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Client preferences for informed consent information

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Title:
Client preferences for informed consent information
Creator:
Braaten, Ellen B
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Language:
English
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vi, 88 leaves : ; 29 cm

Thesis/Dissertation Information

Degree:
Master's ( Master of arts)
Degree Grantor:
University of Colorado Denver
Degree Divisions:
Department of Psychology, CU Denver
Degree Disciplines:
Psychology

Subjects

Subjects / Keywords:
Informed consent ( lcsh )
Psychotherapy -- Moral and ethical aspects ( lcsh )
Genre:
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Bibliography:
Includes bibliographical references (leaves 78-88).
General Note:
Department of Psychology
Statement of Responsibility:
by Ellen B. Braaten.

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|University of Colorado Denver
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Auraria Library
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All applicable rights reserved by the source institution and holding location.
Resource Identifier:
30834716 ( OCLC )
ocm30834716
Classification:
LD1190.L645 1993m .B7 ( lcc )

Full Text
CLIENT PREFERENCES FOR
INFORMED CONSENT INFORMATION
by
Ellen B. Braaten
B.S., University of Wisconsin (Whitewater), 1981
A thesis submitted to the
Faculty of the Graduate School of the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Master of Arts
Psychology
1993


This thesis for the Master of Arts
degree by
Ellen B. Braaten
has been approved for the
Department of
Psychology
by
Date


Braaten, Ellen B. (M.A., Psychology)
Client Preferences for Informed Consent Information
Thesis directed by Professor Mitchell M. Handelsman
ABSTRACT
This study assessed the information people want about
psychotherapy. Thirty-five current therapy clients, 47 former
clients, and 42 college students with no therapy experience rated 27
items in terms of importance for inclusion in informed consent
discussions. Participants also rated when they would prefer to
receive this information. Participants ratings of the importance
and the timing of information were analyzed to determine if they
varied as a function of group membership, depression, anxiety, risk
for eating disorders, and other demographic characteristics.
Overall, participants in this study rated most of the items highly,
indicating that both clients and non-clients value the information
that is conveyed in an informed consent process. The clinical sample
rated information about inappropriate therapeutic techniques,
confidentiality, and the risks of alternative treatments as most
important, and information about the personal characteristics of the
therapist and therapists degree as least important. The client
sample differed from the other groups on a variety of measures,


indicating significantly higher levels of depression, anxiety, and
eating disorders, and more positive attitudes toward therapy. The
client samples also differed from the other groups on the importance
and timing of information, with current and former clients preferring
much information later in the therapy process. Participants also
differed in terms of anxiety, attitudes toward therapy, gender, and
race, with participants with higher levels of anxiety valuing the
overall information less and preferring it later in the therapy
process. These data provide evidence for a process model of informed
consent and differential informed consent disclosure practices.
This abstract accurately represents the content of the candidates
thesis. I recommend its publication.
Mitchell M. Handelsman
iv


CONTENTS
Chapter
I. INTRODUCTION ............................................. 1
The Concept of Informed Consent..........................2
Research on Informed Consent............................14
Purpose of Current Study............................... 20
II. METHOD....................................................23
Participants and Procedure..............................23
Instruments.............................................24
III. RESULTS................................................ 29
Group Differences on ATSPPH, BDI, STAI, and EAT. ... 30
Informed Consent Ratings................................32
The Timing of Informed Consent Information..............37
The Effects of Personal Characterstics. ................42
Specific Analyses on Current Client Participants. . .45
IV. DISCUSSION.............................................. 46
Appendix
A. Demographic Data Questionnaire............................57
B. Informed Consent Questionnaire............................60
C. Attitudes Toward Seeking Professional Psychological
Help Scale...............................................63
D. Beck Depression Inventory.................................67
v


E. Speilberger State-Trait Anxiety Inventory................73
F. Eating Attitudes Test.....................................75
References. ..................................................78
vi


CHAPTER I
INTRODUCTION
Explicit informed consent procedures for outpatient
psychotherapy are increasing in popularity (Beeman & Scott, 1991;
Handelsman, Kemper, Kesson-Craig, McLain, & Johnsrud, 1986). This
increase in popularity may be due to changes in the nature of doctor-
patient relationships in general (Jensen, 1981) and to the growing
awareness on the part of mental health care providers of the
importance of individual autonomy (Andrews, 1984). In addition,
consumer insistence on professional accountability has fueled the
informed consent movement (Bremer & VandeCreek, 1991).
However, there is little consensus on what should be included
in an informed consent procedure (Jensen, McNamara, & Gustafson,
1991) and wide variability in therapists informed consent practices
(Baird & Rupert, 1987; Pope, Tabachnick, & Keith-Spiegel, 1987). For
example, Baird and Rupert (1987) surveyed psychologists about their
procedures in dealing with issues of confidentiality and found that
there was no standard practice for informing clients about
confidentiality. Additionally, only 35.7% of the respondents
indicated that they always say something about confidentiality.
Currently, the "reasonable person" standard (i.e.,
1


professionals should provide information about treatment that a
reasonable person in the same situation would want to know) is the
recognized standard of disclosure in mental health practice (Gillett,
1989; Meisel, Roth, & Lidz, 1977). Because it is a relative standard
of disclosure based on clients needs and desires for information,
there is a need to explore what "reasonable people" would want to
know about psychotherapy. Despite this need, no published studies
have investigated client preferences for informed consent information
(Bremer & VandeCreek, 1991). The major purpose of this study is to
address this oversight by assessing what information clients feel is
most important for inclusion in an informed consent process.
The Concent of Informed Consent
Historically, the doctrine of informed consent began in
medicine and was developed to assure patients rights regarding
medical treatment (Andrews, 1984). The concept of consent was first
discussed in the early 20th century in relation to surgery (Dyer &
Bloch, 1987). More recently, as a result of several offensive and
dangerous "experiments" in which medical patients were abused or
subjected to dangerous procedures without their knowledge, the issue
of informed consent has received much attention in the medical arena
and, as a result, has been subjected to government regulation
2


(Beauchamp & Childress, 1989). Prior to 1975, there were almost no
state laws dealing specifically with this subject (Annas, 1983).
However, informed consent as a legal doctrine has since been adopted
as case law or statute in at least 46 states (Bremer & VandeCreek,
1991). The doctrine imposes two legal duties on physicians. The
first duty is to inform patients about treatment procedures,
alternatives, risks, and benefits, and the second duty is to obtain
consent for administration of the agreed upon treatment.
In medical practice the issue of what information to provide to
patients is considered in terms of either the "reasonable person
standard" or the "professional practice standard" (Beauchamp &
Childress, 1989; Bremer & VandeCreek, 1991; Gillett, 1989). Prior to
1972, the professional practice standard, whereby physicians are
obligated to disclose information that is traditionally disclosed by
a community of doctors, was the unquestioned standard of disclosure
(Beauchamp & Childress, 1989; Faden & Beauchamp, 1986). Because
doctors (as opposed to patients) decided what information to disclose
to their patients, this approach was considered paternalistic in
nature and reflected the high esteem in which physicians were held in
the community.
In 1972, the Canterbury v. Spence decision replaced the
professional community standard of disclosure with a patient-based
3


standard of disclosure (Appelbaum, Lidz, & Meisel, 1987). The court
stressed that "reasonable care demands disclosure of material risks,
and a risk is material when a reasonable person, in what the patient
knows, or should know to be in the patients position, would be
likely to attach significance in deciding whether to forego the
proposed therapy" (cited in Andrews, 1984, p. 177). Since this
decision, doctors can no longer decide unilaterally what information
a patient should be given. Instead, the standard for disclosure is
determined by what is of material concern to the patient involved.
The Concept of Informed Consent in Psychotherapy
In general, mental health litigation has historically followed
the pattern established in medical health care (Haas, 1991). Most of
the literature concerning informed consent has been from a medical-
legal perspective: issues such as the nature of therapists
qualifications and competence, their style of practice, potential
liability for iatrogenic disorders and treatment side-effects, and
maintaining patient confidentiality are among the most commonly
discussed areas (Huber & Baruth, 1987; Widiger & Rorer, 1984). Some
authors have specifically suggested that malpractice might be
prevented through the physician or therapist "sharing his/her
uncertainty" during the process of informed consent (Gutheil,
4


