How Much Autonomy Do Therapy Clients Deserve? Balancing client autonomy with therapist skill
Curt and Katie chat about client autonomy. We look at what patient autonomy is and what therapists need to understand about this very complex topic. We explore how therapists can overstep or abdicate their role in supporting their clients in making decisions. We also look at what true informed consent is and the dimensions of client autonomy. This is an ethics continuing education podcourse.
Click here to scroll to the podcast transcript.Transcript
In this podcast episode we talk about client autonomy
Therapists are faced with balancing their professional knowledge with the needs and desires of clients. At the core of this issue is the principle ethic of client autonomy. How much autonomy do therapists need to give clients? What do therapists do when clients don’t have the capacity for autonomy in the first place? This workshop explores the considerations that therapists must face when balancing the needs of clients with professional mental health services.hen
What is patient or client autonomy in mental health?
- Clients making decisions about their treatment based on solid information and an understanding of that information
- There is a debate related to whether we defer to clients’ decisions no matter what versus standing in the role of professional therapist
What do therapists need to understand about client autonomy?
“It feels like there’s a complex picture here that I think is hard for new clinicians to get their heads around… trying to understand the difference between kind of a paternalistic savior therapist dictating to a client versus an informed professional working collaboratively with a client.” – Katie Vernoy, LMFT
- There is a lot of complexity and nuance related to therapist responsibility as professionals versus when therapists can become too paternalistic
- There is a not a lot of discussion within the ethics codes related to client autonomy, they are usually in the preamble, so it is more important while also be less discussed
- Freedom (or liberty) to make choices versus agency (or capacity) to understand the choices
- Therapists need to clarify for clients the options and make sure they can make informed decisions
How is informed consent related to client autonomy?
“If people’s mental illnesses or their reasons for coming to therapy doesn’t actually give them the capacity to understand what they’re consenting to, is there any space for autonomy in the first place?” – Curt Widhalm, LMFT
- If clients don’t know what their therapists are doing, do they have client autonomy?
- Evaluation of whether someone has the capacity to make treatment decisions can be impacted by bias, but is the role of the therapist within the mental health treatment
- We don’t want to equate autonomy with autonomous decision-making
Dimensions of client autonomy and the therapist’s responsibility
“So if that kind of an autonomy is missing, we may have to actually…[address] how to best treat somebody in that position. If the work that you’re trying to do isn’t able to be carried out, you would have kind of an ethical responsibility to…incorporate other aspects to help them be able to follow through on their treatment.” – Curt Widhalm, LMFT
- Decisional dimension – being able to plan and make decisions about their mental health treatment
- Executive dimension – being able to follow through on the plans made
- Therapists need to be able to step forward and provide additional support to clients to bring them back to autonomy or hold a line in treatment that will and will not be offered
- Informed dimension – understanding the difference between informed consent and informed assent and being able to give instructions ahead of time if have a mental health crises
- Looking at a “Mental Health Advanced Directive” – one example is the Wellness Recovery Action Plan (see the resources section in the show notes).
Paternalism and client autonomy
- Not all “paternalism” is wrong – when clients are unable to care for self, they may need some paternalism to be able to be safe or get the treatment that they need
- Asymmetrical versus libertarian paternalism is discussed
- The importance of understanding your own bias and how the way you frame options can be manipulative
Receive Continuing Education for this Episode of the Modern Therapist’s Survival Guide
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Once you’ve listened to this episode, to get CE credit you just need to go to moderntherapistcommunity.com/podcourse, register for your free profile, purchase this course, pass the post-test, and complete the evaluation! Once that’s all completed – you’ll get a CE certificate in your profile or you can download it for your records. For our current list of CE approvals, check out moderntherapistcommunity.com.
You can find this full course (including handouts and resources) here: https://moderntherapistcommunity.com/courses/how-much-autonomy-do-therapy-clients-deserve-balancing-client-autonomy-with-therapist-skill
Continuing Education Approvals:
When we are airing this podcast episode, we have the following CE approval. Please check back as we add other approval bodies: Continuing Education Information including grievance and refund policies.
CAMFT CEPA: Therapy Reimagined is approved by the California Association of Marriage and Family Therapists to sponsor continuing education for LMFTs, LPCCs, LCSWs, and LEPs (CAMFT CEPA provider #132270). Therapy Reimagined maintains responsibility for this program and its content. Courses meet the qualifications for the listed hours of continuing education credit for LMFTs, LCSWs, LPCCs, and/or LEPs as required by the California Board of Behavioral Sciences. We are working on additional provider approvals, but solely are able to provide CAMFT CEs at this time. Please check with your licensing body to ensure that they will accept this as an equivalent learning credit.
Resources for Modern Therapists mentioned in this Podcast Episode:
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Mental Health Advanced Planning: Wellness Recovery Action Plan
References mentioned in this continuing education podcast:
Arrieta Valero, I. (2019). Autonomies in interaction: Dimensions of patient autonomy and non-adherence to treatment. Frontiers in psychology, 10, 1857.
Beauchamp, T. L., and Childress, J. F. (1979/2001). Principles of biomedical ethics. 5th Edn. New York: Oxford University Press.
Blease, Charlotte; Trachsel, Manuel; grosse Holtforth, Martin (2016). Paternalism, Placebos, and Informed Consent in Psychotherapy: The Challenge of Ethical Disclosure. Verhaltenstherapie, 26(1):22-30. DOI: https://doi.org/10.1159/000442928
Canterbury v. Spence (464 F.2d. 772, 782 D.C. Cir. 1972)
Matthews, Eric (2007). Is autonomy relevant to psychiatric ethics? In Thomas Nys, Yvonne Denier & T. Vandevelde (eds.), Autonomy & Paternalism: Reflections on the Theory and Practice of Health Care. Peeters. pp. 5–129.
Thaler, R. H., & Sunstein, C. R. (2003). Libertarian Paternalism. The American Economic Review, 93(2), 175–179. DOI: 10.1257/000282803321947001
*The full reference list can be found in the course on our learning platform.
Relevant Episodes of MTSG Podcast:
Teaching Wisdom: Best practices for decision-making to support your clients
Should Therapists Admit to Making Mistakes in Therapy?
How to Fire Your Clients (Ethically)
How to Fire Your Clients (Ethically) Part 1.5
Navigating the Social Media Self-Diagnosis Trend
Serious Mental Illness and Homelessness, An Interview with Senator Henry Stern and Dr. Curley Bonds
Is Therapy an Opiate of the Masses?
