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Informed Consent: Is it Attainable With Students in Schools?
9/1/2014
Carolyn Stone, Ed.D.
Monday September 01, 2014
by: Carolyn Stone, Ed.D.

Section: Inside Insight


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A mother and father are getting divorced and ask you to work with her daughter to help her deal with the divorce. You are already working with child whose parents are currently divorcing and know of a third student whose parents are in the midst of a divorce as well, so you decide to form a group. Individual student conferences are held, and all three girls sign the informed consent document to participate. The consent form as well as your initial conversations before and during each group session stresses confidentiality and you are confident the students understand the trust that has been placed in them to protect each other. Have you received informed consent?

All professional ethical codes in the health, social and counseling fields require informed consent for clients and patients, and in many states it is a legal obligation in professional practice statutes. Informed consent comes from the medical principle of primum non nocere, “first do no harm.” Competence, knowledge and voluntarily agreeing are necessary elements of informed consent. Although informed consent is one of the most represented values in the helping professions, many of the codes including the ASCA Ethical Standards for School Counselors recognize that informed consent is difficult and sometimes impossible to attain.

“Professionals are aware that even though every attempt is made to obtain informed consent it is not always possible and when needed will make counseling decisions on students’ behalf. Informed consent requires competence on the part of students to understand the limits of confidentiality and therefore, can be difficult to obtain from students of a certain developmental level” (ASCA, A.2. 2010).
Informed consent for students in schools requires the student to have knowledge of all the components of informed consent, is voluntarily engaging in the counseling services being providing and is competent to understand the implications both positive and negative for engaging in the counseling. Informed consent is not a static ritual but a culturally and developmentally appropriate process that is repeated as needed and broken down with clear explanations as to the counseling goals, the limits of confidentiality and how students can voluntarily participate or exit the services. Competence means students’ decision-making capacity enables them to rationally appreciate the facts, breadth and consequences of entering into the counseling agreement.

Just as school counselors must come from the posture that confidentiality can never be guaranteed, so too must they come from the stance that informed consent is largely unattainable with students in schools. Even when a school counselor breathes easy, secure in the fact that a student is developmentally mature, has solid reasoning ability and understands all the nuances of informed consent, it is best practice for school counselors to question their confidence. Informed consent from a minor mandated to be in the school setting is the rare exception, not the rule.

Setting aside all the other issues in this scenario, (i.e., confidentiality, informed consent, appropriateness of school group topics and parental involvement) it is informed consent that should rally the school counseling profession to better delineate how fragile and infrequent this ethical imperative is to achieve.

Did the school counselor actually get informed consent when she talked to the students individually and obtained their signature prior to the group? In the case of the divorce group, the students put their trust in the school counselor with a level of confidence often unmatched with other educators. In many cases students will assume if the school counselor is asking me to do this, then it must be okay. These students probably never considered the potential for harm, but it can happen. Imagine what would happen if one of the group members heard her private world discussed in the hallways.

The reality of working with minors in groups requires school counselors to come from the posture that confidentiality will be breached, and informed consent will be elusive. Realize that whatever is said in a group will probably be tweeted or repeated within minutes after the group ends, even when students have signed forms saying they will maintain the confidentiality of other group members. By keeping this in mind, you can take the necessary precautions to monitor carefully what you allow one student to talk about in front of another student. School counselors risk the emotional safety of students when they expect that developmentally maturing students will respect confidentiality. The ASCA Ethical Standards specifically state that confidentiality “in group counseling cannot be guaranteed . . . and renders some topics inappropriate for group work in a school setting” (ASCA, 2010, A.6.c). Given minors mercurial behavior of changing friends and loyalties, there is an increased risk of breach.
School counselors have to be the guardian of informed consent, safeguarding, protecting and proceeding on behalf of students who cannot actually act on their own behalf. Being the custodian or guardian of informed consent means:
• Continuing to fight for time to run groups in schools. Groups are a critical tool in the efforts to advantage all students.
• Recognizing and honoring that the current reality of informed consent in schools falls far short of its stated goals.
• Foregoing services when the potential risks outweigh the benefits.
• Honoring the elusiveness of informed consent, while diligently trying to obtain it.
• Enhancing students’ ability to give informed consent and providing many opportunities for students to ask questions and to check for understanding.
• Avoiding a mechanistic, routine approach and finding developmentally appropriate words and opportunities to explain informed consent.
• Protecting voluntariness. Schools by their nature are not voluntary for the overwhelming majority of students. If an educator or parent/guardian asks for services a student does not want, avoid coercion and persuasion.
• Continuing to obtain written or oral permission from a parent or guardian for counseling services but still assuming the responsibility to protect the student. Repeating with each student revelation “this will be in the hallways” will heighten your vigilance to monitor what students say in front of each other.
• Attending to the role that language, cultural background and other elements of diversity play in the informed consent process.
• Reminding yourself that informed consent is not an event but a process to help students move toward self-governance.
• Evaluating and considering other approaches to help, such as generic groups on school success issues, to support students when a theme or topic group may possibly place them in harm’s way.

Carolyn Stone, Ed.D., is chair of ASCA’s Ethical Committee and a professor at the University of North Florida. She can be reached at cstone@unf.edu.