Bursztajn, & Porodsky, 1984). In this method, informed consent is
thought to enhance the therapeutic alliance by not raising the
patients expectations. Informed consent is particularly necessary
when treatment can be hazardous, when it could have both negative and
positive effects, when one treatment is not necessarily superior to
another, and when full patient cooperation is necessary for treatment
success (Sider & Clements, 1982). All of these conditions are
frequently met in the practice of psychotherapy.
The primary philosophical issue underlying the obligation to
obtain informed consent, the promotion of autonomy, is similar in
medical and psychological treatment. The concept of autonomy implies
that individuals have the right to live independently, and to think
and behave in any way they choose as long as they are not harming
others. However, Haas (1991) suggested one difference between
medical and psychological informed consent in regard to autonomy:
Because much mental health treatment is directed toward increasing
individuals autonomy, informed consent procedures could actually be
considered a part of treatment, as well as a precondition for it.
A major difference between medical and psychological informed
consent concerns the issue of competence. In mental health practice,
autonomy may be limited because clients' clinical states may make
them unable to exercise free judgment. For example, certain
5


disorders, such as schizophrenia, may interfere with thought
processes required to comprehend the nature of the treatment proposed
(Grisso & Applebaum, 1991; Soskis, 1987). In addition, the criteria
for competence in current medical practice emphasize cognitive rather
than affective dimensions; however, clients with major affective
disorders can retain the cognitive capacity to understand the risks
and benefits of treatment, yet fail to appreciate its benefits
(Bursztajn, Harding, Gutheil, & Brodsky, 1991). Because clients
competence may affect their autonomy, therapists may find themselves
in a paternalistic role in that they are acting on behalf of their
clients. This role often differs from the doctors role in medical
treatment.
When the doctrine of informed consent is applied to
psychotherapy, it requires that clients enter therapy knowingly,
intelligently, and voluntarily (Bray, Shepherd, & Hays, 1985). While
some have expressed concern that consent procedures may hinder the
therapeutic relationship (Faustman, & Miller, 1987; Handelsman et
al., 1986; Haut & Muehleman, 1986) or decrease clients confidence in
the therapists potential helpfulness as well as potentially causing
a loss of clientele (Lewis, Davis, & Lesmeister, 1983), the promotion
of autonomy and rational decision-making is thought to enhance (Coyne
& Widiger, 1978; Everstien et al., 1980) and help define the
6


relationship between client and therapist (Birch, 1990). Jensen,
Josephson, and Frey (1989) stated that informed consent is "more than
just an ethical or legal obligation: inherent in the process of
informed consent is the potential for the enhancement of the clinical
work" (p. 379).
Approaches to Informed Consent in Psychotherapy
There are two models within which clinicians can conceptualize
the informed consent process (Appelbaum et al., 1987). In the first
model, an event model, informed consent occurs at a single point in
time, usually at the beginning of treatment. The consent form is
often used in this model. In contrast, the process model is based on
the assumption that decision-making is a continuous process that
occurs over the course of treatment and therefore exchanges of
information occur throughout the course of therapy.
Dyer and Bloch (1987) viewed informed consent as a continuing
process that occurs within the framework of a fiduciary relationship
whereby therapists identify specific needs of patients and respond
individually without relying on the use of written contracts or
forms. They defined this fiduciary relationship as one based on
mutual trust, confidence, and openness, and wrote:
The two partners [therapist and client] have one overriding
7


goal in their collaboration: to understand and clarify the
motives of the patient. . The partners recognize that the
communication between them may have many levels of meaning,
conscious and unconscious and that not all these levels can be
appreciated simultaneously. Informed consent occurs not once,
but repeatedly, as therapist and patient work together to bring
into the latters conscious awareness that which has hitherto
been unknown or obscure, (p. 16)
In this context, therapists attempt to identify the specific needs of
clients and to respond to them.
Some authors have advocated the use of written therapeutic
contracts or forms that include descriptions of therapeutic goals,
procedures, risks, and benefits (Everstine et al., 1980; Hare-Mustin,
Marecek, Kaplan, & Liss-Levinson, 1979; Morrison, 1979). Jordan and
Meara (1990) noted, however, that signed contracts suggest that
therapy is first and foremost a legal transaction of commodities or
services and implies that the client is a passive recipient of
therapeutic services. Jordan and Meara stated that some of these
forms were developed in an environment of escalating legal
responsibilities for therapists but noted that consent practices
should instead be seen as "an outgrowth of a professionals concern
for the integrity of the process and practice of psychotherapy itself
8


and an abiding respect for clients who engage in it" (p. 111).
Handelsman and Galvin (1988) suggested a combination of written
and discussion formats whereby clients are presented with a series of
questions that they have the right to ask. In this case, clients
retain their right to request or not request certain information, and
therapists determine the amount of information to be provided.
Regardless of the format used, different ethical problems are
associated with different therapeutic approaches. For example,
Widiger and Rorer (1984) contended that disclosure of therapeutic
methods may undermine certain psychoanalytic techniques that rely on
spontaneous elicitation of unconscious material. Thus, they imply
that it is impossible to delineate informed consent procedures that
are equally applicable to all therapeutic situations. Also, informed
consent disclosure may vary as a function of the population being
served. For example, the ethical problems, particularly in regard to
confidentiality, that are posed in family therapy can affect multiple
levels of individuals and families (Jensen et al., 1989; Miller,
Scott, & Searight, 1990) and are different from those posed by
inpatients (Lidz et al., 1984). The problems posed by minor clients,
whose concerns about therapy are influenced by their developmental
needs (Croxton, Churchill, & Fell in, 1988; Gustafson & McNamara,
1987; Kaser-Boyd, Adelman, & Taylor, 1984), are quite unique.
9


Another ethical, as well as legal, dilemma in the treatment of minor
clients can occur because the client is not empowered by law to give
adequate consent to treatment.
The Ethical Principles of Psychologists and Code of Conduct
(American Psychological Association [APA], 1992) provide
psychologists with some help in regard to these ethical problems.
However, although the Ethical Principles mandate informed consent
procedures as a necessary precursor to engaging clients in therapy,
guidelines concerning the content of such discussions are unclear.
Ethical Standard 4.02 states, "Psychologists obtain appropriate
informed consent to therapy or related procedures, using language
that is reasonably understandable to participants. The content of
informed consent will vary depending on many circumstances" (p.
1605). Ethical Standard 5.01 addresses informing clients about the
limitations of confidentiality, Ethical Standard 1.07 addresses
informing clients about the nature and results of psychological
services, and Ethical Standard 1.25 addresses fees and financial
arrangements. These Ethical Standards provide psychologists with
much latitude about which topics to include in an informed consent
discussion and when to provide such information.
In addition to this ethical requirement, psychologists may also
have legal requirements; however, these legal requirements also
10


provide psychologists with latitude concerning the content of
discussion. For example, Colorado mandates that all licensed and
unlicensed psychotherapists disclose certain information in writing
to all clients, including the therapists credentials, clients
rights to a second opinion, the inappropriateness of sexual contact,
the limits of confidentiality, and a statement indicating that the
client is entitled to receive information about therapeutic
techniques, methods, and the fee structure (C.R.S. 12-43-214).
Washington state has a similar legal requirement (RCW 18.83.115)
that, in addition to those areas covered by the Colorado law,
mentions therapeutic orientation and financial requirements.
Although the information mandated in these laws is important, the
laws do not cover every area that may be of interest to particular
groups of clients, and psychologists ultimately decide how much
information is given to clients.
Despite these guidelines, there is much variability in
therapists informed consent practices. In one study (Baird &
Rupert, 1987), only 35.7% of psychologists reported that they always
discuss confidentiality with their clients. Handelsman et al. (1986)
found that only 28.8% of psychologists surveyed reported using
written consent forms. The most common items on these consent forms
was method of payment, followed by the policy concerning fees for
11


missed appointments, and the limits of confidentiality. None of the
forms included all of the limits of confidentiality. Noll and Haugen
(1985) found that clinicians emphasized disclosure about issues such
as limits to confidentiality, therapist qualifications, and
therapeutic procedures, while deemphasizing potential risks.
Respondents indicated that presenting clients with an initial
presentation of the risks of therapy could overwhelm them and deter
them from seeking therapy. In a 1986 study, Talbert and Pipe
examined the content of written informed consent forms from 40 sites
providing psychological services in five areas of the United States.
The most frequently provided elements of information were a statement
about confidentiality (19 sites) and information on financial
obligations (14 sites). Only one site had material describing any of
the risks involved in therapy and 14 of the centers provided no
information to clients concerning informed consent.
This oversight may be affecting client treatment. The modal
length of therapy is one session (Talmon, 1990) and many studies have
shown that most clients drop out of therapy within the first three to
five sessions (see Garfield, 1986, for review). It could be argued
that these clients were either not suitable candidates for
psychotherapy or were not ready to commit themselves, to the sometimes
painful process. Another possible reason for this early drop out
12


rate could be that therapists are not providing clients with
information that is relevant and important to them during the
beginning of therapy. To address the issue of what information to
provide to clients, many authors have suggested topics that always
need to be covered in an informed consent process, including: (a)
the nature of treatment; (b) benefits and risks of treatment; (c)
likely alternative treatments and their benefits and risks; (d) the
probability of reaching successful outcomes; (e) limits of
confidentiality; (f) financial costs and arrangements; (g) time,
place, setting, and duration of treatment; (h) therapist training,
qualifications, and theoretical orientation; (i) the procedure for
handling grievances; (j) emergency procedures; (k) a statement that
any questions about procedures will be answered at any time; and (1)
a statement that therapy can be discontinued at any time (Andrews,
1984; Annas, 1983; Appelbaum et al., 1987; Beeman & Scott, 1991;
Everstine et al., 1980; Haas, 1991; Handelsman & Galvin, 1988; Hare-
Mustin et al., 1979; Kovacs, 1984).
Although an extensive literature exists that suggests informed-
consent content, less is known about client preferences. This
omission is important because the reasonable person doctrine is the
current judicial standard of disclosure (Gillett, 1989; Meisel, Roth,
& Lidz, 1977), and because this standard is based on clients assumed
13


needs for information as a basis for making informed decisions.
Thus, there is a need for research to determine information needs of
various populations. Despite this need, no published studies have
investigated client preferences for informed consent information
(Bremer & VandeCreek, 1991) and empirical studies on the timing of
obtaining informed consent are scarce (Lidz et al., 1984).
Research on Informed Consent
Much of the research on informed consent has focused on the
issues of whether informing clients of the limits of confidentiality
affects client disclosure or whether informed consent hinders
treatment in some way. Most of this published research has shown
that informed consent neither harms the therapeutic relationship nor
negatively affects disclosure (Handelsman, 1990; Handelsman & Martin,
1992; Haut & Meuhleman, 1986; Meuhleman, Pickens, & Robinson, 1985;
Sullivan, Martin, & Handelsman, 1993). Haut and Muehleman (1986)
assessed the effect that specificity and clarity of pretherapy
information had on client disclosure. They found that when the
limits to confidentiality were conveyed in a clear and specific
manner, there was no decrease in disclosure.
Meuhleman et al. (1985) investigated the effects of providing
varying amounts of detail regarding the limits to confidentiality in
14