Liability Hot Potato: Defensive Therapy practices that give clients inadequate care
Who we are:
Curt Widhalm, LMFT
Curt Widhalm is in private practice in the Los Angeles area. He is the cofounder of the Therapy Reimagined conference, an Adjunct Professor at Pepperdine University and CSUN, a former Subject Matter Expert for the California Board of Behavioral Sciences, former CFO of the California Association of Marriage and Family Therapists, and a loving husband and father. He is 1/2 great person, 1/2 provocateur, and 1/2 geek, in that order. He dabbles in the dark art of making “dad jokes” and usually has a half-empty cup of coffee somewhere nearby. Learn more at: http://www.curtwidhalm.com
Katie Vernoy, LMFT
Katie Vernoy is a Licensed Marriage and Family Therapist, coach, and consultant supporting leaders, visionaries, executives, and helping professionals to create sustainable careers. Katie, with Curt, has developed workshops and a conference, Therapy Reimagined, to support therapists navigating through the modern challenges of this profession. Katie is also a former President of the California Association of Marriage and Family Therapists. In her spare time, Katie is secretly siphoning off Curt’s youthful energy, so that she can take over the world. Learn more at: http://www.katievernoy.com
A Quick Note:
Our opinions are our own. We are only speaking for ourselves – except when we speak for each other, or over each other. We’re working on it.
Our guests are also only speaking for themselves and have their own opinions. We aren’t trying to take their voice, and no one speaks for us either. Mostly because they don’t want to, but hey.
Stay in Touch with Curt, Katie, and the whole Therapy Reimagined #TherapyMovement:
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Connect with the Modern Therapist Community:
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Modern Therapist’s Survival Guide Creative Credits:
Voice Over by DW McCann https://www.facebook.com/McCannDW/
Music by Crystal Grooms Mangano https://groomsymusic.com/
Transcript for this episode of the Modern Therapist’s Survival Guide podcast (Autogenerated):
Transcripts do not include advertisements just a reference to the advertising break (as such timing does not account for advertisements).
… 0:00
(Opening Advertisement)
Announcer 0:00
You’re listening to the Modern Therapist’s Survival Guide where therapists live, breathe and practice as human beings. To support you as a whole person and a therapist, here are your hosts, Curt Widhalm, and Katie Vernoy.
Curt Widhalm 0:15
Hey, modern therapists, we’re so excited to offer the opportunity for one unit of continuing education for this podcast episode. Once you’ve listened to this episode, to get CE credit, you just need to go to moderntherapistcommunity.com, register for your free profile, purchase this course, pass the post test and complete the evaluation. Once that’s all completed, you’ll get a CE certificate in your profile, or you can download it for your records. For a current list of our CE approvals, check out moderntherapistcommunity.com.
Katie Vernoy 0:47
Once again, hop over to moderntherapistcommunity.com For one CE once you’ve listened.
Curt Widhalm 0:54
Welcome back modern therapists. This is the Modern Therapist’s Survival Guide. I’m Curt Widhalm, with Katie Vernoy. And this is the podcast for therapists where we talk about the things that go on in our practices, the ways that we interact with clients in the world. And this is another one of our continuing education eligible episodes. And we are leaning into ethics mostly in this one, and really around the idea of autonomy when it comes to patients opting into treatments. And I have to really kind of give credit to my students at California State University Northridge for inspiring this episode, in being able to actually dive into some stuff and be able to look at what is in fact, autonomy. And this being one of the principal ethics of Beauchamp and Childress, when it comes to healthcare ethics, autonomy, and what people are allowed to do, they get to be involved in the decision making process. But Katie, as my friend, colleague, co-host, I’m going to always start our episodes with a question to you. Why don’t you tell me what your idea of autonomy is, especially when it comes to ethics and mental health care?
Katie Vernoy 2:19
Well…
Curt Widhalm 2:20
That’s, it’s a very deep sigh to start kind of a big conversation here.
Katie Vernoy 2:27
Yes, yes, a big sigh. I think, when I think about client or patient autonomy, there’s such a complexity to how I look at it that I don’t know that my short answer will be helpful. But it’s this combination of a client who’s very informed, and has a whole picture of what it is to do treatment with me and what the treatment I’m recommending is, and then from there, being able to make a decision, and step forward. I think that gets complicated by the client’s understanding of treatment, it’s, you know, generally not just with me, and by a lot of other things and how they enter the treatment relationship. But for me, I feel like autonomy is not absolute, because you can’t be autonomous unless you know what you’re deciding. I mean, we have a whole episode on decision making and how complex I think decision making is. So. So I think I’m potentially unique in that because I think there’s there’s some folks I’ve talked with who believe autonomy is the clients make the decision no matter what. And I think that’s too simple.
Curt Widhalm 3:41
And that’s really part of what the discussion with my students has been. To be fair to my students, they’re in their first semester of their grad program. But a lot of the things that we’ve been talking about in the law and ethics class that I teach is, when given the chance to give clients the ability to make decisions for themselves, one of the things that I’ve noticed my students this semester doing is always giving into what the client suggests no matter what. And at some points in these conversations I’ve always like, but we are the professionals. We have information that clients may not. We have skills that we are training students to have, hopefully the professionals in our field have in order to actually do professional therapy. That by making the decision to not actually use any of these skills, we’re actually abdicating all of our responsibilities to give over to the clients and we become nothing more than very glorified cheerleaders that are able to provide billing documentation to insurance companies.
Katie Vernoy 4:54
Well, I think there’s a lot of different places we can abdicate this responsibility. I mean, I think opting into treatment initially, I think when there’s some sort of a rift or a mistake, we have a whole episode on mistakes or different things that happen. There’s a breach if you don’t try to process it or try to have the conversation to understand it and make repair. I think there’s so many different places that we can just say, well, the client doesn’t want to do this, or Oh, the client wants to do this instead, or whatever it is, without actually getting into the discussion. It feels like there’s a complex picture here that I think is hard for new clinicians to get their heads around. And even other folks who are, are in a space of trying to understand the difference between kind of a paternalistic savior therapist dictating to a client versus a an informed, professional working collaboratively with a client. I mean, in and I guess I got off track with the different spaces where we can abdicate responsibility and over sell client autonomy, but I’m sure we’ll get into it. So, where do you want to start with this, because it feels like this is a big topic that we can go in a lot of different areas.
Curt Widhalm 6:11
You know, it’s funny that you’re saying that this is a big topic, because this is actually much bigger than even I imagined when I was like, we should do an episode on autonomy. And I think that, if anything, this is almost kind of passed over as being maybe not big enough in the way that we actually think about this with clients. I think that a lot of law and ethics lectures kind of basically boil down to All right, we have this principle ethic of autonomy, alongside beneficence, non-malfeasance, all of the the Beauchamp and Childress great stuff. But a lot of autonomy just kind of gets boiled down to a couple of lines, usually, as far as like, we need to provide informed consent to clients, we need to have them be involved in the decision making process, needs to be done in a language that they understand. And then we kind of go from there. Then then let’s get into you know, more of the specific ethics and kind of fine tuning things. But I think that a lot of these principles ethics get lost as far as they’re, they’re not, you know, there’s not an APA code that’s like client autonomy. There is not a NASW code or an ACA code or AMFT code that’s just like client autonomy. A lot of these are things that are in the preamble, but I always have to remind people like, just because there’s not like a 1.1 on this doesn’t mean that it’s less important. Like it’s actually more important. It’s higher up on the webpage. It’s…
Katie Vernoy 7:42
It’s global. It’s the preamble, it’s the basis for all that we do. But I think actually understanding what autonomy is. I have not like until we started preparing for this episode, I hadn’t really thought about it in a really deeper way.
