ERK4499 - SECTION 3: THE STATEMENT OF UNDERSTANDING
Section 3: The Statement of Understanding/Informed consent
A statement of understanding, also called a statement of services or informed consent agreement, is a form provided to a client at the first session that provides clear, written information about important aspects of treatment, beginning the therapeutic relationship with clarity about informed consent. This form allows the clinician to cover, explain and explore these treatment issues with the client before he/she has made an official commitment to enter into treatment. Should any aspect of treatment be unacceptable to the client, he/she can decline to move forward with treatment.
If the treatment terms are acceptable, the client is asked to sign and date the statement of understanding, and is offered a copy of the document for his/her records. Informed consent requires three elements: adequate information on which to base the consent, capacity for making the decision, and freedom from coercion. [President’s Commission for the study of ethical problems in medicine and biomedical and behavioral research. Making Healthcare Decisions. Washington DC: U.S. Government Printing Office, 1982.] A well constructed, and well presented, statement of understanding helps the clinician meet this standard. It also creates a record of this action that allows the clinician to refer back to something tangible should there ever be disagreements concerning the terms of treatment.
Because one of the key components of ethical treatment is a clear right to privacy, the statement of understanding can also serve as a notice of privacy rights under HIPAA. The statement of understanding usually covers the following items:
- The length and cost of sessions
- The clinician’s policies concerning acceptance of insurance payments
- Costs for secondary services, such as copying records, phone calls, or document creation
- Payment policies
- Cancellation policy
- Rights to privacy and confidentiality
- Privacy rights and other rights covered under HIPAA
- Policies concerning the review of case records by the client
The statement of understanding can also address the following:
- Information about the treatment approaches to be utilized
- The risks and benefits of therapy and client responsibilities within treatment
A template for a statement of understanding is shown on the following pages.
STATEMENT OF SERVICES/NOTICE OF PRIVACY PRACTICES
Pat R. Clinician, LCSW provides counseling services that include assessment, evaluation, diagnosis, and direct psychotherapy treatment in accordance with professional standards of practice. These standards of practice include providing each client with information concerning several aspects of the counseling process and the counseling relationship.
Treatment Approaches Utilized in Counseling
The primary modes of treatment to be utilized in counseling are Cognitive Behavioral Therapy, Psychodynamic therapy, Solution Focused Therapy, and family systems models of treatment.
Treatment Areas not Provided in Counseling
Services that are required by the court for anger management, domestic violence, or substance abuse are not offered, and documentation attesting to the successful completion of treatment for purposes of meeting the requirements of the court will not be provided.
The Risks and Benefits of Therapy
Psychotherapy has been shown to be effective for the improvement and resolution of many kinds of personal problems. The process of psychotherapy, however, does involve risks on the part of the client. Change, and the processes involved in creating positive change, can at times be difficult and unsettling. While every attempt will be made to prepare each client for this, each client must make the decision to enter into this process with a clear understanding of these risks.
Estimated Length of Therapy
The length of the course of psychotherapy treatment can vary depending upon the severity of the problems presented, and the ability of each client to utilize therapeutic approaches. Whenever possible, each client will be given an estimation of how much time the psychotherapy process will take.
Length and Cost of Therapy Sessions
Unless otherwise stated, psychotherapy sessions will consist of 45-50 minutes of direct treatment, with 10-15 minutes allotted after the direct treatment for the clinician to complete treatment notes and review the content of the psychotherapy session. Unless otherwise agreed to, each psychotherapy session will be charged at the rate of $125. Clients who have mental health benefits through their insurance will be billed at the rate covered by their insurance, under the arrangement noted in a section below.
Policy for Billing Insurance
Where a professional relationship exists between the provider and the client’s insurance carrier, the client will be expected to pay the co-insurance amount designated under the policies of the insurance carrier. Claims will be filed by the provider of services. Where a professional relationship does not exist with a client’s insurance policy, the client will be expected to pay the full amount for each psychotherapy session and to file his/her own claims. In such cases, where necessary, insurance forms and receipts will be filled out by the provider so as to allow the filing of claims by the client.
Payment Policy
Unless otherwise agreed to, payment will be expected at the end of each psychotherapy session.
Cost for Secondary Services
Time spent performing services that support the counseling, such as writing reports, contact with outside parties by phone or letter, and supportive phone contact to the client outside of regular sessions, will be billed at the rate of $100, prorated for the amount of time spent engaged in the service. Time spent in phone contact to set or re-arrange appointment times, or brief phone contact to give or receive relevant treatment information will not be billed. These services are generally not covered by insurance mental health benefits and will be billed directly to the client.
Cancellation Policy
Clients are expected to provide 24 hours notice of cancellation of any scheduled psychotherapy session. For any unkept session not cancelled prior to 24 hours, the client will be billed the full amount of the cost of the session, unless agreed to otherwise prior to the unkept session. This cost is not covered by insurance, and the full amount will be billed to the client.
