The Psychotherapeutic Benefits of Informed Consent with Suicidal Patients

Informed consent has three dimensions: legal, ethical, and psychotherapeutic, and it is often considered a precursor to the intervention. However, there is no clear break between when the informed consent process ends and when psychotherapy begins because the informed consent process can also contain psychotherapeutic elements. By giving more attention to the psychotherapeutic aspects of informed consent, psychotherapists can significantly enhance the quality of their outcomes. This article delineates the essential elements of informed consent in psychotherapy and how psychotherapists can use the informed consent process to initiate psychotherapeutic movement in suicidal patients.

Elements of Informed Consent

Informed consent is a legal requirement. State boards of psychology, when they incorporate the American Psychological Associations’ (APA) Ethics Code or a version of it in their regulations, and other state or federal laws, mandate informed consent. Standard 10.01 of the APA Ethics Code stipulates that psychologists must inform patients “about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of confidentiality, and provide sufficient opportunity for the client/patient to ask questions and receive answers” (American Psychological Association, 2017, Standard 10.01). The informed consent process should occur “as early as feasible.” This allows for delaying some or all informed consent elements to help patients in immediate crisis. Informed consent may also require complying with the Health Insurance Portability and Accountability Act (HIPAA) or the federal Cures Act, if applicable. Depending on the circumstances, other laws may apply, such as special requirements when delivering telehealth services as required in some states.

In addition to information about fees, limits of confidentiality, and potential involvement of third parties, Standard 10.01 of the APA Ethics Code (2017) requires a discussion of the “nature and anticipated course of psychotherapy.” However, it does not define what this means. The nature of  psychotherapy (and subsequently the nature of the informed consent discussion) may vary according to the personal style of the psychotherapist, their training and theoretical orientation, the age of the patient (e.g., a child versus an adult patient), and the type of psychotherapy (e.g., individual, family, or group) implemented. Topics to be covered might include a brief description of the modality proposed, the frequency and length of sessions, the potential for a medication referral, and practical details, such as how the psychotherapist handles communications or emergency services.

The Code of Ethics does not require psychologists to get their patients to sign an informed consent document, although this may be a prudent risk management strategy (Knapp et al., 2013). This lets patients read the document at leisure, reinforcing points made during the informed consent discussion. A signed document also shows that the psychotherapist met the legal obligations of providing informed consent. Various sample informed consent forms exist, such as the one developed by Scroppo et al. (n.d.) from the Trust, a major professional liability carrier for psychologists, which is readable and easy for patients to understand.

In addition, informed consent has an ethical dimension because it derives its justification from the ethical principle of respect for patient autonomy. According to this principle, patients have a right to make decisions about their own lives, including whether they want to enter treatment (APA, 2017, General Principles). The informed consent process is designed to ensure that patients understand the nature of treatment sufficiently to make an informed decision (Beauchamp & Childress, 2019).

Although the laws establish minimal standards for what should be included in the informed consent process, the ethical principles call upon psychologists to go beyond the minimum and consider what information would be relevant to their patients. Consequently, ethical psychologists will approach the informed consent process as a dialogue, will vary the emphasis on specific points depending on the needs of their patients, add additional information if helpful, and will revisit informed consent issues throughout treatment as the need arises, such as when they introduce new techniques to their patients (Bryan & Rudd, 2018).

Respect for patient autonomy does not end when a patient has been offered the HIPAA Privacy Notice or has signed an informed consent document. Instead, psychotherapists can respect patient autonomy throughout treatment by listening carefully to their patients, explaining treatment details thoroughly, involving patients in treatment decisions as much as feasible, and asking patients for feedback (Knapp, 2024).

Finally, the informed consent process has a psychotherapeutic dimension. Psychotherapists should not view informed consent as a pro forma process that they are required to get out of the way to start psychotherapy. Instead, it can be the first step in psychotherapy.  

Psychotherapeutic Aspects of Informed Consent with Suicidal Patients

Psychotherapists treating suicidal patients should modify their informed consent process to accommodate their patients’ unique needs. This means providing more detail on the nature and anticipated course of psychotherapy, which requires clinical honesty and describes a collaborative approach focusing on how patients can gain more control over their lives. The process contains psychotherapeutic elements to the extent that it improves the psychotherapist/patient alliance, increases expectations concerning the benefit of treatment, and affirms the patient’s agency and capacity to overcome their problems.

Accurately Describing Treatments to Suicidal Patients

Psychotherapists should be transparent about the nature of psychotherapy, including its risks as this builds trust between psychotherapists and their patients. “Clinical honesty related to suicide risk begins with thoughtful and thorough informed consent” (Jobes, 2023, p. 7). This also shows respect for the patient’s right to make treatment decisions because it gives them accurate information when deciding about entering psychotherapy.

Clinical honesty includes discussing facets of psychotherapy that patients might not like. For example, psychotherapists should acknowledge that psychotherapy may involve discussing unpleasant situations and sometimes engenders unpleasant emotions (Scroppo et al., n.d.). With that in mind, Bryan and Rudd (2018) told their suicidal patients receiving brief cognitive behavioral therapy (BCBT) that “treatment will involve discussions of emotionally difficult topics that can sometimes increase a patient’s distress in the short term. These periods of increased distress tend to be very brief, but they could increase the patient’s desire for suicide for short periods. The clinician and patient will work together to help the patient get through these periods” (Bryan & Rudd, 2018, p. 41).