Curt Widhalm 7:59
And considering you being my friend, and how much you are just subjected to my random ethical musings and deep thoughts, that, to me, maybe suggest that the larger mental health field probably also doesn’t think about this in this way. And so I’m pulling heavily from an article by Ian Arietta Valero for this episode, this is called Autonomies in interaction: Dimensions of patient autonomy and non-adherence to treatment. And this is 2019 article from Frontiers in Psychology. Kind of from the get go in this what this article describes is that, yes, Beauchamp and Childress really come about this. And within the original Beauchamp and Childress writings, we have to have two conditions that are essential for autonomy. And that is liberty, which is the independence for controlling influences, and agency, which is the capacity for intentional action. Now, historically, and I think in our discussions here, so far, we have leaned as a field, as a healthcare field, a lot more on the former, the idea of liberty and the independence for controlling influences, rather than focusing on agency, which is the capacity for intentional action. I think that a lot of discussions around this kind of stuff picture highly informed, educated clients who are coming in and are able to speak verbosely about what it is that they want as far as their treatment. We assume that people have the capacity for understanding things. Therefore we grant liberty, we grant the options for people to opt in and out of things. But how do we actually start to think about client capacity in these discussions? For example, if you are a therapist who is working with small children, you automatically are already kind of watering down what the languages as far as what you’re doing, because you understand that a child has a different capacity to be able to understand and make decisions about what treatment is going to be. With teenagers, you might present it in a more mature or adult like sort of way. And with many adults, you may do so in the same way. But when you are faced with adults who have things like severe mental illness, you may also even naturally just kind of start to explain things in a way that the client understands. What I’m suggesting, though, is that there’s those clients who might come in asking for a treatment. ‘Hey, I heard about CBT, I want CBT,’ where we don’t actually go into any sort of depth as far as ‘Do you have the capacity to know what you’re asking for? Or did big CBT just do a really good job of marketing and convince you that this is the treatment that you need?’
Katie Vernoy 11:06
Well, do you think that folks are really not giving any information? Because I feel like my natural response when somebody says, I heard that, you know, and that’s usually some, you know, blank CBT. So see, you know, D C, you know, whatever, I don’t even know that I can think of the names right now. But, but I usually go into ‘Well, here’s where we’ve already used CBT. And this is what CBT looks like, is that something that you’re interested in?’ Or I could say, ‘Hey, we can try a session where I put some more CBT in here, and then we can decide if this is for you.’ I feel like I am, I don’t see this as an issue for myself. But it seems like you’re concerned that folks are going like, Okay, I’ll just switch to CBT. Or I don’t do CBT, let me refer you out.
Curt Widhalm 11:47
And I think it starts even before that. I think that this starts in your initial consultations with clients and being able to describe, here’s what I do, here’s the theory that I work from, here’s how that applies to what you are talking about. So if you are coming in as a brand new client, you should walk out of the first session with an understanding, here’s what a CBT framework is, this is how looking at core beliefs, where those core beliefs are, the types of interventions that we might do in doing thought tracking and changing things. Clients should have a rudimentary understanding of what the procedure of CBT is, so that way, they are fully informed to be able to opt into that. Now…
Katie Vernoy 12:34
Sure.
Curt Widhalm 12:35
…kind of, kind of like you, when I have clients who mid treatment or like, you know, I’m hearing a lot more about CBT. Can we do CBT? And I explained to them, okay, here’s what CBT would look like, in a shift for the kind of work, just like you outlined. And some of them go, oh, no, I don’t actually want that what I want is this other thing. And…
Katie Vernoy 12:58
But you’re saying that when someone comes into treatment at the beginning, you need to fully explain how you work?
Curt Widhalm 13:07
Yes. And…
Katie Vernoy 13:08
And I think I do that. You’re saying you don’t think that people do that? What do you think people are doing instead?
Curt Widhalm 13:13
I think when clients come in, and they say, I have a problem. And I think a lot of people are shortening that conversation down to Yeah, I practice from CBT. Let’s dive into it.
Katie Vernoy 13:25
Ah, got it. So you’re thinking that they just comply. And I think we have a whole episode on self diagnosis, you know, kind of the TikTok diagnosis thing. But if somebody comes in there and says, I have this diagnosis, and I’d like this treatment, as we talked about in that episode, there’s there needs to be further clarification, because you don’t know that they actually have that diagnosis. And you also don’t know that they actually want that treatment. And so clarifying and digging in deeper would be more what we’re talking about. So they can opt in and out to something that’s known versus what they’ve learned about on social media.
Curt Widhalm 13:59
Right. And that’s where, in this article by Arrieta Valero points out that what we tend to do is we tend to have this idea of a principle of respect for autonomy, rather than the principles that underlie it. That while you might be a listener here, who’s kind of saying, you’re saying a lot of things, but ultimately, we’re still trying to get people back to having that liberty option to make it, make make the decisions to do that. But we first have to make sure that people have the agency to make that decision in the first place. You know, if the gold standard of, you know, treatment for anxiety, let’s say is CBT. Probably is, I mean, CBT works pretty well for anxiety, right?
Katie Vernoy 14:46
Yeah, it does, but it’s also big CBT. So let’s, let’s not, let’s just use it as an example and not try to validate the example.
Curt Widhalm 14:52
So, you know, if you have a seven year old who’s coming in, you should, you know, still talk about like, Here’s how how we work with anxiety: we practice on being anxious, we look at our thoughts, when we’re anxious and how we can look at other kinds of evidence. You, you’re still describing CBT. But one of the ways that I really kind of put this out there to a lot of clinicians to help understand this is, if you are going to therapy yourself, and you should be, can, do you know what kind of theory your therapist is working from? And if you can’t identify that even as a professional with your own therapist, this needs to be a more explicit part of the conversation.
Katie Vernoy 15:38
That feels like it may be orientation specific, though. How much how much transparency, how much collaboration, all of those things. Like it feels like there is still a little bit of a treatment orientation question here on how, how collaborative, how informative am I, am, am I with my client. It feels like ethically, there’s a further step, but I’m thinking about folks who are more psychodynamic, or who have more of this kind of integrative or eclectic style, it feels like that’s, there may be an element of this where they’re like, but then that ruins it. Like that ruins my treatment thing, if they know exactly what I’m doing and why I’m doing it. Right?
Curt Widhalm 16:24
Is that autonomy, then? Because…
Katie Vernoy 16:26
I don’t know, that’s why I wanted to bring it up. Because I feel like there’s there’s an argument and we can go into the kind of the making pretzels and forming these things to say, well, well, but this is they’re opting in to working with me, and this is how I work.
Curt Widhalm 16:40
Then I say, this is not autonomy, if people don’t know what they’re opting into. When people tell me I’m an eclectic therapist, I go, ‘How do you decide which eclectic?’ ‘Oh, you know, I’m really reactive in the room.’ ‘Okay, what kinds of things are you reactive to?’ Like…
Katie Vernoy 17:01
Yeah. It’s just getting really good at describing how you work so that folks can opt in or out.
Curt Widhalm 17:06
Right. Because inherently, in what you’re describing is paternalism.
Katie Vernoy 17:12
Yeah.