Client Rights
Each client has the right to expect competent psychotherapy treatment in accordance with accepted professional standards. Each client has the right to request information about any aspect of treatment, including but not limited to assessment results, treatment techniques utilized, course and direction of treatment. Each client has the right to provide feedback to the provider about where treatment is being successful and unsuccessful, and to terminate treatment at any time.
Client Responsibilities
Each client is held to be responsible for engaging in the therapeutic process in ways that further treatment progress, making available to the provider such information as is needed to provide effective treatment, and participating in directing the course and direction of treatment.
Policy for Communication via Social Media
It is the policy of Pat R. Clinician not to initiate any connections with clients via social media and to decline any invitations to connect with clients via Facebook, LinkedIn or any other form of social media, or otherwise engage in internet based communication in ways that might reveal the existence of a therapeutic relationship. This policy is designed to protect the rights of each client to privacy and confidentiality. This policy will be followed both during the time a client is in treatment and after a client has discontinued treatment.
Clinician Duties
Pat R. Clinician, LCSW is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices concerning your health information. In addition to fulfilling this obligation through the provision of this Statement of Services/Notice of Privacy Practice, the clinician is responsible for providing any additional information that may be required to make you fully aware of your privacy and treatment rights.
Confidentiality
The confidentiality of all records is covered by state and federal law. Federal standards for maintenance of your records have been defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The records of clients with alcohol and drug abuse problems may also subject to further restrictions as outlined in Federal Law 42 CFR Part 2. These guidelines mean that all client information, including records of treatment, may not be released except under the following conditions:
1) When the client signs a valid release of information;
2) When a disclosure is made to medical personnel in a medical emergency;
3) When a client expresses suicidal or homicidal intent with imminent risk;
4) When there is suspected child or elder abuse or neglect;
5) When disclosure is required by a valid court order.
Your Rights
Under HIPAA, you have the following rights:
1) The right to inspect or copy your own health information, except to the extent that the information contains psychotherapy notes or information compiled for use in a civil, criminal, or administrative proceeding.
2) The right to request restrictions on certain uses and disclosures of your treatment information.
3) The right to amend health care information maintained in your client record.
4) The right to request and receive an accounting of disclosures of your health related information made during a period up to six years prior to your request.
Statement of Validation.
I have read this Statement of Services, it has been adequately explained to me, and I understand its contents.
By Client(s)
___________________ _____________________ __________
Print Name Here Sign Here Date
___________________ _____________________ __________
Print Name Here Sign Here Date
___________________ _____________________ __________
Print Name Here Sign Here Date
___________________ _____________________ __________
Print Name Here Sign Here Date
By Pat R. Clinician, LCSW
___________________ _____________________ __________
Print Name Here Sign Here Date
Key Details Concerning the Statement of Understanding
As we noted in the previous section, there should be a logical coordination between each part of the clinical record and all other parts. This begins with the statement of understanding. If a clinician is going to engage in treatment utilizing specific treatment approaches, those treatment approaches should be noted within the informed consent agreement. This allows the client to make informed choices about whether those treatment approaches will suit his/her needs and aspirations for treatment.
The statement of understanding can be also designed in a way that clarifies what areas of treatment a clinician does and does not do in his/her work, allowing for discussions prior to a formal decision to move the treatment relationship forward. For example, if a clinician does not provide services to clients who are ordered by the court to seek out treatment, then this can be clarified in a section of the statement of understanding. This protects the autonomy of the clinician and the needs of the client by avoiding situations in which the clinician is asked to provide services he/she does not do after one or more sessions have been held and a therapeutic relationship has been established.
Because there are actually risks that can accompany a decision to enter into treatment – no matter what mode of treatment is used - there is a section in the statement of understanding that notes these risks from the moment of the first face to face contact. The process of change can place the client in a position of facing emotional and psychological material that is painful and unsettling - as well as potentially destabilizing. Change will often include the restructuring of ideas, beliefs, values, relationships and other parts of the self that create a sense of cohesion, meaning and identity. In order for the restructuring process to occur, the old structures may need to loosen their hold over the client’s way of interacting with the world, and this is what can create the difficulties.
Usually this period of destabilization is temporary and the client moves through it, but during that time there can be increased risks for psychological and behavioral responses to the experience. It is helpful for a client to be forewarned concerning these issues, and that is what this section of the statement of understanding attempts to do.
Over and above the normal destabilization that accompanies both traditional therapy and the change process, there are certain modes and approaches to treatment that can have enhanced risks for certain groups of clients. For instance, sexual abuse survivors and other clients with a significant history of trauma can be particularly vulnerable to kinds of therapy that expose them too quickly to their traumatic memories. Ideally, the clinician will have clarity about where certain treatment approaches may be contraindicated, and will choose to err on the side of caution with the application of the treatment approaches that create the enhanced risks.