a psychotherapy analogue. Mildly depressed participants were offered
an "interview" to explore their depression that was conducted much
like an exploratory single-session therapy. Before the interview,
persons were randomly assigned to read and sign one of three consent
forms: a short form with a minimal amount of information, a long form
with a detailed explanation of limits to confidentiality, and a long
form that included an initial paragraph explaining the importance of
giving honest responses in therapy. Comparisons between the long
form and long form with rationale with the short form failed to
reveal any significant differences; detailed information did not
inhibit disclosure. However, the long form with rationale condition
resulted in more self-disclosure and the reporting of more intense
levels of depression than did the long form without rationale
condition. Overall, there was little evidence that providing more
detailed information had any effect on willingness to disclose.
Moreover, there was evidence that providing a rationale for self-
disclosure within the context of the detailed information may
actually overcome the inhibiting effects that consent has on
disclosure.
A separate avenue of research has indicated that failure to
provide clients with information may actually have a negative impact
on treatment. McGuire, Toal, and Blau (1985) found that mental
15


health clients both valued and expected that their communications
with a counselor will generally be held in confidence, yet few
clients adequately understood confidentiality and its limits.
Consequently, many felt their privacy had been violated during a
counseling relationship. McGuire et al. stated that this
belief/experience can have a significantly negative impact on the
valuing of the concept of privacy in counseling and, as a result,
negatively affect the establishment of trust and the willingness of
the client to disclose personal information in the therapeutic
relationship. Yet as few as one-third of psychologists always tell
their clients about the limits of confidentiality (Baird & Rupert,
1987).
There is little evidence to support the premise that the use of
written forms hinders treatment. Handelsman (1990) assessed the
impact of written consent forms on potential clients first
impressions of therapists. Participants rated a hypothetical
psychologist after reading some combination of a consent form with
questions that clients can ask, a legal disclosure form, or a general
brochure about psychologists. In no case did the presence of consent
materials decrease ratings of therapists and in some cases forms led
to higher ratings of likability, trustworthiness, experience, and
willingness to go to the therapist.. Handelsman and Martin (1992)
16


assessed the influence of written forms that were accompanied by a
sample of actual therapist behavior, and found that men who received
a poorly written consent form had poorer first impressions of the
therapist. In a study that assessed the impact of an informed
consent procedure on first impressions of a therapist by potential
clients, Sullivan et al. (1993) found that participants gave higher
ratings to a therapist who used an informed consent procedure.
Overall, although a poorly written form may lead to less favorable
impressions of the therapist, a readable consent form enhances first
impressions.
These findings are similar to those of Epperson and Lewis
(1987) who found that explicit pretherapy information enabled
subjects to form a more complete picture of the counselor and her
orientation, and to those of Scott (1989) who found that detailed,
explicit information enhanced participants knowledge of counseling.
Walter and Handelsman (1993) assessed whether initial perceptions of
a therapist are influenced by the amount of specific information
conveyed in an informed consent process. When the therapist used
specific dialogue to explain the information contained on a consent
form, participants rated the therapist as more trustworthy and more
expert.
One area of research that has received little attention is that
17


of the timing of informed consent information. Miller and Thelen
(1986) asked participants from four populations (high school
students, college students, former clients from a community mental
health center, and former clients from a university counseling
center) when they would prefer to be told that a situation is not
confidential. Across all groups, 46% indicated a preference to be
told before therapy begins, 4% during the first session, 18% when the
special situation is discussed, and 29% at all three times.
Significantly more subjects from the client groups than subjects from
the groups who had no previous therapy prefer to be informed of the
limitations to confidentiality when the special situation is
discussed.
In the first empirical study of consumer preferences for
information, 173 mothers of elementary school children were surveyed
about therapy for their children (Jensen et al., 1991). The mothers
were asked to rate how important it would be for them to receive
information about 17 informed consent items. Overall, mothers placed
a strong emphasis on discussion of therapeutic benefits, limits of
confidentiality, fee structuring, and iatrogenic risks. Jensen et
al. also examined the effect that parent characteristics (such as
their attitudes toward therapy, previous therapy experience, marital
status, education) had on their desire for discussion of these items.
18


The results indicated that differential informed consent disclosure
may be indicated at times to meet consumers specific needs. For
example, divorced parents in the study placed emphasis on information
about therapeutic benefits addressing concerns that were salient to
their roles as single parents (i.e., child-parent relationship issues
and parenting skill issues).
Parents in the Jensen et al. study were not actual therapy
consumers and may have been somewhat limited in demographic
representativeness. Also, their study did not investigate adult
preferences for their own therapy information, only preferences
regarding information for their children.
Braaten, Otto, and Handelsman (in press) assessed the
information people want about psychotherapy and assessed the effects
of therapy experience and prior exposure to a written consent form on
preferences for information using a sample of 108 college students,
half of whom were "primed with the Handelsman and Galvin (1988)
informed consent form. All participants answered the following
question: "What is the MOST IMPORTANT information you would need to
know when deciding to go into therapy with a psychologist? That is,
what would you like to be told by a therapist before you make a
decision about him or her?" Nine categories emerged from a content
analysis of the resultant responses: (a) therapye.g., "What types
19


of therapy do they practice?" and "Will they talk, give examples and
advice?"; (b) financial arrangements; (c) appointments; (d)
alternatives; (e) confidentiality; (f) therapist experience; (g)
therapist education; (h) therapist credentials; and (i) personal
characteristics of the therapist.
Results were consistent with the.Jensen et al. (1991) study in
that participants reported wanting to know a variety of information.
Overall, the most frequently requested information concerned the
personal characteristics of the therapist, followed by the
therapists experience, and therapists credentials. The least
frequently requested information concerned appointments, alternatives
to treatment, and confidentiality. Participants exposed to the'
written consent form were more likely to ask about confidentiality
and financial arrangements, and, if they had not had previous therapy
experience, were less likely to ask about personal characteristics of
the therapist.
Purpose of Current Study
There is a need to investigate psychotherapy information wants
and needs of populations with different characteristics from those of
the Jensen et al. (1991) and Braaten et al. (in press) studies.
Because non-clinical populations have been used for much of the
20


research on informed consent, there is also a need to determine
whether clinical and non-clinical populations are equivalent. The
present study included three groups of participants: persons who are
in therapy, persons with previous therapy experience, and persons
with no therapy experience.
This study looked at a variety of client and non-client
characteristics. Demographic information included gender, age,
ethnic background, relationship status, and previous therapy history.
Clinical characteristics included attitudes toward therapy,
depression, anxiety, and history and risk for eating disorders.
The following issues were explored by this study.
(1) In general, what information is most important or least
important to receive? Is there certain information that clients do
not want to know? Does this information vary in regard to group
membership (e.g., current clients, former clients, depression,
anxiety, etc.)? These empirical data regarding consumers
informational desires could offer potential general guidelines for
informed consent disclosure practices.
(2) When is the best time to receive certain information and
does this change according to group membership?
The following specific results were hypothesized.
(1) Participants with therapy experience will have
21


significantly more positive attitudes toward therapy. This finding
would replicate the results reported by Fischer and Turner (1970).
(2) The clinical population will have significantly higher
scores on measures of depression, anxiety, and eating disorders,
indicating more pathology.
(3) Participants who are currently in therapy will rate the
more salient aspects of therapy, specifically financial arrangements,
and confidentiality, more important than participants who are not in
therapy. Participants who have been or are in therapy will rate the
"personal characteristics of the therapist" as being more important
than participants who have not been in therapy; these findings would
be consistent with Braaten et al. (in press).
(4) Participants with less positive attitudes toward therapy
will place less emphasis on the risks of therapy, partially
replicating the Jensen et al. (1991) study.
(5) Participants who are depressed will place less overall
emphasis on informed consent information than participants who are
not depressed. This would be consistent with data showing that
depressed individuals display a greater cognitive impairment than
normal controls on tasks that require effortful processing
(Henderson, 1987; Raskin, Friedman, & DiMascio, 1982; Roy-Byrne,
Weingarten, Bierer, Thompson, & Post, 1986).
22


CHAPTER II
METHOD
Participants and Procedure
Participants were recruited from the current patient
populations of clients at the Student Counseling Center, the
Counselor Training Center, and from three introductory psychology
classes at the University of Colorado at Denver. Participation was
solicited from all new clients at the Student Counseling Center and
the Counselor Training Center. This resulted in approximately 60
solicitations at the Student Counseling Center over a four-month
period and approximately 20 solicitations at the Counselor Training
Center over a two-month period.
At both counseling centers, clients were given an introductory
letter soliciting participation in the study; clients responding
affirmatively were given a consent form. After signing the consent,
participants were given a packet of questionnaires that they were
instructed to complete at their leisure and then return to the
counseling center office. Participants from the psychology classes
were given a similar introductory letter and consent form. After
signing the consent form, participants were given the packet of
questionnaires and completed the questionnaires during class time.
23