Curt Widhalm 17:13
It’s I know better than my client, therefore, I have information that they don’t. And me sharing that information with them takes away my power. You’re taking…
Katie Vernoy 17:25
I think that’s how so many people worked for so long. I think that there are still some of us trained in more of this blank slate. You know, I’m just coming in here. And I’m going to respond in the room. And I’m going to have these interventions that are behind the curtain. And I don’t appreciate that. I am just raising it as as a place to kind of get into the nuance of this, because I think a lot of folks are maybe not doing it not from a place of a lack of transparency or a lack of client autonomy. I don’t think they’ve thought about it that way. But I don’t know. I mean, I’m not those folks. But I’m always I’m always pulling back the curtain and saying, you know, ‘I’m not supposed to say this, but I’m proud of you.’ They’re like, ‘Why aren’t you supposed to say that?’ Because generally, as therapists this is how we’re supposed to operate. But this is why I’m saying this because I need you to know this, right? Like, I’m super transparent. My clients know what I’m doing. And sometimes it may negatively impact, negatively impact the effectiveness of the intervention. But I feel like I have to be transparent so they know what’s going on. But I think there’s folks who are not that way.
Curt Widhalm 18:30
I don’t think that you should have, like there shouldn’t be many people left in our field who are not affected or were practicing well, before the 1972 US Court of Appeals in the District Court. This is Canterbury versus Spence. And the ultimate judgment out of this is that consent was largely glossed over by…
Katie Vernoy 18:53
Before the seventies.
Curt Widhalm 18:55
…before, you know, it took somebody who was in the hospital, getting a surgery on their, on their spine, falling out of bed in the hospital and injuring themselves more and becoming paralyzed, before we put the very important word informed into informed consent.
Katie Vernoy 19:13
Oh, my gosh, that’s horrible. And it’s it’s shocking, because I think it is informed consent just feels like it’s a part of what we do. But I think actually thinking about what is true informed consent mean? I don’t know that we’ve, I’ve not been part of those conversations, I guess.
Curt Widhalm 19:31
You know, I hear hear my students from time to time being like, you know, there’s a lot of literature on, don’t sleep with your clients, like was this such a big problem that all of these tomes of papers have to be written on it? And I go, yeah, it used to be such a big problem. And we’ve done a good job by talking about enough and it still doesn’t prevent people from doing it. But I think that this was such a problem in you know, prior to this decision that we’ve almost lost touch for what the importance of informed consent is. Good job as far as recognizing, yes, we need to give clients more informed consent. But are we actually providing enough informed consent? And here’s kind of the the challenge to this. If people’s mental illnesses or their reasons for coming to therapy doesn’t actually give them the capacity to understand what they’re consenting to, is there any space for autonomy in the first place?
Katie Vernoy 20:34
I think this is the crux of the issue for me, because there’s a judgment that you’re making. And I think it’s an accurate judgment, not judgment in like, Oh, you’re so judgy, but judgment and that you’re evaluating, right?
Curt Widhalm 20:46
Right.
Katie Vernoy 20:46
That someone with certain diagnoses may not be able to understand what they’re opting in and out of, right. I think there are also elements to it, and maybe this is just getting more detailed than what you’re already saying. But folks who their general coping is avoidant, and they, you know, you get to a hard spot and treatment and they want to opt out, right? Or, you know, there’s those types of things where there’s even more nuanced pictures, folks who are generally, quote, unquote, you know, high functioning, I don’t like that word, but I’ll use it here just as a as a placeholder. But I think there’s that that element of someone generally functioning well in their life, but their tendency is to avoid. Treatment gets hard, they opt out, and we just say, Okay, well, that’s client autonomy, and that we don’t try to do the work to bridge that. And so it’s not even I don’t understand, it’s that clinically, there is an issue here that I need help overcoming to be able to engage in the work that I need to do. And so there’s, there’s all of those things, those assessments of, can this client opt in in a healthful manner, healthy manner, and adhere, comply, whatever the right word is to treatment? And can they understand it? And then there’s this other element is the pesky little piece of, of, are we assuming whether or not they can understand and comply? Is there, are there cultural differences that suggest that we’re going to save them or be a savior? Are there gender differences that think, you know, like, this person is not going to understand because of X or Y. I mean, I think there’s, there’s the reasons behind the informed consent laws in the first place, which was that this paternalistic figure was telling you what you needed for treatment. And then there’s the other elements, which is, you’re coming to treatment for a reason and there are going to be hiccups that get in the way of treatment. And that’s part of the work. And so we have to hold that. So it becomes this complex picture of why do I feel like this person either knows well enough? And I abdicate the clarification and follow through. Or why do I think they don’t? And what are the pieces of that? And then, you know, we have a lot of episodes on kind of intersectionality, and being present and understanding, you know, power privilege, you know, all of those things. But I feel like there’s, this isn’t just an easy like, Hey, you’re the professional, you need to step forward a bit more. Because we need to say, what are we stepping forward to do?
… 22:00
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Curt Widhalm 23:16
I’m thinking of the interview that we did with Senator Henry Stern, and kind of talking about this. And I think a lot of the questions that you’re talking about have tried to be ironed out legally, as far as like, when is a person at a place of grave disability where decisions are made for them?
Katie Vernoy 23:33
Sure.
Curt Widhalm 23:34
And you and I are more familiar with California and some of the stuff that Senator Stern was talking about in that episode is that the laws in California are written to such an extent of patient autonomy that it’s very difficult to kind of get people into treatment unless they are at the absolute, you know, most egregious end of not being able to care for themselves. And it’s freer in other states. Now, as far as being able to make decisions for ourselves, in general, I think that it’s great to give people the most autonomy over themselves. But when we look at it from a healthcare perspective, kind of thing, we have to be careful to not equate autonomy with autonomous decision making. And…
Katie Vernoy 24:24
You got to explain that a little bit more.
Curt Widhalm 24:26
Good because I was going to anyway, so and so that is the capacity to understand the information and to make voluntary decisions on it. And this is why we look at things like severe mental illness. That’s what autonomous decision making is is if somebody is not able to opt in to something is mental health treatment, if they’re not able to understand the information about what the treatment is going to be, can we actually give them the autonomy to opt out of the treatment? In other words, if their capacity is so low to not even understand how what is happening to them could benefit them that beneficiant is part of principle ethics, are we just avoiding doing harm because they say no? Like, if Senator Stern was talking about going to homeless people with severe mental illness on the streets, and being able to say, Hey, would you like to opt into this treatment? If they don’t understand what that treatment could do to benefit them, are they actually able to make an autonomous decision? If they don’t understand, do they have the right to autonomy?
