrine of informed consent is composed of three legal elements: competency, knowledgehformation, and voluntariness (Cohen & Mariano, 1982; Lynn, 1983; Mills, 1985; Simon, 1987). The standard requirements of a voluntary informed consent include (1) an explanation of the nature of the recommended therapy, (2) benefits and potential risks, (3) side effects or long-term consequences, and (4) reasonable alternative forms of care (Kolb & Brodie, 1982; Rozovsky, 1984). Through informed consent the individual is encouraged to be an equal partner within the therapeutic relationship by exercising free choice, furthering personal autonomy, and participating actively in treatment. A major health care concern raised by Mariner and McArdle (1985) addresses the effectiveness of informed consent documents in transmitting usable information to clients. Although these documents have become the client’s primary source of information about a proposed ther-
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apy, studies concerned with information-recall reveal that clients are unable to comprehend and recall vital information about informed consent procedures (Mariner & McArdle, 1985; Robinson & Merav, 1976). Unconscious conflicts over helplessness and dependency can produce difficulties in obtaining informed consent, while emotional factors such as anxiety, distortion, and denial can influence understanding and recollection of information (Zeichner, 1985). Other influencing factors include the environment in which the information is received, perceptions about the purpose of the information, amount of time allotted for reading, familiarity with health concepts, care with which a document is read, and attitudes of those administering the form (Mariner & McArdle, 1985). Because of the many aforementioned complexities, health care professionals have an obligation to evaluate the current practice of relying on informed consent documents in transmitting vital information. Informed consent is a process and should not be perceived a a single event. Therefore, a one-time signature on a form may not be ethically sufficient when one considers the array of emotional difficulties inherent to this process. Many psychotherapists (Lewis, 1985; Rozovsky, 1984; Simon, 1987; Zeichner, 1985), cognizant of the influencing factors, have therefore recommended continuous, progressive dialogue between the health care provider and client within a collaborative relationship.
Informed Consent with Psychiatric Procedures There is general agreement that some type of informed consent requirement exists for psychiatric services (Winslade, 1983). Informed consent for psychiatric treatment is generally obtained for psychiatric hospitalization, electroconvulsive therapy, and psychotropic medication administration. Establishing a contractual agreement is also common practice. Through the use of a contract the therapeutic relationship is clarified and defined as a mutual endeavor. The contract encourages goal-setting and can protect both the therapist and client from false expectations (Hare-Mustin, Marecek, Kaplan, & Liss-Levinson, 1979). Difficulties encountered in obtaining valid informed consent within psychiatry are well documented. A study concerned with the amount of understanding 100 mental hospital patients had of a voluntary admission form revealed that only eight patients were rated as completely informed of the voluntary admission contract (Olin & O h , 1975). Similarly, hospitalized patients on both locked and open wards reported that their understanding of informed consent material on antipsychotic medication was good, yet objective ratings did not confirm self-reports (Irwin, Lovitz, Marder, Mintz, Winslade, VanPutten, & Mills, 1985). However
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well intentioned and detailed the format is, many clients, regardless of psychiatric disorder, encounter various difficulties with the process of informed consent.
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Informed Consent with Therapeutic Paradox “Reverse psychology” encompasses a variety of paradoxical interventions, the most common being reframing, symptom prescription, and restraining. Reframing is an intervention that aims at changing the interpretation or meaning of a problem so it is seen from a different point of view. Symptom prescription is an intervention that encourages the deliberate maintenance or exaggeration of a symptomatic problem, while restraining is an intervention that discourages the client or family from changing. These interventions are flexible and have been utilized in different settings dealing with a variety of clinical problems. Clinical areas in which therapeutic paradox has proved successful include school phobia (Bergman, 1983), marital therapy with older adults (Gilewski, Kuppinger, & Zarit, 1985), delinquency in youths (Kolko & Milan, 1983), treatment of children in an inpatient setting (Jessee & L‘Abate, 1980), therapy for the chronically mentally ill and retarded (Bergman, 1980), vocational rehabilitation problems (Daggett, 1978), and treatment of depressed college students (Hills, Gruszkos, & Strong, 1985). There are several indications and contraindications for the use of therapeutic paradox with certain individuals and families. Papp (1981) reserves paradoxical interventions for “covert, longstanding, repetitious patterns of interaction that do not respond to direct interventions such as logical explanation or rational suggestions” (p. 245). Recommended indications for paradoxical interventions include therapy with “therapist killers” and “therapist addicts.” Therapist killers are clients who have a past history of ineffective treatment from a number of therapists, while therapist addicts live for their therapy session. Both are appropriate candidates for paradoxical treatment because they are highly resistant clients who always manage to sabotage their claim for help (Weeks & L‘Abate, 1982, p. 56). Contraindications for paradoxical interventions include crisis situations such as violence, sudden grief, attempted suicide, loss of employment, acute decompensation, unwanted pregnancy, abuse, and homicide (Deschenes & Shepperson, 1983; Jessee & L‘Abate, 1980; Papp, 1981; Weeks & L’Abate, 1982). Paradoxical interventions also are contraindicated for families that are childlike, impulsive, or chaotic with loose, disorganized, and variable structures (Fisher, Anderson, & Jones, 1981).
