Midterm - Informed Consent, Client-Therapist Relationship, & Confidentiality

Question 1

Why informed consent is needed

Answer 1

1. Clients have right to control their therapy
2. RPs cannot provide therapy without client’s consent
3. Failure to provide informed consent can lead to criminal, civil, or professional consequences

Question 2

What makes consent ‘informed’ according to the CRPO

Answer 2

CRPO: if the person making the decision received all the information that a reasonable person in the same circumstances would require in order to make a decision before voluntarily agreeing to the intervention
* Person has information about: nature of treatment; expected benefits and risks and side effects of treatment; alternative courses of action; likely consequences of not having treatment
* Person’s responses and questions are addressed

Question 3

Laws/Regulations applicable to Informed Consent

Answer 3

• Health Care Consent Act (HCCA), 1996
• Personal Health Information Protection Act (PHIPA), 2004
• Substitute Decision Makers Act, 1992

Question 4

What to include in informed consent

Answer 4

HCCA: Duty to Provide Information:
▪ Nature of the proposed treatment, therapeutic intervention or assessment
▪ Reasons for the therapy/assessment
▪ Material risks of the treatment (foreseeable costs and limitations)
▪ Effects of the treatment, especially if they might be uncomfortable or undesirable
▪ Other treatment options (e.g. medication, other therapy, groups, online apps, etc.)
▪ Consequences of refusing
▪ Particular client concerns
* agency policies
* right to confidentiality and its limits/exceptions
* mandatory reports
* if recording sessions
* if sharing any information with a 3rd party (e.g. supervisor)

CRPO: Transparency and Accuracy:
▪ Truthful and accurate
▪ Awareness of any dual roles if registered with more than one regulatory body and clarity about what “hat” you are wearing
▪ Ongoing provision of relevant information about process of therapy, approach, methods/specific techniques and options and any changes
▪ Developmentally and culturally appropriate

CRPO/PHIPA: Use of Technology:
▪ Measures to ensure confidentiality
▪ Risks and benefit

Question 5

HCCA 4 Elements of Consent

Answer 5

1. Related to treatment
2. must be informed
3. must be given voluntarily
4. cannot be obtained through misrepresentation or fraud

Question 6

8 Exceptions to Confidentiality that must be in informed consent

Answer 6

1. Emergency (e.g. client has stroke and needs medical attention)
2. Mandatory reports of another health care professional (if they have sexually abused a client)
3. Duty to report safety/wellbeing of minor/vulnerable persons at risk of harm
4. Duty to prevent harm/warn client is at risk of harming self/others
5. Improper or incompetent care, abuse, or neglect of elderly in long-term care or retirement home
6. “Other Situations” (e.g. court proceeding, mandatory reports)
7. Missing Person (if contacted by police about MPR, may need to provide information about person)
8. College Requirements (e.g. for CRPO assessment, if a complaint is made, if reporting misconduct of another RP)

Question 7

4 Mandatory Reports to the CRPO

Answer 7

1. Sexual Abuse (of client by a RP)
2. Incompetence, incapacity, and professional misconduct (of another RP, with reasonable grounds)
3. Criminal offences (of self or other RP, if charged or convicted witih crime, whether or not found guilty - exception being a speeding ticket)
4. Self-professional negligence (any court proceedings or complaints filed against you)

Question 8

Signs the client understood and has provided consent

Answer 8

• signed documentation
• client states they have read consent forms
• client able to summarize/repeat consent
• client asks questions for clarification
• client verbally consents
• client engages in therapy

Question 9

Types of Client consent

Answer 9

• Written/signed
• Verbal
• Implied (attending session, nodding, participating in intervention, providing payment)

Question 10

When we obtain informed consent

Answer 10

• Before starting treatment
• Before any changes to therapeutic plan or new interventions
• Before referral to another therapist and/or health professional
• Before providing information/reports to third parties

**Must immediately comply with client withdrawing/withholding consent

Question 11

Ways a client can demonstrate power

Answer 11

• deciding what to talk or not talk about
• choice of therapist
• showing up or not showing up at sessions
• showing up late/leaving early
• payment or not/on time or not
• refusing to participate in intervnetions/do homework
• setting goals
• right to complain to CRPO, boss, social media, etc.
• can ask for notes at anytime (at any age)
• leaving therapy
• asking the therapist personal questions

Question 12

How to communicate to clients their power in the therapeutic relationship

Answer 12

• informing them of their rights
• being collaborative
• asking them to set the goals
• asking permission before doing things/asking things
• acknowledging client’s expertise on their own life
• letting them know they can decline questions or interventions

Question 13

How and when you share your power with clients

Answer 13

• in the first session when providing info and seeking informed consent
• when setting goals
• ongoing when seeking permission to change treatment plan/do new intervention/modality

Question 14

Clinical Record

Answer 14

Client’s entire file including their case notes, treatment plan, all emails, intake forms, ROIs and any other information pertaining to the client

