Man swimming in papersThe informed consent process is mighty important. But I think most would argue that it’s also important to, you know, actually do therapy.

The way things are going in TherapyLand, we can imagine a future where intake sessions are nothing but informed consent and signing papers. The therapy work starts the second time you meet. Something has to be done, and luckily there is at least one technique to help: layering.

At Person-Centered Tech, we have certainly added our share of paperwork to the process. Sometimes we’re just helping you do what ethics say to do, and other times we’re giving new ideas about things to discuss with clients. Here are just a few items we’ve added to the intake process (forms for these items are available free to our newsletter subscribers, as you can see here→):

We also strongly recommend Social Media policies. So we own that we’re not helping to lighten the paperwork load.

What is Layering?

Man during psychotherapy

What? More papers??

Layering is a method of providing a kind of “10,000-foot view” of the items in your informed consent process that clients can read through somewhat quickly. The layering pages then provide references to deeper pages where the client can find details.

Layering is well-exemplified by the layered versions of the Model Notice of Privacy Practice forms supplied at the Department of Health and Human Services website. We all know that “the HIPAA form” can get pretty long, and the model forms that the Feds provide are no exception. In the layered versions of those model forms, the first page contains highlights of the things the client needs to generally know about what’s in the form. It then directs them deeper into the document — to the page where details can be found.

A similar technique can be used for your communications and social media policies and many other policies that contain a lot of details.

Is Layering Legal or Ethical?

contractYour informed consent process needs to include all the information that each client needs, which is why it is getting so bloated as time goes on. Use of layering doesn’t change that — you still need to give them everything.

Layering simply makes it easier to navigate.

Compare layering to some other techniques that are sometimes employed to deal with document bloat:

  • Handing the client a stack of papers, telling them where to sign, and assuming they won’t actually read any of it (but you got your signatures.)
  • Eliminating paperwork items despite the fact that they contain information that clients need.

Layering, when executed well, can actually make informed consent much easier for clients. If you take a quick look at the layered HIPAA form provided by HHS, you’ll see that they use a nice combination of colors, shapes, and summaries to make the top page (the one with the layering) easy and attractive to read. Clients can read through that first page somewhat quickly, and they can follow up on items that catch their attention.

How Do We Use Layering With Risk Assessments?

Lens on PathOne of the big items that we offer to newsletter subscribers at Person-Centered Tech is the email and texting risk questionnaire with sample consent forms to match.

Because clients are so prone to texting or emailing us out of the blue, it can be easy to assume that these documents need to be reviewed in detail before therapy begins. That may or may not be true.

Not every client needs to start using texting or email right after the first session. A well-layered Communications Policy, followed up by a verbal check-in during the intake process, can clearly signal to clients that email and texting are not matter-of-course items in therapy. You don’t need to get into the details to signal this fact.

We recommend you ask clients in the first session if email or texting are communication methods they wish to use. Also remind them of the secure communications methods you have available. They can take the lead on how important that is at intake time.

Eventually, clients are likely to find the need to text or email you. They can bring it up at that time — often in the form of sending an unexpected email or text. If appropriate, simply respond with a phone call. Or if the client is texting to tell you they are running late (a very common first non-secure message from clients), you may choose to not respond and simply wait for them to arrive. You need to judge if it is appropriate or safe to do that, however.

At that moment when they’ve found a need to use email or texting, the client is usually motivated to do the risk assessments and planning around texting and email. Thus the assessment will work much better at that moment than during the intake, when they’re eager to start the therapy work.

You’ll need to use your clinical judgement with each client and with your overall population to determine if this approach is appropriate for them.

You also need to make sure that you have a Business Associate Agreement with your email provider, and that your email service is well-secured. When clients send you messages there, those messages need to land in a well-secured email account.

There are nuances to managing the security of texting and email in therapy, and we cover them in detail in the Level I session of our Digital Confidentiality Course Series→.

Layering Sounds Good, But Isn’t It Just More Work?

Kid Pushing Mom in Toy Car Wearing SuitsIt is true that a smooth informed consent process involves a lot of upfront work. It’s worth it, though, in saved headaches down the road and a better experience for clients.

Really great layering takes a kind of eye for design, as it works best when you use colors and layouts to present information cleanly to the eye. It’s still useful even without good design skills, however. So we recommend it no matter what.

The process can also be improved by overhauling your paperwork to streamline it, and by working on the verbal pitch you use during the intake process.

On April 14th, we will be doing a free (pay for CE) webinar with practice paperwork superstar Maelisa Hall, PsyD of QA Prep. She and Roy will talk about simplifying the informed consent process without losing any of the meat or effectiveness from it. Check out the event information here→

We wish you the best of luck with fighting off the paperwork deluge. With a little preparation, you can not only survive it, but also make it work for you.


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