Katie Vernoy 25:46
That comes to an evaluation or assessment? Is this person competent or not? There are things in the law, but there’s also ways that people understand it, right. And then there’s also how do we know how informed they are? How do we know whether or not they’re able to make a decision? If we disagree with their decision are we in a in a biased kind of way going to lean toward, they don’t, or they do understand, right? And so there’s that element of, even with the laws stating what it is, and having a way to describe that at the highest level with severe mental illness, you know, harm to others harm to self, you know, grave disability, there’s still a lot of interpretation and the letter of the law versus the spirit of the law. But when we’re thinking about folks who are not at that level, you know, we have a whole episode on, you know, is therapy, the opiate of the masses? I mean, it’s a pretty old one at this point. But we have a lot of impact and how we frame the information that we’re giving, we have a lot of impact, in how we, you know, kind of where we stop in the decision making process. We stopped when they make the decision we want versus we stopped when when we feel confident that they’re making the decision they want. And so I don’t think this is simple by any stretch. I feel like it’s it’s something where, especially in some of these tougher cases, this is where consultation is needed to make sure that you’re actually aware of whatever bias you’re holding, and whatever decision you’re pushing, if you are.
Curt Widhalm 27:21
This is from ‘Is autonomy relevant to psychiatric ethics?’ So, I get that this is more to the medication end of things. This is from Matthews, 2007. And out of this comes the question, first and foremost, if we’re trying to respect autonomy, is there anything there to respect if autonomy doesn’t exist in the first place?
Katie Vernoy 27:50
And who assesses if autonomy exists? That’s the part I’m talking about.
Curt Widhalm 27:53
That would that would be the whole point of healthcare professionals. Is you your that’s your job to assess it is. And that’s where going back to this article by Arrieta Valero helps to look at different domains of what autonomy actually is. And that you might have autonomy in some areas. You might have autonomy of mind, but your body may not allow that; somebody who’s paralyzed from the neck down, for example.
Katie Vernoy 28:22
Sure, sure.
Curt Widhalm 28:22
So you would have autonomy of mind, but you might not have autonomy of body there. And so some of the categories that were looked at in this is some different dimensions. So the first one is the decisional dimension, this is the patient’s ability to make free and therapeutically informed decisions, such as capacity to plan sequence and perform tasks related to the management of something like a mental illness. So think of, you know, clients that maybe more impacted by their condition, who, in the moment, they can sure repeat back exactly what you’ve told to them. And then five minutes later, they’re like, I have no idea what we just talked about.
Katie Vernoy 29:11
Okay.
Curt Widhalm 29:13
Let alone the ability to then go and have the executive functioning ability to go and implement that in between sessions. So if that kind of an autonomy is missing, we may have to actually, I don’t know, step up and be mental health care professionals in addressing how to best treat somebody in that position. If the work that you’re trying to do isn’t able to be carried out, you would have kind of an ethical responsibility to do your job and incorporate other aspects to help them be able to follow through on their treatment.
Katie Vernoy 29:53
What do you mean by that? Because I feel like there are also laws and maybe this is more of a California thing where if there’s not a dedicated decision maker. By nature, it defaults back to the client who may not have this decisional or maybe even executive autonomy.
Curt Widhalm 30:12
Yeah, I added in the executive dimension there, that’s the ability to follow through. So.
Katie Vernoy 30:17
But if if if the law says they do, but you think they don’t, I mean, we do get more complicated here.
Curt Widhalm 30:25
And this is where hopefully you are explaining to your clients because ultimately, what you have is, first a responsibility to restore people’s ability to make these autonomous decision things. And that’s really, I think, where I see a lot of hesitation from people just kind of passing on their legal responsibility to others is like, let’s stabilize. So that way you can make this decision. But at some point, we do have to be able to step in and be the educated professional, who is licensed by the state, in order to make these decisions, that’s what a license is, is that you’ve demonstrated a competence to be able to step in, in situations where you are required to do so.
Katie Vernoy 31:13
I agree. And I also am looking at the other element of folks who have stepped into that role too quickly. So I think there’s folks who have abdicated too quickly. And I think that’s more the conversation that we’re talking about today. But I think some people abdicate it so quickly because of a historical lens of folks who have stepped forward too much to medicate without permission, to institutionalize without permission. And there’s that that element of how do we make sure that we’re, we’re walking that line or staying on that tightrope? Because I feel like there are folks who would benefit and maybe need to be, quote, unquote, pushed into treatment of some sort. Whether it’s, you know, kind of inpatient, or medication. But there’s also an element of, there are folks who shouldn’t be that have in the past. And so how do we make sure we’re not stepping across that line, in adhering to our responsibility?
Curt Widhalm 32:09
So, I’m going to give you credit for what I’m going to put in. This is the example that you gave before we started recording, but let’s talk about like, eating disorder clients who don’t maintain enough body weights to be biologically functional, like in an outpatient kind of setting. At what point do you say, I have to withhold treatment, because you are not functionally able to biologically take care of yourself. We do these kinds of things like, you know, there’s kind of this decision making process that we have to go through in order to be like, Alright, when is it appropriate to say, I am no longer going to see you because you are not adherent to treatment. But part of the decision making process that we do on that is going back to these dimensions from Arrieta Valero is looking at like the functional dimension, which he defines as ‘functions and tasks that can be carried out by the statistical majority of people.’ So, there’s the using an eating disorder client, as an example here, there’s the ones that are kind of restricting a little bit, but they’re still eating somewhat regularly. I don’t think that we’re the ones saying like, you have to go and perform all of these other, you know, tasks with your medical doctor at this point. Like, we know that you’re working through things, you may be on the disordered eating end of things rather than full eating disorder end of things. That’s different than the ones who are obviously very emaciated in sessions and are listless and not able to, you know, have kind of that mental capacity because their body is not being fed. Like there is a line in there somewhere and eating disorder therapists don’t roast me on all of this. But as far as this, but I’m trying to use an example here where like, there is a line in there. Some people may overstep, but being able to do that is something where all right, if somebody doesn’t have this capacity, when do we bring in family members? When do we bring in other people who can make this decision for them? And how do we, as many people are going to ask here, how do we ethically end those relationships when people are not adherent to the treatment?
Katie Vernoy 34:43
There are so many questions I have in there because it is complex. And I think there are there’s a line and I think at this point we’ve had you’ll know it when you see it. But I think there’s that that element of some folks have very strong viewpoints that that becomes their line. And so, you know, and this is folks who are abdicating too quickly, I guess. But there’s that that element of, well, if a person steps across this line for me, then I’m either going to abdicate or step forward, right? I’m going to either say, that’s up to you, you are autonomous, or I now must control you, because you clearly don’t understand or you’re clearly not adherent, or whatever it is, right. And I think this is, this is a scary part of being a therapist is that there is these functional pieces of you must go to the doctor, or I’m not going to see you again, right? Or, I’m going to allow you to make that decision medically. And I’ll just be here for you for whatever, and and not push anything, because you’ve made that decision. I’m not a medical doctor. And so you do you, and I’m not adequately caring for, using your example, an eating disorder client.
Curt Widhalm 35:55
So you know, you’re not writing and your SOAP note for the 17th consecutive week, requested client go to the doctor again.
Katie Vernoy 36:02
Yeah, yeah.