This is especially relevant if a clinician is attempting to utilize treatment approaches that are innovative and less thoroughly researched. The work of therapy involves making important decisions about how to balance the risks and rewards of treatment. A very skilled clinician may decide that an innovative treatment approach can offer advantages to the client’s process and may be worth the risks involved in moving beyond more traditional techniques of therapy. However, the clinician should first make a conscientious attempt to secure the informed consent of the client in deciding to move this forward.
If the clinician is inclined to bring into treatment those less traditional treatment approaches, it is extremely important that this issue be addressed somewhere in the statement of understanding. This establishes a record of the consent offered to and accepted by the client. Should negative outcomes ensue from the choice of the riskier treatment, this helps protect the clinician from liability.
It is important to note that it is not sufficient to simply provide the client with this kind of information within the written document. It is also the responsibility of the clinician to make sure that the client has sufficient understanding about the implications of this kind of information. If the client does not understand what constitutes psychodynamic therapy, or systems based therapy, then informed consent has not been reached.
There are several assumptions that the clinician should not make concerning the statement of understanding. It should not be assumed that the client understands the process of therapy nor any of the different treatment approaches that may be chosen by the clinician. It may be useful to ask the client is he/she has any questions about the nature of the treatment approaches that will be used, and to provide some brief explanations of what constitutes the predominant theories that will inform the treatment.
It should be assumed that the client does not have a thorough understanding of his/her rights within the treatment relationship, including the right to privacy. When a clinician engages in some careful explanation of the right to privacy, it can support the development of trust within the relationship. However, it can also be useful to spend a little time on the responsibilities inherent in the treatment process. This begins to prepare the client for the work of therapy, and helps prevent later problems with dependency, as well as disappointment when the client is not allowed to assume an overly dependent stance in the therapy.
Most fundamentally, it should also not be assumed by the clinician that every client will read each section carefully. It is always important to remember how confusing and overwhelming the first session can be for many clients. During the first session, the client is usually preoccupied with a number of other concerns and worries besides completing the paperwork. In truth, most clients may elect to perform only a cursory reading of the statement of understanding, not taking the time to look at each section carefully. This can mean that the client does not understand important aspects of the agreement into which he/she is entering.
During the first session, the clinician as well has a number of other concerns and worries that work against a thorough exploration of the statement of understanding. During the first session, a clinician needs to focus on the establishment of trust - and creating the sense that the client’s concerns and worries are important to the clinician and central to the treatment process.
Spending the first hour just going over the informed consent agreement in tedious detail may work against these other important components of entering successfully into the treatment relationship. There is a balancing process that must occur here, and a conscious decision may be made to return to provide progressively deeper clarification about the informed consent agreement over the course of more than one session.
For all these reasons, it is recommended that each client be given a hard copy of the statement of understanding and encouraged to read it more thoroughly at their leisure prior to the next session. This can be accompanied by a verbal statement expressing a willingness to answer any additional questions that may arise out of examination of the statement of understanding.
Additionally, it may be wise to return from time to time to the statement of understanding and the informed consent elements contained therein as the treatment moves forward. This will require that the clinician be attuned to opportunities to provide further clarification, and a good sense of timing concerning when to bring up informed consent understandings.
As the first session winds down, for instance, there may be an opportunity to refer to the cancellation policy when a time for the next section is set. If a release of information is created that allows the clinician to speak with other treatment providers, it affords an opportunity to reinforce the privacy sections of the statement of understanding. As a treatment plan is formulated and shared with the client, it gives the clinician a chance to further clarify the treatment approaches to be used.
Questions concerning payment and the use of insurance plans should also be covered verbally, in addition to what is covered in the statement of understanding. For many people, money is an emotionally loaded concern, and disagreements or misunderstandings about money can disrupt the formation of trust within the therapeutic relationship.
Included in these nuts and bolts discussions should be real clarity about a clinician’s cancellation policy. Many clients are unaware of the fact that insurance companies do not pay for missed sessions and can be surprised and upset if they are asked to pay the full amount for a cancellation or no show. These open discussions can be incorporated into the therapeutic process, since they cover issues related to responsibility and accountability on the part of the client, and the modeling of planning, forethought, and healthy communication on the part of the clinician.
Finally, one of the most recently emerging areas that should be covered in the informed consent agreement is concerned with the use of social media. There are considerable complications related to privacy should the client establish connections with the clinician’s social media platforms. For members of the generation that has grown up with social media, there may be an extremely high level of comfort with the sharing of personal information through these tools. Clients may feel that it is altogether natural to request connections with their clinician on Facebook, LinkedIn, Twitter, or other electronic communication vehicles.