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Contrary to the beliefs that paradoxical interventions be used discriminately is Fraser’s (1984) viewpoint on the usage of paradoxical interventions:
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Not to choose such therapeutic actions as a first resort, on the grounds that they appear contradictory when reasoning from some conventional orthodoxy, may not only be ineffective, but also irresponsible to our therapeutic contracts to most efficiently and effectively help facilitate change. (P. 364)
Although therapeutic paradox has attracted many clinicians it has been met with resistance from others. Weeks and L‘Abate (1982) attribute this resistance to changing work habits and threatening of confidence and security: “Clinicians may feel more threatened with paradoxical therapy than other methods because it does not make sense within traditional views of therapy” (p. 239). The therapist’s behavior may be perceived as illogical (Fisch, Weakland, & Segal, 1986) and manipulative. Some critics believe that paradoxical therapy is manipulative because it is an “insightless” form of therapy; yet Haley (1976) claims that it is “out of fashion” to be a therapist using an insight approach (p. 206). This issue of manipulation also has raised concerns of coercion and deception in therapy resulting in harm to the client. Not surprising is the fact that some psychotherapists have raised the issue of the use of informed consent with therapeutic paradox: “Future endeavors in the area of paradoxical intervention must begin to address pragmatic issues regarding their implementation, their social validity, and the ethics surrounding the absence of informed consent that is inherent in paradoxical procedures” (Kolko & Milan, 1983, p. 660).
METHODOLOGY Design
This exploratory study examined the responses of 34 medical clients and/or significant others to a hypothetical consent form for therapeutic paradox. Sample Obstetrical-gynecological clients and/or significant others awaiting treatment in the waiting room of an urban, midwestern obstetriciangynecologist’s private office comprised the sample. The nonprobability sample size of 34 represented 74% of 46 individuals approached to
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participate in the study. Medical patients rather than psychiatric patients were selected so that an initial, general reaction to the consent form could be obtained without jeopardizing the possible use of paradoxical interventions in a psychiatric or mental health setting. The sample is characteristic of that found in an obstetriciangynecologist’s office, with the overwhelming majority being female (88%). The mean age of the sample was 30 years, with 85% being 34 years of age or younger. The majority of the sample was Caucasian (84%)and married (56%);41%were never married. Nearly 13% of the sample completed high school, while 25% had earned a graduate degree. One-half stated that they experienced therapeutic paradox in everyday life, usually in situations that dealt with disciplining of children (3 1 %). Thirty-one percent experienced therapeutic paradox at the workplace. The majority (66%) had never sought mental health counseling. Of those who had experience with mental health counseling, 73% had sought counseling in the past. lkenty-seven percent were currently seeking counseling.