Question 15

Age of Consent in Ontario

Answer 15

There is no minimum age of consent in Ontario. Clients under 18 years can, if they are capable of understanding and appreciating the consequences of their decision, give consent. It is up to the therapist’s clinical judgement on a case by case basis in light of their capacity to provide consent and applicable laws (must document reasons why or why not capable) .
*may also depend on agency policy

Question 16

Competence

Answer 16

The client’s ability to perform a particular task, such as making a decision. It depends on many things (e.g. what the decision is, conditions under needing to make the decision, state of health/intoxication, their development/cognitive capacity, knowledge, skills, abilities)

Question 17

Determining competence/capacity

Answer 17

There is no universally accepted assessment measure to determine competence/capacity, is based on clinical judgment.
Is ongoing. May have capacity for some things and not others and capacity may change over time/session to session.

Question 18

Ways to determine capacity/competence

Answer 18

• Can the client orient to time and place/show awareness of their situation?
• Can the client remember or track the conversation?
• Can the client sufficiently weigh the options presented?
• Are communication/behavior congruent and proportionate to the circumstances?
• Can the client say their decision?
• Any cultural or language issues?
• Is the client currently under the influence of any substance, cognitive impairment or or other person or illness?
• Does the client demonstrate understanding of the information?

Question 19

What to do if a client is not capable of consent

Answer 19

• obtain consent from a “valid substitute decision maker”
• discuss with your client your concern(s)
• involve the client in any discussions about therapy
• respect the dignity and autonomy of the client (e.g. that they may be able to consent for one thing but not another)

Question 20

HCCA hierarchy for SDM

Answer 20

▪ Court appointed guardian
▪ Person with “attorney for personal care”
▪ Person appointed by Consent and Capacity Board
▪ Spouse/partner of the client
▪ Child of client/parent of the client or CAS (if wardship)
▪ Parent that does not have custody
▪ Brother/sister of client
▪ Any other relative
▪ Public Guardian or Trustee

Question 21

Items to include in written/signed informed consent

Answer 21

✓ Issues pertaining to confidentiality and its limitations
✓ The therapeutic process
✓ Background of therapist – therapist bias?
✓ Costs involved in therapy
✓ The length of therapy and termination
✓ Consultation with colleagues
✓ Interruptions in therapy
✓ Procedures & policies for making and canceling
appointments
✓ Policies regarding phone contact between sessions
✓ How to contact the counselor in the event of an
emergency.
✓ Dual Relationships
✓ Benefits and risks of treatment ✓ The client’s right to refuse any recommended services
or modality change and be advised of the
consequences of refusal
✓ Alternatives to traditional therapy
✓ Tape-recording or videotaping sessions
✓ Clients’ right of access to their files
✓ Rights pertaining to diagnostic labeling
✓ The nature and purpose of confidentiality
✓ The client’s recourse if dissatisfied with counseling
services, including names and contact information for
supervisors and addresses and phone numbers of
licensing boards and professional organizations.
✓ Any agency policy
✓ For MFT – no secrets policy

Question 22

How to meet standard of confidentiality

Answer 22

▪ Explain what confidentiality is and all the exceptions
▪ Document informed consent about collection, use and disclosure of information
▪ Only collect, use or disclose information that is REASONABLY REQUIRED
▪ Apply privacy principles in research
▪ Notify clients if information has been disclosed or request to disclose from another
▪ Put in place processes to protect PHI
▪ Avoid non-secure communication (email)

Question 23

2 Parts of Privacy

Answer 23

Privacy is the client’s right to keep their PHI concealed from others. Two aspects of privacy are:
1. Confidentiality - the duty of the therapist to keep any information the client shares with them from others.
2. Privilege - the client’s right to withold information from others including the therapist unless court-ordered to share this information or chooses to have this information shared with a 3rd party

Question 24

Unintentional Breaches of Confidentiality

Answer 24

• clients seeing other clients in the waiting room
• verbally discussing somethign about a child’s therapy with a parent without the child’s consent
• acknowledging the client in a social setting
• discussing therapeutic topics in the hallway of the clinic/overheard conversations
• slip of tongue revealing client’s name/other PHI
• therapist’s family member interupts a online therapy session
• pop-up on computer with client information during online session screen sharing
• clerical help mishandle confidential information
• security breach
• acknowledging or asking another colleague about a referral
• returning telephone calls/emails/faxes
• inappropriate storage of files

Question 25

What to do if there is a breach of confidentiality

Answer 25

If the breach is intentional or not, the therapist must inform the client of the breach and inform them of their right to complain and provide them with the contact information for the privacy commissioner.

Question 26

Right to Confidentiality for Deceased Client

Answer 26

The client’s right to confidentiality does not end upon death. Right to consent to collection of PHI, use, and its disclosure is transferred to the estate or trustee.

Question 27

breach of confidentiality

Answer 27

Sharing of a client’s PHI or any identifying information about a client with someone other than the client without their informed consent to do so.