This paper introduces empowered consent as a novel and robust approach to dealing with consent between a client and a sport psychology practitioner (whether accredited with a protected title or not). It must be acknowledged that ethical challenges in sport inhibit best practices in sport psychology. As a profession, sport psychology should move on from assuming that clients’ initial consent remains valid when it is not revisited in a timely manner. Accordingly, an interactive approach to agreeing on an intervention could sow the seeds for a better therapeutic alliance, enhance athlete autonomy and perceived competence in the face of challenges. These aspects are hallmarks of a successful intervention and could enhance practitioners’ competencies.
Two decades ago, Moore (2003) raised the issue that there has been little academic interest in how practitioners use consent procedures in sport psychology, despite the agreed-upon importance of this issue. An extensive literature search conducted for this paper shows that this is still the case. Some researchers have commented on consent challenges when sport psychology practitioners do work that is visible to others in the sport environment (Andersen et al., 2001), such as the use of teletherapy, (Watson et al., 2017), agreement on interventions with clients (Aoyagi & Portenga, 2010), and formulate cases with other people in the sport environment (e.g., coach, physiotherapist; Bickley et al., 2016). However, these researchers have not explored in detail how to develop consent procedures to address the current challenges (e.g., asymmetric power relations, surveillance, increased use of technology in sport). An interest in consent processes should be instrumental to sport psychology because it is an ethical cornerstone underpinning safe and successful interventions (e.g., cognitive behavioral therapy, acceptance and commitment therapy, and goal setting; Stamoulos et al., 2016). Consequently, the absence of discussions on ethics (and specifically consent procedures) may hinder the sport psychology profession’s potential to establish itself among the more recognized professions (Quartiroli et al., 2022).
In the psychology and psychotherapy disciplines outside sport, there are ongoing discussions on the limits of informed consent and potential solutions (Blease et al., 2018; Copnell, 2018; Stamoulos et al., 2016). There are no such discussions in sport psychology aside from brief acknowledgements of informed consent not meeting its ethical imperative (Aoyagi & Portenga, 2010; Moore, 2003). Hence, it is necessary to introduce a new approach to consent that deals with the current challenges and develops more autonomy in athletes. Athletes and other clients in sporting industry need a voice and empowerment to flourish (Henriksen et al., 2020; Krane & Waldron, 2020). Therefore, based on a changing context demanding adjustments to applied practice, this paper proposes empowered consent, a model for consent adapted to the current challenges and possibilities in sport. First, the paper defines consent. It then discusses how the current sport context creates consent issues. Finally, it proposes empowered consent as an approach that addresses current contextual and individual concerns.
Defining Consent and Associated Challenges
It is essential to define and describe consent, and informed consent, to discuss the related shortcomings of current informed consent procedures in the sporting context. In this paper, informed consent is defined as an essential biomedical process based on assumptions, which have different legal and moral implications gathered from professional ethics and national, state, and provincial laws. Also, underpinning the consent process are assumptions of client autonomy (i.e., linked to the idea of individual agency; Copnell, 2018; Turner et al., 2021). Copnell (2018) argued that there are two fundamental prerequisites to autonomy: rational thought (i.e., doing what one has decided to do, implying reasoning) and liberty (i.e., freedom from external influences).1 Therefore, consent processes can be strategies for athletes’ (or other clients’) empowerment if they are secure in their own agency.
It is the European researcher’s and practitioner’s responsibility to ensure that no work is undertaken without first having the informed consent of all participating clients. Primarily, informed consent should be demonstrated through the client signing a document about information relevant to the proposed investigation, intervention, treatment, or test. This should include a description of the investigation, its objectives, the procedure to be followed, an outline of the risks and benefits, an offer to answer any queries, an instruction that the client is free to withdraw at any point without prejudice, and an explanation concerning confidentiality and its limits. In some cases, informed consent may be obtained verbally, employing an appropriate written record confirming that informed consent was obtained. (European Federation of Sport Psychology, 2011, p. 3)
Professional practice guidelines (American Psychological Association, 2018a, 2018b) also indicate that individual differences (e.g., gender, religion, sexuality, ethnicity) shape practitioners’ and clients’ understandings of consent; therefore, practitioners must tailor consent-related information to individual clients’ needs.