Students from the psychology classes who agreed to participate were
given extra credit for their participation.
A total of 124 surveys were completed from three distinct
groups. Group one consisted of thirty-five participants (9 males, 26
females) who were current therapy clients. Group two consisted of 47
students (19 males, 28 females) who have had previous therapy
experience. Group three consisted of 42 students (24 males, 18
females) who had no previous therapy experience.
Instruments
Six questionnaires were used in this study. In the first
questionnaire (see Appendix A), participants supplied demographic
data including age, gender, ethnic background, and
marital/relationship status. In addition, participants responded to
questions about prior therapy experience and were asked to rate their
experience with their therapist on a seven-point Likert scale ranging
from extremely negative through neutral to extremely positive.
Participants from the counseling centers were also asked to rate
their experience with their present counselor and to provide
information about how many sessions they had received at the
counseling center.
24


Informed Consent Questionnaire
The second questionnaire consisted of 27 informed consent items
(see Appendix B). The items on this survey were generated from the
literature (Andrews, 1984; Annas, 1983; Beeman & Scott, 1991; Braaten
et al., in press; Everstine et al., 1980; Handelsman & Galvin, 1988;
Hare-Mustin et al., 1979; Jensen et al., 1991; Kovacs, 1984). Items
on this scale include the benefits and risks of therapy, information
about therapeutic methods and alternatives, information about the
therapist (personal and professional), the limits of confidentiality,
financial arrangements, and other information that therapists are
legally required to provide in Colorado. Participants rated how
important it would be for them to receive this information, using a
six-point Likert scale ranging from extremely unimportant to
extremely important. In addition, participants were asked when they
would prefer to receive this information, using the following scale:
(1) Never: (2) Even before the first therapy session: (3) During the
first therapy session: and (4) Sometime after the first therapy
session.
Attitudes Toward Seeking Professional Psychological Help Scale.
Participants also completed the Attitudes Toward Seeking
Professional Psychological Help Scale (ATSPPH; Fischer & Turner,
25


1970, see Appendix C). The ATSPFH is a 29-item inventory assessing
individuals attitudes toward psychotherapy. The authors purpose
for this scale was to "clarify an attitude and personality domain
which applies to ones tendency to seek or to resist professional aid
during a personal crisis" (Fischer & Turner, 1970, p. 79). Higher
scores indicate more positive attitudes toward therapy. High scorers
generally acknowledge the possibility of seeking professional
support, have faith in practitioners, and are more willing to reveal
troubles to an appropriate professional. Low (negative) scorers see
little necessity for professional help for emotional problems,
believing that psychological conflicts resolve themselves. The
internal reliability of the scale was .86 with a two-month test-
retest of .84. The scale reliably distinguished persons who had
experienced psychotherapeutic help from those without such
professional contact (p < .0001), and womens help-seeking attitudes
were consistently more positive than mens (p < .0001).
Psychosocial Inventories.
In order to examine how patient pathology may affect peoples
preferences for information, participants were asked to complete the
Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, &
Erbaugh, 1961; see Appendix D), the Spielberger State-Trait Anxiety
26


Inventory (STAI; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983;
see Appendix E), and the Eating Attitudes Test (EAT; Gamer &
Garfinkel, 1979; see Appendix F). The BDI is a widely-used 21-item
self-report measure used to assess the presence of symptoms
associated with depression. Participants responded in terms of how
they had been feeling over the past two weeks.
Like the BDI, the STAI has also been used extensively in
research. It comprises separate self-report scales for measuring
state and trait anxiety. The state anxiety scale (A-State) measures
situationally determined feelings of tension and apprehension that
vary over time. The trait anxiety scale (A-Trait) measures
individual differences in the tendency to experience anxiety states
in general, and is suggestive of fearfulness in a variety of social-
interpersonal situations. A-state tends to fluctuate as a function
of transitory stresses and is indicative of a persons current
anxiety whereas A-trait reflects long-term learning and adjustment
processes associated with anxiety proneness. For this study, the
State-Anxiety scale (STAI Form Y1) was used. Higher scores indicate
higher levels of anxiety.
The EAT is a 44-item scale that assesses a persons risk for
eating disorders; the EAT is a valid index of symptoms frequently
observed in anorexia nervosa. Cross-validation procedures revealed
27


the scales predictive validity to be consistent across two
independent samples of patients and controls (Gamer ftGarfinkel,
1979). Higher scores indicate more severe symptoms.
28


CHAPTER III
RESULTS
A total of 52 men and 72 women participated in this study. The
median age of client participants (Group 1) was 26 years with an age
range of 18 to 48 and the mean number of therapy sessions was 8.85.
The median age of participants who were previously, but not
presently, in therapy (Group 2) was 21 years with an age range of 18
to 53 and the mean number of therapy sessions was 17. The median age
of participants who have had no therapy experience (Group 3) was 20,
with an age range of 17 to 35. An ANOVA showed that groups differed
significantly in age, F (2,121) = 10.04, p < .001. Duncans Multiple
Range tests revealed that Group 1 was significantly older than Groups
2 and 3, and Group 2 was significantly older than Group 3, p < .05.
Participants in Group 1 rated their recent experiences with
their therapists very highly (M = 6.00 on a 7-point scale). Of the
35 participants in this group, 15 had previous therapy experience.
They rated their previous experiences in therapy fairly neutrally (M
= 4.87, 4 = neutral, 7 = extremely positive). Participants in Group
2 rated their previous therapists similarly (M = 4.62). This
difference was not significant. Table 1 contains selected
demographic statistics and group means obtained from
29


the questionnaires.
Table 1: Group Characteristics and Means on ATSPPH. BDI. SAI. EAT
Characteristic Group 1 (n=35 V Group 2 (n=47) Group 3 (n=42)
M M M
Age (years) 29.05 24.91 21.78
ATSPPH 66.14 53.70 49.34
BDI 12.77 9.31 8.59
SAI 47.17 40.93 38.70
EAT 18.81 13.54 11.95
Marital Status (% sample)
Married 20.00 19.10 11.90
Divorced 22.80 10.70 00.00
Widowed 00.00 00.00 00.00
Living Together 17.10 8.50 11.90
Single 40.00 61.70 76.20
Ethnic Background
Hispanic 2.90 14.90 11.90
Black 00.00 6.40 00.00
Native Amer. 00.00 4.30 00.00
Asian 5.70 4.30 23.80
White 91.00 70.00 62.00
Males 9 19 24
Females 26 28 18
Group Differences on ATSPPH. BDI. STAI. and EAT
Overall, participants demonstrated fairly positive attitudes
toward therapy, as measured by the ATSPPH scale (M = 55.78, SD =
30


12.38). An ANOVA revealed that groups differed significantly in
regard to their attitudes toward therapy, F (2,120) = 26.02, p <
.001. Duncans Multiple Range tests revealed that current clients
demonstrated significantly (p < .05) more positive attitudes toward
therapy (M = 66.14) than did previous clients (M = 53.70) or college
students with no therapy experience (M 49.32). The later two
groups did not differ significantly.
Group differences on the BDI, STA1, and EAT were investigated
with multivariate analyses of variance (MANOVA) designs. Significant
multivariate F statistics were subsequently investigated with
analysis of variance (ANOVA) designs. Duncans multiple range test
was used as a post hoc test when appropriate. All reported Duncans
tests were significant at the .05 level.
Differences between groups on the BDI, STAI, and EAT were
examined using a MANOVA. This analysis showed that groups differed
significantly on scores on these measures (using Pillais criterion),
F (2,120) = 2.79, p < .025. The univariate ANOVA revealed that
groups differed significantly on the BDI, F (2,120) = 4.54, p < .01.
Post hoc tests demonstrated that participants in Group 1 were
significantly more depressed than either Groups 2 and 3. Similarly,
the univariate ANOVA revealed that groups also differed significantly
on the STAI, F (2,120) = 4.60, p < .01, with Group 1 significantly (p
31


< .05) more anxious than either Groups 2 and 3. A final ANOVA
revealed that groups differed significantly on the EAT, £ (2,113) =
4.11, p < .01, and again current clients were significantly (p < .05)
different than groups 2 and 3, with the client group showing more
symptoms of eating disorders. The group means for the BDI, STAI, and
EAT are presented in Table 1.
Informed Consent Ratings
Participants rated 27 informed-consent items in terms of
perceived importance for inclusion in informed consent discussions on
a six-point Likert-type scale ranging from 1, extremely unimportant.
to 6, extremely important. These items, along with their mean '
importance ratings, are presented in descending order of importance
for Group 1 in Table 2.
Across all groups, information about inappropriate therapeutic
techniques, confidentiality, the therapists credentials, and
theright to a second opinion were rated most important. Information
about the date of the therapists degree, the procedure for
scheduling appointments, the procedure for handling grievances, and
the personal characteristics of the therapist were rated least
important in terms of disclosure. These results differed in some
respects from the Braaten et al. (in press) study that found that
32


Table 2: Importance Ratines and F Ratios for Informed
Consent Items bv Groups
Item G1 Means G2 G3 F(2,121)
There are certain techniques that are inappropriate when used in therapy. 5.43 5.36 5.07 N.S.
Typically, everything discussed in therapy is confidential, except for a few certain cases. 5.29 5.44 5.02 N.S.
The risks of alternative treatments. 5.20 4.60 4.33 N.S.
Therapy may help with problems that are too serious to cope with alone. 5.11 5.09 4.57 3.86*a
In some situations confidentiality may need to be broken. 5.11 5.37 4.79 3.14*b
Therapy may provide a supportive environment in which to discuss personal problems and concerns. 5.11 4.81 4.34 4.73**a
"You have a right to a second opinion." 5.06 5.15 4.79 N.S.
The therapists area of specialization. 5.06 5.02 4.88 N.S.
How to contact the therapist in an emergency. 5.00 4.91 4.67 N.S.
What methods or techniques will be used in the counseling process. 4.94 4.85 4.74 N.S.
The therapists education. 4.86 5.04 4.86 N.S.
The therapists credentials. 4.80 5.39 5.40 4.22**c
33
(Table continues.)