Procedure The research study was discussed with an interested physician who gave approval for data collection to be conducted in the waiting room of his private office. A formal letter was sent with the instrument to the physician prior to data collection. During each visit to the physician’s office, the researcher began collecting data by inviting the last client on the waiting list to participate in the study while everyone thereafter was approached. This format was instituted so that ample time was given to record and complete responses. Verbal explanation was given to all subjects regarding their informed consent to participate in the study. Subjects were informed that completing the paperwork was evidence of their informed consent to participate. Before comments were recorded on the instrument, a hypothetical situation about going to a mental health professional for counseling was read aloud. Hypothetical Situation Pretend that you are going to a mental health professional for a persistent personal problem that restricts you from engaging in important activities of daily living. You have learned that the therapist is respected by your physician. As part of registration with the therapist, you are asked to read and sign the following consent form. As with all consents, your decision to receive therapy is made voluntarily and freely and there
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has been no guarantee made regarding the outcome of therapy. Any questions regarding your therapy have been answered to your satisfaction. The following is a one-page consent form broken into parts. This allows for the record of your comments and opinions. After the hypothetical situation was read, subjects began completing the instrument by writing their reactions to each of the four sections of the consent form. Following instrument completion, the researcher read a condensed version of a case study described by Papp (1977) entitled “The Family That Had All the Answers.” This case study was chosen to give subjects a reliable and valid account of therapeutic paradox as it is practiced in therapy. Case Study
A middle-class family consisting of a mother and father and two children, Debbie, aged 15, and John, aged 12, are seeking counseling at a family therapy clinic. Mother is interested in solving John’s behavior problems of being disruptive in class, smoking pot, kicking holes in the walls at home, and taking pleasure in annoying his parents. John and his sister also fight frequently. Disciplining of both children is done by the father as the mother has no backbone for this. Counseling in the past has failed. Therapist’s Hypothesis
After getting to know the family and establishing a good relationship, the therapist believed that John’s behavior problems were due in part to the unshared job of discipline between the parents. Knowing that previous counselors had unsuccessfully advised father to assume less and mother to assume more disciplinary activities, the therapist decided to avoid making the same suggestion. Furthermore, the therapist expected the parents to defy most therapeutic recommendations. Therefore, the father was told to continue being the bad guy because the children are accustomed to finding protection and companionship from their mother. A change would be upsetting to the entire family and may even threaten their marriage. Following this intervention the parents did defy the therapist by sharing the activities of discipline. John’s behavior problems decreased and the marriage remained intact. Following the reading of the case study with the therapist’s hypothesis, subjects were then asked in writing whether they would allow their family to be treated by competent therapists who use this type of psychotherapy (paradoxical) and more conventional types of interventions. A demographic data sheet was then completed. Each demographic data sheet and instrument was coded with a number to protect and maintain confidentiality. To establish anonymity, no
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names or addresses were recorded. Data collection was completed in 11 hours during five visits to the physician’s office.
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Instrument A consent form for therapeutic paradox was developed by the investigator and a nursing research advisor. The form was labeled “Consent for Treatment” and was divided into four sections: Introductory Paragraph, Basic Conditions for Treatment, Benefits of the Treatment, and Possible Risks of the Treatment. From recommendations in the literature, the visual format of the consent form was prepared with concise statements using simple language and was proofread for spelling and grammatical errors (Lewis, 1985; Mariner & McArdle, 1985). Wording of the consent form was in the second person, as advised by Lewis (1985). Subjects wrote their reactions to each of the four sections of the consent form and responded to a seven-point Likert scale (with a range of strongly agree to strongly disagree) as to whether they would sign the consent form and accept treatment. Responses were condensed into three categories: (1) agreement (strongly agree, slightly agree, agree), (2) undecided, and (3) disagreement (slightly disagree, disagree, strongly disagree). The one-page consent form was divided into seven pages. Each page represented one of the four sections of the consent form previously mentioned. This format encouraged concentration on each individual issue within the consent form and gave ample space for written responses. After the consent form was developed, it was pretested on five people (mental health professionals and lay persons). They were asked to complete the instrument and make recommendations regarding format, clarity, and readability. Recommendations were incorporated into the consent form based on their comments. The consent form was judged to have content validity by a clinical nurse specialist who was trained and experienced in strategic therapy. Introductory Paragraph The initial section of the consent form relayed information about one’s right to be informed of the conditions, benefits, and possible risks of therapeutic paradox. Statements explained that some of the directions from the therapist might seem to be out of the ordinary as emphasis was given to new ways of relating to oneself and others. The goal of treatment was defined as finding answers to the problems identified in therapy. A brief statement was incorporated into this section explaining that
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a referral to other types of psychotherapy would be made available if desired.
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Basic Conditions for Treatment This section included neutral statements applicable to most types of psychotherapy. The style of therapy required (1) a description of the problem as a new observer would see it even if most of the difficulty is internal, (2) a therapeutic contract expressed in observable terms between the client and therapist regarding the goal of therapy, and (3) the client’s openness to following instructions given by the therapist.
Benefits of Treatment Promoting the goals of therapy by alerting clients to uncommon solutions found in the paradoxical nature of the everyday world was identified as a benefit of treatment. A statement was made regarding possibly meeting therapeutic goals within a few sessions even if previous treatments had failed.
Possible Risks of the Treatment The last section of the consent form incorporated the risk areas identified in the literature such as manipulation, harm to the client, deception, and withholding of information.
