Toward a participatory model of psychotherapy.

Abstract

A pervasive model of the psychotherapeutic relationship has assumed that patient welfare is best served by the therapist's exercise of control over, and responsibility for, methods, goals, and decisions in treatment. However, increased sensitivity to ethical dilemmas in the routine conduct of therapy and more vocal demands by the users of mental health services are likely to lead to a restructuring of the psychotherapeutic relationship. This article argues for a mutual participatory model of therapy that would give a central place to active, skeptical efforts by the patient to be informed and to share responsibility for therapeutic decisions.Recent efforts to define rights and responsibilities in the psychotherapeutic relationship have focused almost exclusively on involuntarily committed or at least hospitalized patients. These discussions have tended to ignore the problems of voluntary outpatients, because violations of their rights are not as blatant. However, in the long run, cases in which outpatients consent to treatment or even request it pose complex ethical questions for psychotherapists and society as a whole (Halleck, 1974). The present paper considers how aspects of traditional practice that have been previously considered noncontroversial enter into these questions and how they are in need of change. Much of traditional thinking has been based on an inappropriate analogy to medical treatment by physicians. The results have been a consistent and pervasive model in which it is assumed that patient welfare is best served by the psychotherapist's exercise of predominant control over and responsibility for methods, goals, and decisions of treatment. This paper suggests the need for an alternative model in which it is assumed that patient welfare is best served when the patient participates actively in decisions as to whether to or how to treat his problems and that this participation is facilitated by the therapist's sharing of information.Increasingly, patients are defining themselves as consumers of mental health services with legitimate demands for full participation in treatment decisions (Adams & Orgel, 1975). Recent discussions of the treatment of a highly religious person (Cohen &

Client Preferences for Informed Consent Information

“…Although some have expressed concern that consent procedures may hinder the therapeutic relationship (Faustrnan & Miller, 1987;Handelsman, Kemper, Kesson-Craig, McLain, & Johnsmd, 1986;Haut & Muehleman, 1986), decrease clients' confidence in therapists' potential helpfulness, and potentially cause a loss of clientele (Lewis, Davis, & Lesmeister, 1983), the promotion of autonomy and rational decision making is thought to enhance (Coyne & Widiger, 1978;Everstine et al, 1980;P. S. Jensen, Josephson, & Frey, 1989) and help define the relationship between client and therapist (Birch, 1990).…”

Pretherapy Information, Counselor Influence, and Value Similarity: Impact on Female Clients' Reactions

“…Several authors have suggested that counselors can avoid the pitfall of covertly influencing clients by openly discussing their goals, values, techniques, and expectations with clients prior to the commencement of counseling (Coyne & Widiger, 1978;Hare-Mustin, Marecek, Kaplan, & Liss-Levinson, 1979;Humphries, 1982;Lewis, Davis, & Lesmeister, 1983;Rawlings & Carter, 1977). These authors believe that the provision of such pretherapy information will increase clients' awareness of the potential for counselor influence as well as clients' ability to detect subtle influence attempts when they occur.…”

A follow-up study of clients who fail to begin counselling or terminate after one session

“…Second, the results were based solely on client self-reports. While this type of data can be said to be biased (Lambert, Ogles & Masters, 1992;Margolis, Sorenson & Galano, 1977), it has also been argued that the client's opinion is the one that is the most informed (Lambert et al, 1992) and the most important (Coyne & Widiger, 1978;Morrison, 1978) since the central goal of counselling 'is to make the patient feel better' (Stuart & Lieberman, 1993). In reality, client self-reports of internal states are the most frequently used data in counselling outcome studies (Lambert et al, 1992).…”