Table 2. continued
The financial cost of therapy. 4.74 4.87 4.67 N.S.
"Your problems may get worse." 4.69 5.39 4.69 5.49**d
The risks of not seeking treatment. 4.74 4.62 4.45 N.S.
The possible risks of treatment. 4.60 5.17 4.71 3.54*d
How often therapy sessions will be scheduled. 4.69 4.46 4.19 3.37*e
The therapists years of experience. 4.54 4.66 4.57 N.S.
The length of each individual session. 4.51 4.40 4.21 N.S.
How appointments are scheduled. 4.49 4.28 4.10 N.S.
Alternative treatments that may work. 5.20 4.63 4.34 7.43**c
"Therapy may not work." 4.37 4.57 4.62 N.S.
How long treatment might take. 4.34 4.89 4.52 N.S.
The procedure for discontinuing therapy. 4.31 4.45 4.44 N.S.
The procedure for handling grievances. 4.31 4.51 4.24 N.S.
The personal characteristics of the therapist. 3.14 3.00 3.29 N.S.
The date of the therapists degree. 3.00 3.19 3.38 N.S.
a Groups 1 and 2 differed significantly from Group 3 on
Duncans Multiple Range test.
b - Group 2 differed significantly from Group 3.
c - Group 1 differed significantly from Group 2 and 3.
d - Group 2 differed significantly from Groups 1 and 3.
e - Group 1 differed significantly from Group 3.
*p < .05. **p < .01.___________________________________________
34


participants placed the highest value on information about the
personal characteristics of the therapist and the lowest value on
appointments, alternatives, and confidentiality.
The effects of group membership (i.e., current clients, former
clients, never clients), attitudes toward therapy, anxiety,
depression, and risk for eating disorders on importance ratings were
investigated with MANOVA designs; significant multivariate F
statistics were subsequently investigated with ANOVA designs. When
appropriate, Duncans Multiple Range tests were used as post hoc
tests. Of 135 contrasts, using 5 independent variables (three levels
of group membership, and median splits on the BDI, ATSPPH, SAI, and
EAT) and 27 dependent ratings, only 11 (8.15%) achieved statistical
significance. To preserve clarity and relevance, only those F-ratios
achieving statistical significance will be reported and described.
Scores on the BDI and EAT had no effect on importance ratings;
however, there was an effect for group membership, attitudes toward
therapy, and the STAI. Results of the effect of group membership are
presented in Table 2. The groups differed on 8 out of 27 items.
Within Group 1, information about inappropriate therapeutic
techniques, confidentiality, the risks of alternative treatments, and
the statement that therapy may help with problems that are too
serious to cope with alone were rated most important. Information
35


about the date of the therapists degree, the procedure for
scheduling appointments, the procedure for handling grievances, and
the personal characteristics of the therapist were rated least
important in terms of disclosure.
Within Group 2, information about confidentiality, the
therapists credentials, and inappropriate therapeutic techniques
were rated most important. The personal characteristics of the
therapist, the date of the therapists degree, the length of each
individual session, and the procedure for handling appointments were
rated least important. Across all groups, all items were rated
somewhat important or higher, except for The personal characteristics
of the therapist and The date of the therapists degree, which were
rated somewhat unimportant or lower. Sixty percent of participants
gave The personal characteristics of the therapist a rating of
somewhat unimportant or below.
Attitudes toward therapy had minimal effect on participants
importance ratings. Participants demonstrating more positive
attitudes toward therapy (i.e., placing in the upper half of a median
split of ATSPFH scores, Median = 55) rated disclosure about Therapy
is a supportive environment in which to discuss personal problems and
concerns as being more important (M = 5.00) than did participants
demonstrating less positive attitudes toward therapy M = 4.50, F
36


(1.121) =8.22, p < .01. Participants demonstrating more positive
attitudes toward therapy also rated How to contact therapist in an
emergency as being more important (M = 5.05) than participants
demonstrating less positive attitudes toward therapy, M = 4.65, F
(1.121) = 5.41, p < .02.
To get an overall indication of how important participants felt
these informed consent items were, the total importance rating scores
were examined. Participants who were more anxious (i.e., placing in
the upper half of a median split of SAI, Median = 39) had
significantly lower composite scores (M = 128.39) than participants
who were less anxious, M = 122.39, t (120) = 2.12, p < .05. There
were no significant total importance rating differences for group
membership or attitudes toward therapy.
The Timing of Informed Consent Information
Participants were also asked to specify when within the therapy
process they would prefer to receive information about these 27
informed consent items, using a scale from 1, Even before the first
therapy session, to 4, Never. The effect of group membership,
depression, anxiety, attitudes toward therapy, and risk for eating
disorders on the timing of these items were similarly investigated.
Of 135 contrasts, using 5 independent variables (group membership,
37


BDI, ATSPPH, SAI, and EAT) and 27 dependent ratings, 17 (12.59%)
achieved statistical significance. Lower mean values on these items
represented an earlier desire for information; higher mean values
represented a later desire for information.
The EAT, BDI, and ATSPPH had no effect on the timing of
informed consent information. However there were main effects for
anxiety and group membership.
Of the 27 items rated by the three groups, 10 ratings (37%)
were significantly different. The results are presented in Table 3.
In 9 out of 10 cases, Group 1 rated these items later in terms of
disclosure. In the one case where former clients preferred
information earlier in treatment than current clients, the post'hoc
comparison was not significant. In this case, former clients rated
The personal characteristics of the therapist significantly later
than participants with no therapy experience.
Participants who demonstrated more anxiety rated Therapy mav
not work [Ms = 2.01, 1.53, F (1,121) = 10.07, p < .00], In some
situations confidentiality may need to be broken [M = 1.71, 1.43, F
(1,121) = 4.21, p < .04], and The therapists education [M = 1.66,
1.30, F (1,121) = 6.20, e < *01] later than participants
demonstrating less anxiety. Participants demonstrating more anxiety
rated Alternative treatments that mav work for you earlier (M = 1.95)
38


TABLE 3: Ratings and Group Differences on the Timing of Informed
Consent Information_______________________________________________
Item Means
G1 G2 G3 F(2.1211 P
The financial cost of therapy. 1.37 1.21 1.14 N.S.
The length of each individual session. 1.40 1.60 1.50 N.S.
How appointments are scheduled. 1.43 1.55 1.48 N.S.
The therapists education. 1.51 1.45 1.50 N.S.
The therapists credentials. 1.57 1.21 1.14 5.26** .01
There are certain techniques that are inappropriate when used in therapy. 1.60 1.43 1.33 N.S.
The therapists area of specialization. 1.63 1.45 1.33 N.S.
Typically, everything discussed in therapy is confidential, except for a few certain cases. 1.71 1.51 1.55 N.S.
In some situations confidentiality may need to be broken. 1.74 1.43 1.60 N.S.
Therapy may provide a supportive environment in which to discuss personal problems and concerns. 1.80 1.80 1.31 8;80*** .01
The therapists years of experience. 1.83 1.47 1.43 N.S.
The possible risks of treatment. 1.86 1.68 1.52 N.S.
(Table continues.)
39


Table 3. continued
Therapy may help with problems
that are too serious to cope
with alone. 1.86 1.70 1.55 N.S.
"You have a right to a second opinion." 1.86 1.74 1.76 N.S.
What methods or techniques will used in the therapy process. be 1.91 1.72 1.52 N.S.
How to contact the therapist in emergency. an 1.91 1.89 1.76 N.S.
The risks of not seeking treatment. 1.97 1.83 1.67 N.S.
How often therapy sessions will scheduled. be 2.00 2.02 1.50 N.S.
The procedure for handling grievances. 2.09 2.09 1.76 N.S.
"Your problems may get worse" 2.20 1.83 1.67 5.34** .01
"Therapy may not work." 2.06 1.81 1.50 4.15* .02
Alternative treatments that may work for you. 2.26 2.21 1.79 4.45*** .01
The risks of alternative treatments. 2.31 2.23 1.73 5.00*** .01
How long treatment might take. 2.57 2.28 1.67 13.48*** .01
The procedure for discontinuing therapy. 2.71 2.26 1.93 7.93** .01
Personal characteristics of the therapist. 2.86 3.06 2.45 3.67* .05
(Table continues.)
40


Table 3. continued
The date of the therapists
degree. 2.89 2.55 2.21 3.00* .05
Group 1 is significantly different from Group 3.
Group 1 is significantly different from Groups 2 and 3.
Groups 1 and 2 are significantly different from Group 1.
than participants demonstrating less anxiety, M = 2.23, F (1.121) =
3.78, p = .05.
To get an overall indication of how participants differed in
regard to the timing of informed consent information, the total
timing of information scores were examined. Higher composite scores
indicate a later desire for information. The composite score for
participants with more positive attitudes toward therapy (M = 50.03)
was significantly later than the composite score for participants
with less positive attitudes toward therapy, M = 46.09, t (119) =.-
2.01, p < .05. The composite scores for current and former clients
(M = 52.91, 48.65, respectively) was significantly later than for
participants with no therapy experience, M = 43.56, F (2,119) = 7.82,
2 < .01. There was a trend for depression. Participants who were
more depressed had higher composite scores (M = 50.05) than those who
were less depressed, M = 46.28, t (120) = -1.93, p < .056.
41