Client investment. This risk involved investing time and money without achieving desired therapeutic goals. It was specified that the success of psychotherapy reflected the amount of work invested by both therapist and client. Miscommunication: Harm or embarrassment. Because miscommunication could result in embarrassing or harmful situations, a statement was included encouraging clients to ask questions to clear up any possible confusion. Emphasis was made on communication being a two-way responsibility, with the therapist making efforts to keep instructions clear and understandable. Withholding interpretations. The therapist’s sharing of the most helpful ideas while not sharing less helpful ideas was the focus of this identified risk. The consent form explained that because the therapist interprets situations from many points of view, it is impossible to share all ideas. Denying beliefs. Information was given regarding the therapist denying his or her own beliefs about a client’s situation during the course of treatment in an effort to achieve the therapeutic goal. Denial of beliefs was explained to be necessary at times to prevent a block in progress to the therapeutic goal.
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RESULTS Handwritten responses to each section of the consent form were duplicated on index cards. Using Q sort technique, the investigator sorted the cards into categories according to the theme expressed. The cards were then sorted by a graduate nursing student. The number of agreements for each section of the consent form was divided by the total number of agreements and disagreements. The percentage of agreement ranged from 80 to 94% ,with a mean of 89 % . Comments obtained about willingness for family treatment elicited 78 % agreement. An evaluation of the written responses on the instrument led the investigator to eliminate 2 of the 34 subjects. These subjects exhibited a set response in their attitude. They were the only ones that answered “strongly disagree” to the items in the Basic Conditions for Treatment section of the consent form, which includes neutral statements applicable to most types of psychotherapy. Both subjects were identified as outliers and their responses were eliminated from the study. There was overwhelming acceptance to two sections of the consent form, with 94% and 97% of the sample exhibiting agreement to the Introduction and Basic Conditions for Treatment sections, respectively. Differences were noted in the remaining areas, as seen in Fig. 1 . Analysis revealed differences between the structured questionnaire items on the scale and handwritten responses.
Benefits of the Treatment Seventy-eight percent agreed to the Benefits section of the consent form. Two subjects (6%) disagreed and 16% were undecided. Upon content analysis, 58% of written responses were positive statements that reflected the major theme of therapeutic paradox “opening doors to ideas” that might not have been thought of regarding one’s personal situation. The issue of meeting therapeutic goals within a few sessions was perceived as positive treatment because brief psychotherapy would alleviate the prolonging of problems. The content analysis of responses that were in disagreement (13%) addressed the unrealistic expectation of solving problems in a few sessions. There was a feeling of being wary and suspect of such success (6%)while questioning how the therapist would have solutions that the client had not considered (3%). Two subjects (6%)exercised caution in their written responses, stating they would try therapeutic paradox only after other therapies had failed.
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Possible Risks of the Treatment
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Client Investment Sixty-nine percent of the subjects were willing to invest time and money without achieving desired therapeutic goals. ”kenty-five percent were undecided, while 6% disagreed. Upon content analysis, 37% of written responses were positive statements. There was agreement that a possible risk of therapy was investing time and money without achieving therapeutic goals. This risk would probably have to be taken if there was a chance in solving a problem. The theme of “nothing ventured, nothing gained’ was apparent in these responses. The content analysis of responses that were in disagreement were divided into two themes. Thirty-three percent of written responses emphasized the expectation of benefitting from therapy. If time and money were invested without achieving goals, other therapy would be needed. The second theme, representing 10% of the written responses, addressed the need for statistical information such as estimate of time needed to reach goals, percentage of people who failed this type of therapy, and the odds of a patient helping himself without therapy.
Miscommunication: Harm or Embarrassment Over 80% were willing to accept the risk of miscommunication in therapy. Those who disagreed numbered two (6%), with 12% being undecided. Content analysis revealed that 35 % were openly accepting of this risk because it was understandable and made sense. An additional 32% emphasized the importance of the client taking responsibility in being honest in expressing feelings and asking questions. The theme that emerged from 21 % of written responses addressed the two-way responsibility in communication between the therapist and client. There was an expectation that the client should not have to talk all of the time without feedback from the therapist. In addition, the therapist may not always communicate clearly and the client may not ask enough questions to understand the information discussed.
Wdhholding Interpretations Responses on the seven-point scale to this third risk were divided, with 44% of the sample in agreement and 40% in disagreement. Content analysis revealed that 40% wanted the therapist to share all ideas. Three themes were identified from these responses:
1. The therapist should share all ideas because those that are viewed as less helpful may actually be most beneficial to the client. 2. Because therapy is expensive, all ideas should be shared.
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3. If the client is to be honest and open with information, the same should be expected from the therapist. The view expressed by 20% of written responses indicated that withholding interpretations by the therapist was understandable. Sharing only the most helpful ideas would not only be easier for the client to interpret, but would also not waste time. The theme emerging from 17% of written responses focused on the issue of a therapist’s skill in deciphering which ideas would be most helpful. These responses indicated that less helpful ideas added together could be more beneficial.