Curt Widhalm 36:04
But part of this, and looking at somebody’s informed consent in this, I would also maybe suggest for many of us to consider, especially if you are working with populations like this, to also put in informed assent into your documentation and to explain to people like, if you ever reach a point where there is a question of your capacity to remain informed in treatment, that these are the conditions that we may have to incorporate family members as far as getting your treatment back on track to restore you to a level of functioning to where you can make these decisions for yourself. And this is out of that informative dimension from the Arrieta Valero article. The informative dimension is to have control on their situation in the matter of choosing and to retain, understand and communicate this to others, that there does become a place where all right talking with you, even if you provided informed consent into treatment, what may be best practices is incorporating other family members to help you be able to restore that functioning.
Katie Vernoy 37:23
To me, I’m what I’m hearing when you say that is this kind of mental health advanced directive. And I think there’s a lot you know, and I think it has other names, some people would might call it a pretty extensive safety plan. But when folks who have these tougher conditions, more challenging sets of symptoms, where they do get to a place where they know that they won’t be able to make informed decisions in that moment, and there’s been enough of a conversation, I think that there are really great advanced directive type documents where someone can say, when I’m in this state, which obviously there would need to be an agreed upon what that looks like, these are the decisions I want to make, or this is the person I’d like to make decisions for me. And I do believe that requires a lot of family. And I think that, I think to me, that provides an element of autonomous decision making, because it is when they are in a place to be able to make those decisions they are making decisions for times when they cannot. Is that what you’re talking about, in some ways, with a sense is being able to get to a place of like, I know, I may not be able to make decisions for myself, but I’m gonna tap this person and give these ideas?
Curt Widhalm 38:29
That’s exactly what I’m talking about. Stuff from SAMSA on this as well.
Katie Vernoy 38:33
And NIMH, and yeah, that will I’ll put some stuff in the show notes that may be helpful for folks.
Curt Widhalm 38:37
But again, this is taking extra steps at the beginning of treatment so that way, you’re not in a place where there is no capacity to do this. That there is some ability for you in your role as a professional to help make sure that your clients are remaining at a level where they can either be restored to or make these informed decisions themselves. But this also ends up becoming something where having the foresight to do this is the point of this conversation that we’re having right now.
Katie Vernoy 39:12
Well, and I just want to clarify that may not happen at the beginning of treatment if somebody’s coming in a very heightened state of crisis coming from the hospital or something like that. There may, there may only be an element of this. And so it’s you know, you’ve mentioned this before, I think I think we’ve it’s on the recording, but we talked about it beforehand, as well. Part of the work is getting them back to a place or getting them to a place where they can get to, you know, a better, a better state of mind to be able to do, you know, like the advanced directives or those kinds of things. But they may not have that when they walk in the in the session the first time if they’re in high state of crisis or are having a lot of hard things going on. And so I think you may have to make that assessment at the beginning.
Curt Widhalm 39:57
But yeah, that’s exactly what I’m talking about is you are responding to the level you are making a decision in those moments that you are not respecting patient’s autonomy in those moments. And I’m advocating that that is the correct decision, because you are doing that assessment to say: okay, because of the situation, I am stepping in with the knowledge that I have as a mental health professional, this is the right thing to do. I am making a paternalistic decision in this moment to respond to your needs. And once we restore you, then we will go back and we will provide you the full buffet of informed consent options that you should have when you have the capacity to make that consent. I I’m glad that you bring that up. I’m genuinely glad because that is the perfect example of this.
Katie Vernoy 40:50
I don’t love the term paternalism. I prefer protective. But I think, but I think there’s I understand what you’re saying. I dont, we don’t need to go into that.
Curt Widhalm 41:00
No. I think I think we I think we do need to get into that distinction. Because part part of this is looking at health care historically. And one of the big problems up until this 1972 Court of Appeals case is that all healthcare providers were in this very asymmetrical paternalistic position where: we know better than you do, as I say.
Katie Vernoy 41:24
Yeah.
Curt Widhalm 41:24
And I think our field has largely done a good job over the last 50 years of helping to incorporate clients more and more into their treatment. We have things like recovery oriented systems of care. We have clients having better access to their notes. We have good faith estimates where all of these things, they’re more burdensome to us as professionals, but what they do is they give clients the legal right, to be able to be involved, as much as humanly possible into as many aspects of their healthcare treatment as possible. Our field has done a really good job of that, on the legal end of things. I think, kind of hidden deep in the background of this is, are we also doing this on the ethical end of things, which is, are we actually evaluating do people, and the point of this episode, do people have the autonomy to make those decisions at all of these points?
Katie Vernoy 42:25
I think it’s also a clinical decision, too. So, it the ethics and the clinical, I think are very entwined…
Curt Widhalm 42:31
Sure.
Katie Vernoy 42:31
Just as a comment.
Curt Widhalm 42:31
Yes, they are. And I think that that’s where we have to draw attention to them. Because we do sometimes have to make sure that people are informed of all of their decisions. Sometimes that does require us to act paternalistically because we do have some information. I know that there’s a lot of negative energy around the term paternalism because it gets equated with that asymmetrical paternalism. This is where I love the term: libertarian paternalism. This comes from Richard Thaler in behavioral economics, which is: provide people with all of their options. You can influence them a little bit with your knowledge, as a professional, they can still make the decision, but you can set them up in ways to still make the decision that is best for their overall health care treatment.
Katie Vernoy 43:23
But that’s, that can be fairly manipulative, right? I mean, how you frame it, what you put, you know, like, when, before we were recording, you talked about kind of setting up the buffet with the salad first and the sweets at the end. I mean, it does deeply impact the decisions people make. And how do we know if someone is actually autonomously making a decision or being deeply manipulated by how we framed all the options?
Curt Widhalm 43:49
I don’t think that you are randomizing the way that you present information to clients. You don’t…
Katie Vernoy 43:55
Of course not, of course not.
Curt Widhalm 43:57
There’s always going to be some sort of bias there.
Katie Vernoy 44:01
Of course. That’s why that’s why I wanted to bring it up, though, because it’s, it is something that we can’t get rid of. But I think that is the fear for folks who kind of radically allow their clients to diagnose themselves and to determine their treatment is that we we’re worried about this huge manipulative power that we have to to encourage our clients to behave in certain ways or to make certain decisions. And so I think it is it is a reasonable philosophical conversation to have of how okay, are we with how manipulative we can be in this situation? And is it about being aware that we’re manipulating versus being manipulative based on bias? Like, I feel like I get very worried sometimes that the way that I interact with my clients leads them to live their lives in a certain way. And so I’m I try to be very conscious with it while also still, you know, putting my my responsibility towards information and making sure that they’re actually able to make auotonomous decisions. But, but I think it’s worth a couple of minutes of conversation about this manipulation and bias.