The Effects of Personal Characteristics
Participants personal characteristics (gender, ethnicity, and
age, Median = 21.2) on the overall importance and the timing of
informed consent information were investigated with MANOVA designs.
Significant multivariate F statistics were subsequently investigated
TABLE 4: Gender Differences in Importance Ratings.
Item Means
Alternative treatments that may Males (n=52) Females (n=72) F(1,122)
work for you. How to contact the therapist in an 4.42 4.89 6.45*
emergency. How often therapy sessions will be 4.48 5.13 15.16**
scheduled. 4.21 4.58 5.77*
The length of each individual session. There are certain techniques that are 4.17 4.51 4.58*
inappropriate in therapy. *p < .05 **p < .01 4.96 5.51 8.15**
with ANOVA designs. Of 81 contrasts using three independent
variables (gender, 5 levels of ethnicity, median split on age) and 27
importance ratings, 16 (19.75%) achieved statistical significance.
Of 81 contrasts using three independent variables and 27 timing
ratings, 11 (10.19%) achieved statistical significance. There was an
effect for gender on importance ratings, and effects for ethnicity on
42


importance ratings and timing ratings.
Differences due to gender are presented in Table 4. On each of
these items, womens importance ratings were significantly higher
than mens. However, womens total scores were not significantly
higher than mens total scores.
TABLE 5: Ethnic Differences on the Importance of Informed Consent
Information________________________________________________________
Item F(5,118) E
The possible risks of treatment. Asians differed significantly (M = 4.07) from Whites (M = 4.96) and Hispanics (M = 5.15). 2.47 .05
Therapy may help with problems that are too serious to cope with alone. Asians (M = 4.43) differed from Hispanics (M = 5.31). 2.41 .05
Typically everything in therapy is confidential, except for a few certain cases. Asians (M = 4.64) differed from Whites (M = 5.30), Hispanics (M = 5.38), and Blacks (M = 6.00). 3.05 .02
The effect of ethnic background on importance ratings are
presented in Table 5. Of the results reported in Table 5, post hoc
tests showed that Asians differed from one or more groups. In
everycase Asians rated these items as less important than the other
groups.
43


The effect of ethnic background on participants ratings on the
timing of information are presented in Table 6. Results of post hoc
TABLE 6: Ethnic Differences on the Timing of Information Informed Consent
Item F(5,118) £
The financial cost of therapy. Asians differed significantly (M = 2.07) from Blacks (M = 1.08) and Hispanics (M = 1.08) 4.52 .001
The possible risks of treatment. Asians differed significantly (M = 2.36) from Hispanics (M = 1.54) and Whites (M = 1.56). 4.07 .01
The length of each individual session. Asians (M = 2.07) differed from Hispanics (M = 1.38) and Whites (M = 1.41). Blacks (M = 2.33) differed from Whites. 3.61 .01
In some situations confidentiality may need to be broken. Asians (M = 2.14) differed from Blacks (M = 1.00) and Whites (M = 1.64). 5.14 .001
comparisons are difficult to interpret; however, in all cases
the"Asian/Pacific Islander" group is significantly different from one
or more groups. In each of those cases, Asians reported wanting that
particular information later in the therapy process. An ANOVA was
performed to determine whether these differences were due to ethnic
differences in attitudes toward therapy. There were no differences
between groups on attitudes toward therapy, F (4, 117) = .84, p = .50.
44


Specific Analysis on Current Client Participants
Because participants who were currently in therapy differed in
many ways from the other two groups studied, all of the previously
described analyses were completed on Group 1. Most of the results
were not significant and could have been affected by the small number
of participants in Group 1. However, more anxious clients had
higher (later) total scores for the timing of information (M = 56.31)
than less anxious clients M = 48.87, t (33) = -2.56, p < .02.
45


CHAPTER IV
DISCUSSION
A lack of standard practice (Baird & Ruppert, 1987; Pope et
al., 1987) and specific guidelines regarding informed consent content
combined with a "reasonable person standard of disclosure indicates
a need for research investigating clients informational preferences.
This study presented 27 informed consent items to current clients,
previous clients, and persons without therapy experience, and
investigated the importance of including these items in an informed
consent discussion. This study also investigated when participants
would prefer to receive this information. Participants ratings of
the importance and the timing of information were analyzed to
determine if they varied as a function of group membership,
depression, anxiety, risk for eating disorders, and other demographic
characteristics.
In addition to examining preferences for informed consent
information, this study analyzed how client groups differed from non-
client groups on a variety of measures, indicating significantly
higher levels of depression, anxiety, and eating disorders in the
client group. The client sample also showed significantly more
positive attitudes toward therapy as measured on the ATSPIFH than the
46


other two groups, replicating the results of Fischer and Turner
(1970). These findings confirmed hypotheses #1 and 2 and have
implications for research. Much of the research on informed consent
has been performed on non-clinical samples, yet these samples are not
representative of client populations on a number of important
measures. Thus there is a need to include clinical samples in
research on informed consent.
In answer to Question #1 (What information is most important or
least important to receive?), participants in this study rated most
of the items highly, indicating that both clients and non-clients
value the information that is conveyed during an informed consent
process. This is consistent with other studies that showed that
consumers consider this information valuable (Braaten et al., in
press; Jensen et al., 1991). Two of the items on the informed
consent questionnaire, The date of the therapists degree, and The
personal characteristics of the therapist, had means of somewhat
unimportant or below, indicating that there may be a few items that
are not considered important for inclusion in an informed consent
process.
The clinical sample rated information about inappropriate
therapeutic techniques, confidentiality, the risks of alternative
treatments, and statements that therapy may help with problems that
47


are too serious to cope with alone and therapy may provide a
supportive environment as most important. These items are congruent
with the suggestions of professionals in the literature. Common
themes in these highly rated items are: (a) they set the boundaries
for therapy, and (b) they provide information about some of the most
important benefits of therapy.
The client sample rated information about the personal
characteristics of the therapist, the procedures for handling
grievances and discontinuing therapy, and the date of the therapists
degree as least important. The Group 1 means for all the items,
except for Personal characteristics of the therapist and Date of
therapists degree, were rated somewhat important or above.
Therefore, with only two exceptions, clients want to know about all
of the topics that can be covered in an informed consent process,
while they particularly want reassurance about the benefits of
therapy and want to know the "rules" of therapy in regard to
confidentiality and inappropriate techniques.
In answer to question #2 (When is the best time to receive
certain information?), the items that the clinical sample wanted
earliest in therapy differed from the items rated most important.
They rated information about the financial cost of therapy, the
length and scheduling of sessions, and the therapists credentials
48


and education as items that they would prefer to have covered
earliest in therapy. This shows that the information that is
considered most important is not necessarily the information that
needs to be covered first. Instead, clients first want to know how
much therapy will cost, whether the therapist has the appropriate
credentials, and how sessions are scheduled. The means for three of
these items, The financial cost of therapy. The length of each
individual session, and How appointments are scheduled, indicate a
preference for this information even before the first therapy
session. It is likely that potential clients need to know that they
can afford therapy and schedule convenient appointments before they
can commit to the process. Once they have made the commitment to
begin therapy, other issues become more important and relevant.
Most of the items that clients preferred latest in therapy,
such as the date of the therapists degree and personal
characteristics of the therapist were also rated less important. The
reason that clients preferred other items, such as how long treatment
might take and the procedure for discontinuing therapy, later in
therapy may be because these issues are more relevant later in
therapy. These data provide evidence for a process model of informed
consent. There is certain information that becomes more important,
and therefore needs to be presented, at different times during the
49


therapy process.
The current client group differed significantly from the other
groups, rating information about the therapists credentials as less
important and information about alternative treatments and the
frequency of therapy sessions as more important. They did not, as
predicted in hypothesis #3, rate financial arrangements or
confidentiality as more important. A possible reason for the
relative lack of interest in financial arrangements may come from the
fact that this particular client sample pays little, or nothing, for
therapy.
It was also hypothesized (#3) that current or previous therapy
clients would rate information about the personal characteristics of
the therapist as being more important than participants with no
therapy experience, replicating the Braaten et al. (in press) study.
This was not the case. In fact, while Braaten et al. found that the
personal characteristics of the therapist was the most frequently
requested informational category, this study found the opposite.
Participants in all groups rated this as one of the least important
topics to include. The differences in the results could be due to
the fact that this study had participants respond to a list of topics
rather than to an open-ended question. It is possible that people
are not aware of the wide variety of information to which they are
50


entitled. Thus, when they are asked to report spontaneously what
information is important, they focus on information about the
personal qualities of the therapist. However, information about the
therapists personal characteristics becomes much less important when
participants are presented with a wide range of information. This is
consistent with an effect found by Braaten et al. in which
participants without therapy experience who were exposed to a written
consent form were less likely to ask about personal characteristics
of the therapist.
Former clients placed more emphasis on some of the risks of
therapy by rating In some situations confidentiality may need to be
broken. Your problems may get worse, and The possible risks of
treatment more important than one or more of the other groups. It is
possible that former clients have had more experience with some of
the potential problems inherent in therapy and are therefore more
aware of the importance of being informed of these risks. It is
interesting that although it has been suggested that clinicians may
withhold information about treatment risks because of concerns about
potential negative effects on clients (Handelsman et al., 1986; Noll
& Haugen, 1985), people who have been through the therapy process
value that information.
The groups also differed on when they would prefer to receive
51


this information, with current and former clients preferring much
information a little later in the therapy process. Again, this
points out the danger in using non-clinical samples to draw
conclusions. If only a non-clinical sample had been used in this
study, the conclusion may have been drawn that the "reasonable
person" prefers much information at the beginning of therapy.
However, although clients value this information, it seems that they
would prefer to hear about it after the therapy process has begun.
It is likely that they are more interested in having their needs
addressed and receiving relief from their symptoms.
This was also true for anxious participants. Participants with
higher levels of anxiety valued the overall information less and
wanted it later in the therapy process. One exception to this was
information about alternative treatments, which anxious participants
wanted earlier in therapy. The effect of anxiety On overall timing
ratings was also true for the client sample alone. More anxious
clients preferred information later in the therapy process. These
data provide evidence for a process model of informed consent. In
practice, therapists should initially provide anxious clients with
legally mandated information and information about available options.
Then, after their anxiety and/or other needs are addressed, clients
can be provided with more comprehensive information.
52