Denying Beliefs This risk was the least acceptable, with 34% agreeing to have the therapist deny beliefs during the course of treatment. Twenty-five percent were undecided, while 40% were in disagreement. Content analysis revealed that 30% of written responses were in agreement to accept this risk. The therapist was supported in denying beliefs during the course of treatment so as not to slow or block progress to the therapeutic goal. The reason the client is seeking therapy is to make progress. From those responses that were in disagreement with this risk, several themes were apparent:
1. The therapist should disclose all beliefs whether or not doing so blocks progress (23 %). 2. Therapy is a two-way responsibility of communication and both therapist and client should be open with beliefs (10%). 3. The therapist should remain objective and not let his or her beliefs interfere with a client’s therapy (7%).
Willingness for Family Treatment Upon hearing an example of therapeutic paradox from the case study, 81 % of the subjects agreed that they would consent to treatment for their family members. Content analysis revealed a general willingness to give therapeutic paradox a try in an attempt to solve a problem (30%). Experiencing a feeling of well-being with an end result of being “cured” was valued. Two other themes emerged in addition to the general willingness to undergo therapeutic paradox in therapy: 1. The objective of treatment is more important than the process and the risks seem no greater than for other types of therapy (15%). 2. If other alternatives were tried and did not produce results, then therapeutic paradox would be attempted as a last resort (1 1%).
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Four subjects would not consent for their family members to experience therapeutic paradox in therapy for the following reasons:
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1. Therapists are not needed to solve,problems. The family should take responsibility to solve their own problems. 2. Both parents (in the case study) were not encouraged by the therapist to be actively involved in the family therapy session because each parent was given different information.
DISCUSSION The number of objections to the components of the consent form and general willingness to permit treatment is noteworthy. Although many were willing to sign the consent form and allow their family to be treated with therapeutic paradox, written responses revealed internal reservations. Circled responses on the seven-point scale differed from written responses to several sections of the consent form. This discrepancy may be attributed to several factors. One explanation could be that signing a consent form is considered by most to be a “normal procedure.” After all, without a signature on a consent form it is understood that treatment will not be rendered. Others may feel helpless in making health care decisions and succumb to signing the form. In addition, by placing the case study between the last component of the consent form and the final question (regarding family treatment), subjects may have had their decision influenced by the successful case study, thus overriding possible earlier objections to the components of the form. The use of a consent form with therapeutic paradox would likely prevent a small but important percentage of people from receiving treatment. Four subjects (13%) would not allow their families to receive psychotherapy involving therapeutic paradox. Although 4 out of 32 is relatively small, these subjects displayed a critical attitude about therapy with the general belief that problems can be solved individually without third-party intervention. Therapeutic paradox, when conducted in the context of a therapeutic relationship, is known to be effective with clients who are critical of the therapeutic process and who have had previous treatment failures. By using a consent form, it is feared that discussion of treatment with these clients would block participation of those for whom therapeutic paradox could be most helpful. Informed consent is one of several methods of involving clients in treatment decisions. The process of informed consent is ongoing and is connected to a therapeutic alliance in which the client is encouraged to make choices and decisions responsibly. Ideally, informed consent with therapeutic paradox can occur as a process over time and not only at the
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beginning of treatment. Therapists often invite clients to share and explore concerns about treatment as questions arise. In this way, clients remain informed as needed while the therapist avoids the abrupt and overwhelming presentation of complicated risks inherent to the consent form format. Clients remain free to discuss the style of treatment gradually as they experience the process. Although client autonomy in making health care decisions is valued in psychotherapy, there are times when clients surrender autonomy to health care professionals such as leaving certain decisions to a surgeon while under anesthesia. It may be appropriate for nurse clinicians who use paradoxical interventions to assume a paternalistic position as a means of providing the most effective treatment for clients. However, this does not rule out the need to pursue methods of describing paradox to clients in the context of a progressive dialogue. Because this study consisted of a nonprobability sample of 32 obstetric-gynecological patients and/or significant others, further research should be conducted with a larger, preferably random, representative sample of clients who have direct contact with psychiatric-mental health treatment. Future investigation of this topic should solicit subjects’ judgments after responses to the consent form are completed and before the case study is presented. The influence of the case study could be ascertained by asking for a second judgment from the subjects after the case study is read. In addition, efforts to establish content validity for the instrument could be determined more firmly by knowledgeable psychotherapists. Some measure of test-retest reliability could be established by repeating the instrument over a moderate length of time.
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