… 45:07
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Curt Widhalm 45:07
And this is where understanding that there’s going to be some there. Some bias from all of us, we all have our biases, it’s being able to do it in a way that we are upfront about things. And well may, it might be helpful in order to provide an example from this. And I will give credits that this is stolen from Dr. Ben Caldwell with permission. So, one of the scenarios that we bring up is, let’s say that you are working with a client. Let’s, I’m just flat out stealing this. I make fun of Dr. Caldwell, all of his client scenarios. It’s always centered around somebody named Marco. Marco, Marco is divorced. Marco lives in the same town as his ex spouse and kids. Marco is your client. Marco is extremely depressed, his kids are reaching an age where their peers are becoming more important. And Marco sees the writing on the wall that he is going to be less and less important to his kids as they progress through middle school in high school. Marco comes to session and says, you know, I’m thinking about moving out of states back to my hometown, with my parents, my friends from my previous life. I think I’m gonna do it. Now, the question that we often pose to our law and ethics classes on stuff like this is, how much do you respond back to Marco with in this situation? And especially Katie, as a marriage and family therapist, do you bring up information like, there’s a ton of evidence that says, you being physically near your kids and being accessible to them ends up in all kinds of literature being more beneficial to them as far as you know, things like higher test scores, getting into college, being less involved in truancy and drugs and those kinds of things. Do you bring that kind of stuff up? Or are you just like, you know, what, Marco, good luck, I’ll find you a therapist or if I’m in a compact state, we can do things over telehealth.
Katie Vernoy 47:17
I think this is a great example. Because I feel like there there’s a particular bias towards you got to stay by your kids that is presented with the research that you’re describing.
Curt Widhalm 47:29
So the truth is bias.
Katie Vernoy 47:32
I love how you interrupted me before I finished the other part of that. I also wonder, and part of this is, oh, maybe I shouldn’t say this, because it’s a spoiler alert for anybody who hasn’t watched Ted Lasso. But I’ve also been watching Ted Lasso about how impacted he was by his dad’s suicide, right. And I think about how kids are impacted by a deeply depressed parent, and what that could look like. So to me saying, well, there’s all this stuff that says you need to sacrifice yourself to stay close to your kids. And I don’t know that there’s an equal, and I’ve not looked at the data, I would I would want to have data, but I’m assuming that there’s also elements around how depressed parents impact kids. And so to me, I feel like I wouldn’t, I would probably, to the best of my ability, help them to kind of identify what’s going through that decision. And, you know, again, referring to the decision making episode that we did, really talk through all of the options and and all of the different things. It’s not do I leave or not? There’s, there’s a lot of different pieces to this, you know. But I would deeply go into that decision. But I wouldn’t only present the data that supports my the decision I think they should make, which is to stay. Because I feel like that is bias. And that is manipulative. I’m not going to be like, oh, good luck. Off you go. I would actually deeply dig into it. But I’m hoping I wouldn’t only present data that supports a single decision, because I feel like that is too manipulative.
Curt Widhalm 49:03
So what you’re describing is libertarian paternalism.
Katie Vernoy 49:06
Absolutely. But I but the way you described it was would you tell them this information? It’s like, maybe, but I would have to time it. Because it would be too much of a like, Dude, you got to you got to know this information in the first conversation about moving, I wouldn’t do that.
Curt Widhalm 49:23
How long is this conversation? You know, all right, we need to come up with, all right, if you move and you’re depressed away, how much does that affect your kids? If you stay in, you’re depressed? How much does that affect your kids? If your stay and you fix your depression? How much does that affect your kids? If you stay and you only kind of partially address your depression, how much does that affect your kids?
Katie Vernoy 49:46
Well then, it’s also what do you want for your life? And how important is it that you impact your kids in a certain way. You’re also making the paternalistic decision that they should care, the impact on their kids. Right? I mean, there’s a lot of moralism here, that moralistic kind of behavior here of like, you should care what happens to your kids. Maybe they don’t. Right? And granted, I would love them to care about their kids. But like, there’s, there’s so much here that I feel like you, you need to deeply, you can’t abdicate the responsibility of helping them make a really informed decision. Recognizing that there’s probably complexity around the relationship with their kids and their ex spouse. There’s complexity around how much can they do based on their depression, because maybe they’re deeply depressed, but very realistic, or maybe they’re deeply depressed. And there’s some psychosis there. Like, there’s so much assessment that has to happen. So, I think we agree that you have to have some sort of a protective paternalistic, whatever the right word is, to get them to a stronger decision making process. But I think if we’re only coming at them with stuff that supports the decision that we’re wanting to make, I don’t, I feel like that’s manipulative, and not helping them to become more able to have autonomous decision making.
Curt Widhalm 51:02
Ounce of prevention comes back to: here’s how I work.
Katie Vernoy 51:07
Yeah, absolutely.
Curt Widhalm 51:08
Here’s, here’s what my license type ends up being. You’re bringing up here’s what my morals are in therapy.
Katie Vernoy 51:15
Sure.
Curt Widhalm 51:16
All of these are things that you and I have advocated for six years now.
Katie Vernoy 51:22
I can’t believe the podcast has been six years. It feels like it’s been like, very little time and like, since the dawn of eternity.
Curt Widhalm 51:29
But these are consistent with kind of the not only what kind of therapy do you practice? But what is therapy like with you? And if you are more upfront with, you know, in, you know, I look at the whole person as part of kind of the treatment. I look at how their relationships are also going to be affected by the decisions that they make. In general, I’m going to be more biased towards improving those relationships. But that doesn’t mean that I’m absolutely like every relationship needs to be improved upon. Some of those are addition by subtraction kinds of things and setting some healthy boundaries by putting limits on other people. But if what we’re trying to get to, as far as you know, some ideas for people to take, like, yes, there is a lot of this stuff. And whether we’re conscious of these biases in presenting this information or not, those biases exist. And the more open that we are with clients about this is actually true client autonomy and autonomous decision making. It’s not just taking what clients say, up front as unchallengeable fact, and just rubber stamping that as a good decision.
Katie Vernoy 52:47
Absolutely. I agree with that 100%, I was just wanting to make sure that we dug deeply into the other side. Because just saying you have a responsibility to try to help your clients make good decisions don’t, doesn’t get to the other elements. I think, for me, there’s a lot you can say up front. But if you don’t recognize how you’re, how you’re situated in the world, your bias is going to impact that. There are times when just rubber stamping your clients decision may be better than helping them to make a harmful decision because of how strongly you believe that something must happen. And so so I think there’s the extremes, you know, one sided, whatever you call it paternalism versus complete abdication of a professional responsibility. But there’s a whole bunch of gray area in the middle of how we do it. And I think being able to do your own work, understand your bias, understand how you work. I mean, some people have a difficulty, a huge difficulty describing it. I mean, that’s why there’s folks who have whole businesses helping people to write copy and, and, and make, you know, you know, its marketing, but still like being able to clearly understand in the in the language that your clients understand like, what it is that you do and how you do it. And so this all comes back to deep self awareness of who you are as a clinician, and your willingness to step forward into potentially conflict, if your client disagrees with you into deep clarification and all of that versus stepping back and saying, Well, my client knows themselves I must allow them to do what they’re thinking to do.