Other than anxiety, the psychosocial measures had little effect
on the ratings of importance and timing of information. Depressed
participants did not differ from non-depressed participants and
participants with less positive attitudes toward therapy did not
place less emphasis on the risks of therapy as predicted in
hypotheses 4 and 5. However, participants with more positive
attitudes toward therapy did rate one of the benefits of therapy
(i.e., therapy is a supportive environment) as being more important.
They also wanted the information a little later in therapy.
Some ratings also differed in regard to gender and ethnicity.
There appears to be certain information that women value more than
men, specifically information about inappropriate therapeutic
techniques, alternative treatments, how to contact the therapist in
an emergency, and the length and frequency of sessions. At least one
of these items (inappropriate techniques) may be more important to
women because they have historically been the victim of inappropriate
therapeutic techniques (Holroyd & Brodsky, 1977).
One of the most surprising findings of this study was in the
area of ethnic differences. Asians appeared significantly different
from other ethnic groups on both the timing and the importance of
information by valuing some items less and preferring some
information later in therapy. They did not differ from other ethnic
53


groups on their attitudes toward therapy. Other data on Asian-
Americans have shown that their views and preferences about therapy
differ from Whites in many important ways. Asian-Americans prefer
directive over non-directive counseling (Atkinson & Matsushita, 1991;
Atkinson, Maruyama, & Matsui, 1978), have a lower tolerance for
ambiguity, and prefer structured situations and immediate solutions
to problems (Sue, 1988). This study is further evidence that
psychologists need to be sensitive to the particular concerns of
Asian-Americans. Obviously, more research needs to be done before
conclusions can be drawn about what to provide Asian-Americans in an
informed consent process.
The results of this study suggest that differential informed
consent disclosure is necessary in order to meet consumers
informational wants and needs. The results also suggest, because
clinical populations differ from non-clinical populations, that the
"reasonable person" standard may be difficult to apply to therapy
clients. The "reasonable" therapy client is anxious and depressed
and may not be ready to confront some of the informed consent issues
that are presented early in the therapy process. If we use non-
clinical samples to draw conclusions about therapy clients we may
overlook important information such as this. Research has shown that
the client-therapist relationship is formed during the first few
54


therapy sessions and is relatively unchangeable after that (Levine &
Herron, 1990; OMalley, Suh, & Strupp, 1983; Saltzman, Leutgard,
Roth, Creaser, & Howard, 1976). Therefore it is extremely important
that the informed consent process and content is relevant and helpful
for the client.
The small sample of clients limits the generalizability of the
results of this study. The study was also limited by the fact that a
relatively homogeneous sample was used. All participants had
affiliations with university services (courses and/or counseling
services), implying a well-educated sample. It can be assumed that
the diversity of illnesses/problems from which the clients sought
treatment was small.
Although the surveys used in this study provided information
regarding depression and anxiety, because of confidentiality
restrictions no information was provided regarding the presenting
problem. It is possible that the presenting problem, which may not
have been measured on any of the scales used, would influence
clients desires for information. In addition, the services provided
at the counseling centers were free or inexpensive, possibly
affecting clients importance ratings. For example, items regarding
scheduling issues and the cost of therapy were rated relatively low,
but scheduling and financial issues may be more important for clients
55


at lower income levels where disruption of family schedules may have
greater financial implications (Graziano & Fink, 1973). One final
limitation is that this study did not survey clients who were at the
very beginning (e.g., before the first session) of the therapy
process. Preferences of persons who have not yet begun therapy may
be quite different from those used in this study. Ultimately these
are the people to whom this information is most important, yet this
information may not be generalizable to them.
While this study was limited in a number of ways, results
indicate that clinical consumers place a high value on ethically and
legally mandated disclosure of information about therapeutic issues.
Future investigations of larger clinical populations with different
characteristics will indicate the extent to which these results are
representative of therapy clients in general.
56


Appendix A
Demographic Data Questionnaire
(Client Version)
1. Sex: _______Male __________Female
2. Age: I am _______ years old.
3. Ethnic Background:
_____Hispanic ___________Black Nat ive American
_____Asian/Pacific Islander White
_____Other
4. Current relationship status:
Married _________Divorced __________Widowed
_____Separated __________Living Together ________Single
5. Have you already begun therapy at the University Counseling
Center? __________YES _________NO
5A. How many counseling sessions have you had at the University
Counseling Center? ____________
5B. I would rate my experience with my therapist at the University
Counseling Center as:
1 2 3 4 5 6 7
Extremely Neutral Extremely
Negative Positive
6. Before coming to the University Counseling Center, were you ever
in therapy with a therapist, psychologist, psychiatrist, or
57


social worker (this does NOT include things like academic
counseling or career counseling)? YES NO
IF YES, PLEASE ANSWER QUESTION 6A AND 6B.
6A. I would rate my experience with this therapist as:
1 2 3 4 5 6 7
Extremely Negat ive Neutral Extremely Positive
6B. How may session were you in therapy (do not include sessions at
the University Counseling Center)?
(Student Version)
1. Sex: ________Male _________Female
2. Age: I am_______ years old.
3. Ethnic Background:
______Hispanic __________Black Nati ve American
______Asian/Pacific Islander White
______Other
4. Current relationship status:
______Married _________Divorced _________Widowed
______Separated _________Living Together _________Single
5. Have you ever been in therapy with a therapist, psychologist,
psychiatrist, or social worker (This does NOT include things
like academic counseling or career counseling)?
58


YES _________NO
IF YES PLEASE ANSWER QUESTION 5A AND 5B.
5A. How many counseling sessions did you have? ________
5B. I would rate my experience with this therapist as:
1 2 3 4 5 6 7
Extremely Negat ive Neutral Extremely Positive
6. Are you currently in therapy? ______YES _________NO
7. Are you currently seeking therapy? ______YES _________NO
59


Appendix B
Informed Consent Questionnaire
Directions: When people go to therapy they are typically given
some information. Some of the things clients may be told about are
presented below. Please rate how important it would be for you to
receive this information by circling the one response that best
reflects you viewpoint. Then rate when you would prefer to receive
this information by checking one response.
Answer Key:
Extremely Very Somewhat Somewhat Very Extremely
Unimportant Unimportant Unimportant Important Important Important
When would you prefer to receive this information?
Never
Even before the first therapy session
______During the first therapy session
______Sometime after the first therapy session
1. The financial cost of therapy.
2. The possible risks of treatment (For example: divorce,
depression).
3. "Therapy may not work."
4. "Your problems may get worse."
5. Therapy may help with problems that are too serious to cope with
alone.
6. Therapy may provide a supportive environment in which to discuss
60


personal problems and concerns.
7. How appointments are scheduled.
8. In some situations confidentiality may need to be broken. (For
example, if you threaten to commit suicide or to harm someone
else, you therapist would be required to notify someone. Also,
your therapist may be required to report you progress to you
insurance company.)
9. What methods or techniques will be used in the counseling
process.
10. Alternative treatments that may work for you (For example:
self-help books, different techniques, support groups).
11. The therapists education.
12. The therapists years of experience.
13. The therapists area of specialization. (For example, the
approach that the therapist is most comfortable with).
14. How to contact the therapist in an emergency.
15. How long treatment might take.
16. How often therapy sessions will be scheduled.
17. The procedure for handling grievances (For example: Who do I
talk to if I have a complaint?)
18. The personal characteristics of the therapist (For example: the
therapists marital status, age, interests).
61


19. The risks of not seeking treatment.
20. The risks of alternative treatments.
21. The procedure for discontinuing therapy.
22. The date of the therapists degree.
23. The therapists credentials (For example: Is the therapist
licensed?)
24. The length of each individual session.
25. There are certain techniques that are inappropriate when used in
therapy (such as sexual contact).
26. "You have the right to a second opinion."
27. Typically, everything discussed in therapy is confidential,
except for a few certain cases.
62


Appendix C
Attitudes Toward Seeking Professional Psychological Help Scale
Directions: Below are a number of statements pertaining to
psychology and mental health issues. Read each statement carefully
and indicate you agreement, probable agreement, probable
disagreement, or disagreement. Please express your frank opinion in
rating the statements. There are no "wrong" answers and the only
right ones are whatever you honestly feel or believe. It is
important that you answer every item.
Answer Kev:
Disagree Probably Disagree Probably Agree Agree
1. Although there are clinics for people with mental trouble, I
would not have much faith in them.*
2. If a good friend asked my advice about a mental problem, I might
recommend that he see a psychiatrist.
3. I would feel uneasy going to a psychiatrist because of what some
people would think.*
4. A person with a strong character can get over mental conflicts by
himself, and would have little need of a psychiatrist.*
5. There are times when I have felt completely lost and would have
welcomed professional advice for a personal or emotional
problem.
63