However, there are risks and dangers for the clinician who has a strong web presence on these platforms. First, it can make it difficult to project a sufficient level of professionalism and therapeutic distance if one’s personal information is available to a client. This can have negative effects on the use of professional authority and the client’s willingness to trust the clinician.
More importantly, it is very difficult to offer a sufficient degree of protection for client privacy if social media connections are made. If the very nature of social media is to share personal information in a widely distributed way, the clinicians do not want to be placed in the position of participating in that process. Clinicians are guardians and protectors of privacy, not enablers of sharing. The statement of understanding - and related discussions concerning privacy - represent an opportunity to clarify our professional commitment to privacy protection and the reasons why this protects the client.
Because the statement of understanding should also contain information about the client’s privacy rights under the Health Insurance Portability and Accountability Act (HIPAA), there is an opportunity to connect the restrictions on the use of social media with a larger discussion about privacy, the law and clinical professionalism. Again, this is an opportunity to display the kinds of conscientious behaviors that establish trust and lay a solid foundation for the therapeutic relationship.
One major issue not addressed around the use of this form is the question of rights when more than one client is being seen in treatment in conjoint or family sessions. This question will be addressed with some thoroughness in another section of this course, as it will have implications for a number of the different forms and templates to be covered in this course.
Informed Consent and Electronic Communication
Use of E-communication Devices for Contact with Clients
Because communication with clients may involve the transferring of Protected Health Information over electronic devices that are not perfectly secure, it is recommended that clinicians address e-communication in the informed consent document and within the informed consent process. Under the guidelines denoted in the 2010 HIPAA update known as the Hi-Tech Act, clinicians are expected to utilize secure, encrypted platforms to communicate with clients: email, texting, chatting, etc.
However, clients may not understand the risks to their privacy through the use of unencrypted platforms and/or may choose to communicate via unencrypted platforms because they are less cumbersome to use. In real life practice, clients simply prefer the ease of unencrypted platforms – where a separate password is not needed in order to open a message – over more secure encrypted approaches.
To address this discrepancy between privacy rules and the real world of how clients choose to communicate, it is sensible to use the informed consent agreement and the informed consent process to educate the client about the potential risks to their privacy over unencrypted platforms. Many or most clients will still prefer ease of use over security of information transfer, but in securing consent for this, the conscientious clinician will be meeting his/her ethical obligations to this aspect of privacy.
An example of how to address this is shown below:
The Use of E-communication Devices
Secure and private communication cannot be fully assured utilizing cell/smart phone or regular email technologies. It is the client’s right to determine whether communication using non-secure technologies may be permitted and under what circumstances. Use of any non-secure technologies to contact Jan Q. Clinician, LCSW will be considered to imply consent to return messages to client via the same non-secure technology, pending further clarification from client.
If the clinician wishes to keep a thorough record of what the client agrees to in the use of e-communication, then a checklist may be constructed for the client to denote what is permitted and what is not: email, text, cell/smart phone, fax, etc.. This is provided in the next section.
Use of E-communication for Conducting Counseling: Telemental Health
Clinicians across the US are increasingly using modern technologies to conduct clinical services over a distance, a service delivery model known as Telemental Health (TMH), or teletherapy. For clinicians who wish to add this option to what they are already doing, there are some important items that will need to be addressed in the informed consent agreement and process.
The International Society for Mental Health Online, has issued a set of principles for the provision of Telemental Health services that begins by addressing the informed consent elements that should be addressed during the informed consent process. In particular, the client should be informed about the process of providing TMH services, the counselor who will be providing the services, the potential risks and benefits of TMH services, safeguards against those risks, and alternatives to those services. (Source: International Society for Mental Health Online, Suggested Principles for the Online Provision of Mental Health Services, http://ismho.org/resources/archive/suggested-principles-for-the-online-provision-of-mental-health-services/)
Here are the elements that should be addressed:
Process: Possible misunderstandings when using TMH, turnaround time (for asynchronous modes of TMH), privacy of the counselor
Counselor: Name, qualifications, competency in TMH, how to confirm the above
Potential benefits of TMH
Potential risks of TMH
Safeguards for Privacy and the Process
Alternatives to TMH Services
Additional topics to address:
An Overview of TeleMental Health Services: Rationale for using TMH, potential uses of TMH, limitations for use of TMH services
Additional Points for Client Understanding:
No recording of sessions.
Overview of the degree of security provided by the platform used, but acknowledgement of the potential risk of access by others.
The possibility of interruptions to the technology, and the need to have work arounds for possible technical difficulties.
Need for emergency contact and procedures to handle loss of communication signal
The need to have a plan to manage emergency medical crises
The need to have a safety plan for mental health emergencies
Any clinician who provides TMH services should review this source material prior to entering into a treatment relationship in order to create a thorough informed consent document.