Curt Widhalm 54:37
I’m glad that you bring up kind of that moral piece going back a couple of things that you said ago. And this is coming from an article called Paternalism, Placebos, and Informed Consent in Psychotherapy: The Challenge of Ethical Disclosure, and this is a 2016 article by Blease, Trachsel and grosse Holtforth. And one of the things that they conclude is adequate disclosure and informed consent serves the empowerment of patients. It emphasizes the patient’s role in making treatment decisions, increasing a sense of ownership over the process. And what is not being said here is fully giving over every decision to clients, it’s emphasizing their role in the process, not just giving them, here’s the keys to the car. This is helping them to learn how to drive the car. And with that comes a lot of unfortunate education experience that you have as a professional and the ability for you to use it. And I think that, in a lot of these examples that we’re talking about is that and I look at this, and one of the questions that my class brought up to me is, is this a generational thing? Is this, you know, many of my students are younger millennials, and some of the oldest Gen Zers at this point in grad school, which few years we’re gonna have to talk about an episode, as far as Gen Zas therapists to follow up are millennials a therapist episode from a few years ago. But they did ask like, is this just part of Gen Z, kind of taking the idea that everybody has their truths, and we are here to support them and to be able to make that something that is part of what they want out of mental health care? And I would say there’s a line somewhere in there, where are are we supporting clients if they don’t know what all of their decisions are? How do we present that information to them? Is the crux of this. We have a responsibility as professionals, as you’ve outlined, for us to say, Have you considered these other things? You know, if we’re, if we’re going back to Marco, it’s, we do have a responsibility, okay, I’m a, I’m a marriage and family therapist, I consider the impact of the family in our decision making. And guess what, my license requires me to do that, because that’s part of the scope of practice. That’s why we have an MFT license versus a PCC license. You’re gonna get that bias because that’s what the state of California stamps upon me in my role of working. You might not get that from somebody else. But part of the problem is, we’ve all just blended together so much. But we do have a responsibility to bring this stuff up. And the fear that bringing up facts is going to influence people seems to be a minor inconvenience that’s actually part of our job.
Katie Vernoy 57:56
I just am laughing. Because what I think back to that millennials as therapist episode. That was kind of what I was saying. You were like, but they know more, and you got to learn from them! And I now we’ve our roles have been reversed. I’m saying, we need to learn from our clients, we need to make sure we fully understand their perspective, make sure that they fully have all the knowledge that we have, but recognize we may not have all the knowledge that they have. And you’re saying, but we have to give them enough information so they can make decisions. And we need to take, you know, kind of that stance. So it’s really interesting, because I think both are true. I think they’re both possible. But it’s, it’s funny, because like I’m the one that’s going but wait, we have to give them agency. I’m not saying, you’re not saying this, but like, we have to like fully be aware of their reality. And you’re saying but they need to be aware of other reality.
Curt Widhalm 58:50
I think we need to go back and re-listen to that episode together. Because I don’t remember that. But…
Katie Vernoy 58:55
Well, I kept saying you need to give supervisees enough information to be able to do the job. And sometimes they need more structure than…
Curt Widhalm 59:05
I think I think we need to go back and listen to that episode together and do a commentary on it for our Patreon members. But I think that in trying to make sense of this, there’s a lot of laws that tell us here’s where, where patient autonomy is part of the decision making process that we’re giving in a lot of these examples is where autonomy may not exist. And it’s being able to convey that as part of your decision making process. And again, I don’t think a lot of people are doing that consciously. I think that we are trained, whether it’s experience, the community mental health people who are making those, like decisions where it’s like, alright, this is a, you know, day where, I’m reacting to an actual crisis that’s going on that was not planned for. Therefore I’m stepping in, in certain ways, is different than, alright, here’s, you know, private practice high up in a expensive office building where we’re, you know, talking about existentialism in philosophical sorts of ways. Yes, there are fundamental differences there. And those clients should be treated differently in those moments where the autonomy levels are different. I think the fear of stepping in is based on, you know, law and ethics professors being like, you can be sued for anything. But good law and ethics professors are going to say, Good decision making is your best defense. Like, if you accept, like any anything can be a lawsuit, your thought process going into these things and your documentation of that thought process. Hey, I don’t feel that this client has autonomy in this particular moment, because of X, Y and Z. That’s why we’re making this decision. That’s why we are able to tell if we go back to the eating disorder client. Here is how this was explained to client. We need to restore you to this level of autonomous decision making before we can continue treatment. This is not, I’m withholding treatment from you, because you are not able to participate. This is more of we have to restore you to a level of functioning in order to be able to do treatment in the capacity that I can provide it to you. It may be two different ways of saying the same thing. But one leads to patient’s autonomy. The other, the I’m withholding from you is the incredibly asymmetrical paternalism, right? It’s with the goal of restoring patient autonomy first, and I’m emphasizing.
Katie Vernoy 1:01:57
I think there’s probably a whole other episode on how we communicate those things. Because I’ve heard, especially within the eating disorder community, that there are clients who cannot get treatment because their eating disorder is so bad. So that’s a whole other conversation. But when you were talking, I feel like a good sister episode is the defensive therapy practices episode. So I’ll link to that in the show notes. Because I think there’s, there’s the abdication, but then there’s also the full stepping forward of, I’m going to be completely 100% defensive. And maybe those are not opposites. I think that there’s some that are very much on the same page. But it just is very interesting, because we have a lot of decisions that we’re making. And I see that there’s, you know, out in the world, people think, Oh, well, a therapist just gets paid to listen to you. And this is I mean, this is the stuff, right? This is the how do we help our client get to a place where they can fully make autonomous decisions in treatment in their life, and feel confident in them, then feel confident that they’re doing that in a healthy way, and how they define health. But I think there’s that that element of so much nuance, based on whether it’s generational differences, cultural differences, privilege differences. About how much as a therapist, am I supposed to, in you know, encourage decisions to go a different way or impact their decision making, and when. That I think this conversation has been very helpful with that. But I’m sure there’s going to be more questions and conversation that comes from this. And so I really hope that as a as a result of this, we get folks who are wanting to come into like a Q&A with us and what like our Patreon Q&A is or Coffee Hours. So we can actually dig into this because I think people have opinions on this. And there’s stuff because the two of us have our own perspectives that we’ve missed, I’m sure. And so to me, I’d love to have like real live conversations, whether it’s in social media or in person with our Patreon folks or in person on video. Because I think that there’s so much to this. Like you said before, and I mentioned as well like this is bigger than I think we give credit to because it is so poorly defined. And our ethics codes are and it’s just a passing sentence. And so I’ve enjoyed this conversation clearly because we’ve been both very lively about this, but I just feel like there’s there’s a lot that probably will come from this. So I’m here for it. Send us emails or, you know, shoot us additional questions on social media or join our Patreon so that you can join our actual real conversations.
Curt Widhalm 1:04:29
You can find our show notes over at mtsgpodcast.com will include our list of references there. Follow the directions at the intro and the outro of the episode for how you can get your CE information. Follow us on our social media, join our Facebook group, the Modern Therapist Group. And like we’ve mentioned a couple of times our Patreon supporters do get some extra benefits. So that’s another way that you want to support us you can do it through there or Buy Me a Coffee. And until next time, I’m Curt Widhalm with Katie Vernoy.
… 1:05:04
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Katie Vernoy 1:05:05
Just a quick reminder, if you’d like one unit of continuing education for listening to this episode, go to moderntherapistcommunity.com, purchase this course and pass the post test. A CE certificate will appear in your profile once you’ve successfully completed the steps.
Curt Widhalm 1:05:19
Once again, that’s moderntherapistcommunity.com
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