6. Considering the time and expense involved in psychotherapy, it
would have doubtful value for a person like me.*
7. I would willingly confide intimate matters to an appropriate
person if I thought it might help me or a member of my family.
8. I would rather live with certain mental conflicts than go through
the ordeal of getting psychiatric treatment.*
9. Emotional difficulties, like many things, tend to work out by
themselves.*
10. There are certain problems which should not be discussed outside
of ones immediate family.*
11. A person with a serious emotional disturbance would probably
feel most secure in a good mental hospital.
12. If I believed I was having a mental breakdown, my first
inclination would be to get professional attention.
13. Keeping ones mind on a job is a good solution for avoiding
personal worries and concerns.*
14. Having been a psychiatric patient is a blot on a persons life.*
15. I would rather be advised by a close friend than by a
psychologist, even for an emotional problem.*
16. A person with an emotional problem is not likely to solve it
alone; he is likely to solve it with professional help.
17. I resent a person professionally trained or not who wants to
64


know about my personal difficulties.*
18. I would want to get psychiatric attention if I was worried or
upset for a long period of time.
19. The idea of talking about problems with a psychologist strikes
me as a poor way to get rid of emotional conflicts.*
20. Having been mentally ill carries with it a burden of shame.*
21. There are experiences in my life I would not discuss with
anyone.*
22. It is probably best not to know everything about oneself.*
23. If I were experiencing a serious emotional crisis at this point
in my life, I would be confident that I could find relief in
psychotherapy.
24. There is something admirable in the attitude of a person who is
willing to cope with his conflicts and fears without resorting
to professional help.*
25. At some future time I might want to have psychological
counseling.
26. A person should work out his own problems; getting psychological
counseling would be a last resort.*
27. Had I received treatment in a mental hospital, I would not feel
that it ought to be "covered up."
28. If I though I needed psychiatric help, I would get it no matter
65


who knew about it.
29. It is difficult to talk about personal affairs with highly
educated people such as doctors, teachers, and clergymen.*
Reversed-keyed items.
66


Appendix D
Beck Depression Inventory
In this questionnaire are groups of statements. Please read
all the statements in a given group. Then pick out the one statement
in each group which describes you best for the past two weeks.
Circle the number beside the statement that you have chosen. If
several statements in the group seem to apply equally well, circle
each one. Be sure to read all the statements in each group before
making your choice.
1. 0 I do not feel sad or blue.
1 I feel sad or blue.
2a I am blue or sad all the time and I cant snap out of it.
2b I am so sad or unhappy that it is quite painful.
3 I am so sad or unhappy that I cant stand it.
2. 0 I am not particularly pessimistic or discouraged about the
future.
1 I feel discouraged about the future.
2a I feel I have nothing to look forward to.
2b I feel I wont ever get over my troubles.
3 I feel that the future is hopeless and that things cannot
improve.
3. 0 I do not feel like a failure.
67


1
I feel I have failed more than the average person.
2a I feel I have accomplished very little that is worthwhile or
that means anything.
2b As 1 look back on my life all I can see is a lot of
failures.
3 I feel I am a complete failure as a person (parent, husband,
wife, etc.)
4. 0 I am not particularly dissatisfied,
la I feel bored most of the time.
f
lb I dont enjoy things the way I used to.
2 I dont get satisfaction out of anything anymore.
3 I an dissatisfied with everything.
5. 01 dont feel particularly guilty.
1 I feel bad or unworthy a good part of the time.
2a I feel quite guilty.
2b I feel bad or unworthy practically all the time now.
3 I feel as though I am very bad or worthless.
6. 01 dont feel I am being punished.
1 I have a feeling that something bad may happen to me.
2 I feel I am being punished or will be punished.
3a I feel I deserve to be punished.
3b I want to be punished.
68


7. 01 dont feel disappointed in myself,
la I am disappointed in myself.
lb I dont like myself.
2 I am disgusted with myself.
3 I hate myself.
8. 01 dont feel I am any worse than anybody else.
1 I am critical of myself for my weaknesses or mistakes.
2 I blame myself for my faults.
3 I blame myself for everything bad that happens.
9. 01 dont have any thoughts of harming myself.
1 I have thoughts of harming myself but would not carry them
out.
2a I would feel better off dead.
2b I feel my family would be better off if I were dead.
3a I have definite plans of committing suicide.
3b I would kill myself if I could.
10. 0 I dont cry any more than usual.
1 I cry more now than I used to.
2 I cry all the time now; I cant stop it.
3 I used to be able to cry but now I can't cry even though I
want to.
11. 0 I am no more irritated now than I ever was.
69


1 I get annoyed or irritated more easily than I used to.
2 I feel irritated all the time now.
3 I dont get irritated at all the things that used to irritate me.
12. 0 I have not lost interest in other people.
1 I am less interested in other people than I used to be.
2 I have lost most of my interest in other people an have little feeling for them.
3 I have lost all of my interest in other people and dont care about them at all.
13. 0 I make decisions about as well as ever.
1 I try to put off making decisions.
2 I have great difficulty making decisions.
3 I cant make any decisions at all anymore.
14. 0 I dont feel I look any worse than I used to.
1 I am worried that I am looking old or unattractive.
2 I feel that there are permanent changes in my appearance and that they make me look unattractive.
3 I feel that I am ugly or repulsive looking.
15. 0 I can work about as well as before.
la It takes extra effort to get started at doing something,
lb I dont work as well as I used to.
70


2 I have to push myself very hard to do anything.
3 I cant do any work at all.
16. 0 I can sleep as well as usual.
1 I wake up more tired in the morning than I used to.
2 I wake up 1-2 hours earlier than usual and find it hard to
get back to sleep.
3 I wake up early every day and cant get more than 5 hours of
sleep.
17. 01 dont get any more tired than usual.
1 I get tired more easily than I used to.
2 I get tired from doing anything.
3 I get too tired to do anything.
18. 0 My appetite is no worse than usual.
1 My appetite is not as good as it used to be.
2 My appetite is much worse now.
3 I have no appetite at all anymore.
19. 0 I havent lost much weight, if any, lately.
1 I have lost more than 5 pounds.
2 I have lost more than 10 pounds.
3 I have lost more than 15 pounds.
Are you trying to lose weight? _______Yes __________No
20. 0 1 am no more concerned about my health than usual.
71


1 I am concerned about aches or pains or upset stomach or
constipation.
2 I am so concerned with how I feel or what 1 feel that its
hard to think of much else.
3 I am completely absorbed in what I feel.
21. 01 have not noticed any recent change in my interest in sex.
1 I am less interested in sex than I used to be.
2 I am much less interested in sex now.
3 I have lost interest in sex completely.
72


Appendix E
Speilbereer State-Trait Anxiety Inventory
DIRECTIONS: A number of statements which people have used to
describe themselves are given below. Read each statement and then
circle the appropriate choice that indicates how you feel right now,
that is, at this moment. There are no right or wrong answers. Do
not spend too much time on any one statement but give the answer
which seems to describe your present feelings best.
Answer Kev:
NOT AT ALL SOMEWHAT MODERATELY SO VERY MUCH SO
1. I feel calm.*
2. I feel secure.*
3. I am tense.
4. I feel strained.
5. I feel at ease.*
6. I feel upset.
7. I am presently worrying over possible misfortunes.
8. I feel satisfied.*
9. I feel frightened.
10. I feel comfortable.*
11. I feel self-confident.*
12. I feel nervous.
73


13. I am jittery.
14. I feel indecisive
15. I am relaxed.*
16. I feel content.*
17. I am worried.
18. I feel confused.
19. I feel steady.*
20 I feel pleasant.*
Reversed-keyed items


Appendix F
Eating Attitudes Test
Directions: Most of the questions below relate to food or
eating, although some other types of question have been included.
Please place an (x) under the column which best applies to each
statement. Please answer each question carefully.
Answer Kev:
Always Very Often Often Sometimes Rarely Never
1. Like eating with other people.*
2. Prepare food for others, but do not eat what I cook.
3. Become anxious prior to eating.
4. Am terrified about being overweight.
5. Avoid eating when I am hungry.
6. Find myself preoccupied with food.
7. Have gone on eating binges where I feel that I may not be able to
stop.
8. Cut my food into small pieces.
9. Am aware of the calorie content of the foods that I eat.
10. Particularly avoid food with a high carbohydrate content (bread,
potatoes, rice, etc.).
i
11. Feel bloated after meals.
12. Feel that others would prefer if I ate more.
75


13. Vomit after I have eaten.
14. Feel extremely guilty after eating.
15. Am preoccupied with a desire to be thinner.
16. Exercise strenuously to bum off calories.
17. Weigh myself several times a day.
18. Like my clothes to fit tightly.*
19. Enjoy eating meat.*
20. Wake up early in the morning.
21. Eat the same foods day after day.
22. Think about burning up calories when I exercise.
23. Have regular menstrual periods. (Males SKIP).*
24. Other people think that I am too thin.
25. Am too preoccupied with the thought of having fat on my body.
26. Take longer than others to eat my meals.
27. Enjoy eating at restaurants.*
28. Take laxatives.
29. Avoid foods with sugar in them.
30. Eat dies foods.
31. Feel that food controls my life.
32. Display self-control around food.
33. Feel that others pressure me to eat.
34. Give too much time and thought to food.
76


35.
Suffer from constipation.*
36. Feel uncomfortable after eating sweets.
37. Like for my stomach to be empty.
38. Enjoy trying new rich foods.*
39. Have the impulse to vomit after meals.
40. Am very active and industrious.
41. Sleep very well.
42. Pretend to eat food that I have hidden or thrown away.*
43. Take diuretics.
reversed-keyed items
77


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