Despite these guidelines, informed consent in psychotherapy is often reduced to the challenge of getting a young person’s, or a parent’s/guardian’s signature on a form (Blease et al., 2018, 2020; Isles, 2013). In some cases, the principle of informed consent has been taken to the extreme, with athletes (e.g., National Collegiate Athletic Association athletes and youth footballers in the United Kingdom) signing away their rights to confidentiality and privacy (Andersen et al., 2001; Feddersen et al., 2022). Notably, Moore (2003) stated that “written informed consent is not sufficient to meet the spirit and letter of this ethical imperative” (p. 603). A signed consent form gives little indication of the consent process. It is also unlikely that sport psychology practitioners working in sport environments obtain signed consent forms from athletes and/or guardians whenever they agree on a new intervention with a client (e.g., due to time constraints and a lack of relevant working practices). Nonetheless, informed consent should be sought throughout the practitioner–client collaboration as interventions change and new risks are introduced.
Challenges to the Current Consent Procedures
Addressing consent procedures also requires dealing with the pervasive tension created by the need to balance sporting results with care for athletes and those working in sport. Wagstaff and Quartiroli (2020) argued that how practitioners handle this tension could influence their professional identities and their ability to provide effective and ethical service delivery. Hence, it is worthwhile to consider Weimer’s (2012) critique of the sporting context’s influence to understand why such tension arises. Weimer claimed that moral evaluation within sport often diverges from those outside, rendering normally impermissible actions permissible. Building on this point, Salim and Winter (2022) noted that the context of sport can gradually influence how athletes and coaches think, feel, and behave. Taken together, these two viewpoints suggest that the unique moral baseline of the sport context influences the thoughts, emotions, and behavior of people in this environment. As a result, the tension between ensuring athlete performance and caring for the well-being of athletes, and others working in sport, may slowly build.
Feddersen and Phelan (2021) and Robertson and Constandt (2021) showed how people in sport are sometimes influenced by idiosyncratic rationales (e.g., “it has always been like this”) when they engage in behaviors challenging ethical and professional standards. This research also suggests that most people can “slip” into unethical behaviors (e.g., misconduct or abuse), which are rarely as binary as being either good or bad behaviors (Feddersen & Phelan, 2021). For example, Feddersen et. al. (2022) showed how rationales related to unobstructed insights led to some football coaches and managers demanding information from confidential practitioner–client conversations. Similar accounts were provided in the study of Jones and Denison (2017). They revealed how professional footballers must deal with pervasive surveillance as a disciplinary device and are gradually socialized into accepting unlimited information sharing. These processes are not confined to football but also appear in gymnastics (Barker-Ruchti & Tinning, 2010), women’s elite cycling (Zehntner et al., 2019), and other sports. Altogether, these studies show compelling evidence of the gradual socialization process in which staff and athletes fail to distinguish between their own views and those that might have been produced by the social environment (Zehntner et al., 2019). This idea is supported by research demonstrating how the sport environment can reinforce potentially extreme desires to comply with dogmatic beliefs (e.g., “coach is king,” “I am only worth my medals;” King et al., 2022).
The same gradual socialization process likely influences how sport psychology practitioners think, feel, and behave. Gilmore et al. (2018) exemplified this point by stating that sport psychology practitioners might be most influenced by a desire to “[help] professional sportspeople improve their performance” (p. 429). Similarly, Tod et al. (2009) showed that status often motivates sport psychology practitioners’ to work with elite athletes, but this can lead to anger or personal disappointment if clients fail to succeed. Accordingly, such desires might gradually influence sport psychology practitioners’ moral evaluations in justifying their actions. This has widely unacknowledged implications for ethical sport psychology practice. It is, therefore, worthwhile to explore specific consent-related challenges for clients (e.g., athletes, staff) and sport psychology practitioners.
Challenges for Clients
This section focuses on the two preconditions for informed consent (i.e., rational thought and liberty) and their relation to potential challenges and anxieties for clients. Current consent guidelines for agreeing on an intervention should involve preparing questions to which a client would respond “no,” making it clear that it is fine to say “no,” and that consent can be withdrawn at any time (Oates et al., 2021). This is especially the case when working with children and vulnerable populations. However, previous research indicates that contextual challenges may prevent clients from exercising rational thought in the informed consent process. For example, the dominant heuristics in their context influence their capacity for rational thought (Copnell, 2018). Furthermore, in sport environments, athletes often simply reproduce others’ beliefs or do not recognize that they have the autonomy to say no (Zehntner et al., 2019). Hence, athletes may be prone to adopting the irrational beliefs of key social actors in their environment (e.g., coaches, support staff, parents; King et al., 2022).
Moreover, implicit and sometimes explicit (e.g., signing away privacy) expectations of unobstructed insights might limit clients’ autonomy or liberty (Andersen et al., 2001). Such expectations might lead to trust issues that could undermine the therapeutic alliance, which Stamoulos et al. (2016) showed is likely the most important common factor of successful interventions. Rationales linked to functionalist approaches (Krane & Waldron, 2020), “smoothening processes” (Andersen et al., 2001), or “winning medals is all that counts” (Feddersen & Phelan, 2021) could influence the consent procedure and limit clients’ autonomy and instead make them compliant. However, it is effortful and time-consuming to look past such rationales in the collaboration between individual clients and practitioners (Copnell, 2018).