Honesty also requires acknowledgment that no psychotherapist can guarantee a nonfatal outcome. For example, in their informed consent process, Bryan and Rudd (2018) explain that some suicidal patients will attempt suicide while in treatment but that their risk of an attempt usually declines over time.

However, honesty also involves describing the positive outcomes that can occur, and psychotherapists should not be shy about touting the benefits of good psychotherapy because evidence shows that many psychotherapies are highly effective in reducing suicide attempts and deaths (Sufrate-Soranzo et al., 2023). For example, one suicide intervention, safety planning, has been shown to reduce suicide attempts by an average of 48% (Nuij et al., 2021), and a trial with BCBT reduced suicide attempts in the treatment group by 60% compared to a treatment-as-usual group. There is no need to puff up or exaggerate the effectiveness of these techniques, and the psychotherapist should acknowledge there may be a need for some trial and error. As described by Bryan and Rudd (2018), “treatment involves experimenting with new skills designed to solve problems without suicide attempts” (p. 41).

Suicidal patients often encounter friends or even other mental health professionals who avoid talking about suicide (Frey et al., 2016). Patients may feel relief when they can speak to someone who appreciates the severity of their suicidal urges yet is not afraid to talk about it openly and can honestly describe the risks and benefits of treatment (Jobes, 2023). Although psychotherapists can offer optimism, they should not minimize their patients’ concerns nor exaggerate the ease or speed of recovery. 

Suicidal patients often feel a sense of entrapment or a belief that they do not have the power to stop the intense and unbearable pain that they feel. Entrapment is similar to the concept of hopelessness in that patients do not see a way out of their difficulties, but it differs in that it necessarily includes intense pain. The discussion of the effectiveness of psychotherapy may challenge their entrapment beliefs and give patients hope that they will be able to get more control over their lives. Patients who enter psychotherapy with expectations of improvement are more likely to benefit from psychotherapy (McAleavey et al., 2019).

Accurately Describing Their Attitude Toward Coercive Techniques to Suicidal Patients

Psychotherapists should be honest about when they would use coercive interventions with their patients. Many suicidal patients fear that their psychotherapist will force or pressure them to go into the hospital against their will, take medications that they do not want to take, or disclose information to third parties without their consent. The fear of coercion is one of the most common reasons that patients hide or minimize their suicidal thoughts (Blanchard & Farber, 2020). Their fear of disclosure may be exacerbated by the stigma attached to being the subject of involuntary treatment.

Consequently, psychotherapists should describe the circumstances under which they would use coercive interventions. Ideally, this would be the rare circumstance when the risk of a patient’s death is imminent, and there is no other way to stop a suicide attempt. Even then, an effort will be made to involve patients in the decision as much as possible. Psychotherapists can then describe their personal experiences using coercive measures, which is likely very rare, thus giving more weight to their promise of collaboration.

As written by one former patient, “Promise to listen to everything I say and take into consideration my emotional state at the time. . . Then see admitting to a hospital as a LAST resort” (Blanchard & Farber, 2020, p. 131). Psychotherapists who follow this advice will significantly improve their patients’ trust and increase the likelihood that patients will be honest with them. Tucker and Gonzalez (2024) found that veterans who watched an informed consent video that presented a collaborative approach to treatment and limited reliance on coercion expressed a greater willingness to disclose suicidal thoughts and related risk factors compared to those who watched a more general informed consent video.  

Describing a Collaborative Approach to Suicidal Patients

The best treatments for suicidal patients focus on respecting their autonomy (e.g., Bryan & Rudd, 2018; Jobes, 2023; Knapp, 2024) not only during the informed consent process but also throughout psychotherapy. Psychologists can demonstrate this respect by adopting a collaborative approach to assessment and psychotherapy (Knapp, 2024).

Psychotherapists can emphasize the importance of collaboration during the informed consent process. They can express faith that the patient has the internal ingredients (with guidance from their psychotherapists) to overcome their problems. Jobes tells his patients that “the answers to your struggles exist within you—we will find these answers together as treatment partners” (Jobes, 2023, p. 64). They are told that they are experts in their own experiences. They are expected to participate actively in treatment and honestly express any concerns about psychotherapy. Just the expression of faith in the patient’s latent strengths can start the process of dismantling self-devaluing emotions.

Practice Pointers When Discussing Informed Consent with Suicidal Patients

Although it is a legal requirement and an ethical mandate, the informed consent process can also contain the first steps in psychotherapeutic interventions.  

The informed consent process with suicidal patients emphasizes clinical honesty about the benefits and risks of psychotherapy, an expectation that the patients will be partners in a collaborative relationship, and faith in the patient’s ability to redirect their lives.

These elements can help patients develop trust in their psychotherapists, increase their willingness to be honest with them, instill hope that there may be an end to their suffering, and foster confidence that they can overcome their difficulties with guidance from their psychotherapists.