Several studies show that clients’ sense of competence in the face of challenges is one of the main reasons why psychological interventions are successful (Stamoulos et al., 2016), while accounts of misconduct highlight how affected athletes have a sense of losing control (e.g., limited power in decisions related to them; Daniels, 2017; Gale et al., 2022; Jones & Denison, 2017; King et al., 2022; Krane & Waldron, 2020). Hence, clients might face issues related to perceived limited autonomy and power over their own lives. Ryan and Deci (2008) emphasized that limited autonomy can significantly influence the likelihood of successful treatment. If their basic need for autonomy is not fulfilled, clients might fail to develop competence in the face of challenges (Ryan & Deci, 2008).
Challenges for Sport Psychology Practitioners
Contextual challenges in the sport environment are also likely to influence the consent-related beliefs and practices of sport psychology practitioners. Important issues pertaining to consent might be somewhat overlooked depending on (a) working conditions, (b) the perceived risks of an intervention, and (c) contractual relationships. First, most guidance on working conditions echoes Andersen et al. (2001), who argued that sport psychology practitioners should “keep as many interested parties ‘in the loop’ as possible ... to smooth over potentially rough times” (p. 15). Along the same lines, Henriksen et al. (2020) suggested that “mental health is everybody’s business but should be overseen by one or a few specified members” (p. 557). Managing multiple and complex relationships with athletes and staff can be challenging. In such cases, practitioners cannot get too close to any group without others becoming suspicious and possibly limiting self-disclosure (McDougall et al., 2015). For example, athletes who believe that practitioners are overly associated with coaches might exhibit decreased help-seeking and self-disclosure (Andersen et al., 2001). In these cases practitioners must carefully judge how to maintain boundaries since sharing information could have grave consequences for athletes.
Second, Darby and Weinstock (2018) suggested that informed consent might be overlooked in contexts where the risks of psychotherapy are not as salient as in other contexts. Accordingly, if sport psychology practitioners see themselves as working in performance enhancement with people who are mostly well, they might believe that the risks of interventions are lower than when they are applied to cases of depression or mental health disorders. One example of a practice with perceived low risk is the use of teletherapy, which increased during the COVID-19 pandemic (Shortway & Wolanin, 2021). However, Lustgarten and Elhai (2018) showed that technology use in therapy can limit self-disclosure due to confidentiality concerns. In light of this, Watson et al. (2017) proposed that informed consent processes could change as a result of increased use of teletherapy. It is clear that limited awareness of risks, salient or not, could make sport psychology vulnerable to unethical, unprofessional, and ineffective service delivery (Quartiroli et al., 2022). Hence, adjustments to working practices are likely needed even though the perceived risks of these practices might be low.
Third, sport psychology practitioners may be employed on a full-time, part-time, or short-term basis in sport environments. These different arrangements have various benefits (e.g., a deep understanding of the context) and challenges (e.g., precarious work, contractual relationships, and managing multiple roles). Gilmore et al. (2018) showed that short-term contracts and poor working conditions impact job performance and might influence practitioners’ decisions as they try to ensure future employment. Similarly, Turner et al. (2021) outlined how practitioners who benefit directly (e.g., financially), or indirectly (e.g., reputation), from contractual relationships should interrogate the potential influence of these benefits to address conflicts of interest.
Proposing an Adapted Process for Obtaining Consent
Clients more secure in their autonomy are likely to have better outcomes from working with a psychologist (American Psychological Association, 2018b). Hence, an adapted client consent procedure should involve an open client–practitioner discussion regarding interventions, risks, and benefits. The focus should be on empowerment to respond to the contextual challenges for clients and practitioners in the sport environment. Aoyagi and Portenga (2010) suggested an empowered consent approach based on Brown (1994) but did not indicate how to adapt it to the sport context. The current paper adapts empowered consent to the sport context and does so by blending it with understood consent (Isles, 2013). To emphasize the importance of empowerment, the procedure adopts the term Empowered Consent. In this paper, empowered consent goes beyond informed consent by engaging clients in the process of determining what is in their best interests. Accordingly, adapting these two into a procedure focused on empowering athletes and building added understanding should be well equipped to address interventions (e.g., psychotherapy, sharing information with coaches to collaborate on support) in sport environments, where practitioners are faced with time scarcity and pressure to provide results, and athletes might be socialized into accepting taken-for-granted practices.
Empowering clients helps give them autonomy and some degree of power in a context where misconduct often takes away that power (Salim & Winter, 2022; Zehntner et al., 2019). Empowered consent could, therefore, support the well-being, development, and performance of young and adult athletes. Also, the contextual challenges in the sport environment are such that athletes, parents/guardians, and staff might need to hear the message of consent and confidentiality multiple times to agree on a course of action (Andersen et al., 2001; Moore, 2003). Even if a client is aware of all the critical elements of an intervention decision and is not influenced by their emotions in this regard, challenges can emerge in the consent procedure. It is believed that empowered consent could start to address these issues and create a more robust approach.
A Brief Background on Empowered and Understood Consent
Empowered consent (Brown, 1994) highlights the importance of boundaries and boundary violations in psychotherapy. It does not provide concrete do’s and don’ts (e.g., answering whether a practitioner can be friends with a client after the therapy has ended). Instead, it highlights the diversity of the human experience and that boundary violations are inherently individual. Hence, clients’ understanding of boundaries varies from one individual to the next and from one time to the next. It is, therefore, necessary to treat any client as a gendered human being (rather than a normative referent group; American Psychological Association, 2018a).
Understood consent is a process that focuses on helping clients understand an intervention’s parameters (Isles, 2013). It involves open discussions on important issues, such as the approach to the treatment, the understanding of the problem, alternative options, and accessibility. It might be helpful to view this as the process of assessing a client’s understanding of what might happen if they agree to a new intervention. In order to establish understood consent, the practitioner should ask the client brief questions after describing the intervention. Asking these questions helps the client engage in psychological processes highlighted in self-determination theory (e.g., autonomy and competence; Ryan & Deci, 2000). These questions may also help the client interrogate irrational beliefs adopted from others in the sport environment. Consequently, focusing on empowering clients could increase their sense of autonomy and feelings of mastery in dealing with their challenges. Stamoulos et al. (2016) showed that psychologists enhancing clients’ sense of mastery is a common factor in successful intervention outcomes.
Table 1 outlines five principles of the proposed consent process and the challenges they aim to address. It is likely that they will need to be modified as the sport context changes over time, and when they are applied to different cultures.
Principles Underpinning Empowered Consent in Applied Sport Psychology
| Principle | How it addresses current challenges | |
|---|---|---|
| 1 | The process is underpinned by attentiveness as a moral imperative. It requires a recognition of others’ needs, and it is a two-way dialog with the athlete that sets out the parameters for any intervention (Brown, 1994). | Principle 1 aims to empower clients and enhance their sense of mastery when facing challenges, ultimately increasing their freedom from external influences. |
| 2 | There should be clear evidence of a two-way dialog in which the client (and, where relevant, a parent/guardian) is given a chance to ask questions, consider information, and discuss any risks and benefits pertinent to the situation (adapted from Turner et al., 2021, p. 542). | Principle 2 aims to provide a space for clients to reason and obtain clarity in line with their rights and personal boundaries. |
| 3 | Sport psychology practitioners should try to elicit examples (e.g., asking athletes to repeat using their own words) rather than confirmation (e.g., agreeing or disagreeing) of parameters (e.g., boundaries for intervention, whom to share information with) during the two-way dialog. | Principle 3 aims to increase clients’ recall, reasoning, and understanding by providing a space for them to reflect on benefits and risks. It also aims to stop clients simply reproducing others’ beliefs and opinions (King et al., 2022; Zehntner et al., 2019). |
| 4 | The process must be timely and specific to the proposed intervention and valid only for this intervention. The sport psychology practitioners and other staff members must not exceed the scope of authority agreed with the athlete (adapted from Turner et al., 2021, p. 542). | Principle 4 aims to implement Andersen et al. (2001) and Moore’s (2003) suggestion to repeat consent and confidentiality boundaries for all relevant stakeholders. It should also help prepare practitioners for dealing with other people in the environment. |
| 5 | The process is specific to a given intervention. Hence, sport psychology practitioners must repeat the process with the same client, because clients’ understanding of the parameters and boundaries is likely to change over time (e.g., due to age, experience, and compounding challenges). | Principle 5 addresses the tendency of athletes and those working in sport to adopt idiosyncratic beliefs and heuristics. It also addresses emotions, since some interventions might be introduced due to setbacks (e.g., loss, stagnation, injury). |
Suggestions for Implementing the Principles When Obtaining Consent
The principles of empowered and understood consent lead to suggestions for enhancing the practitioner–client dialog. The aim of this dialog should be to ensure that the client has understood the content and boundaries of an intervention. In addition, the client should be able to describe the intervention and the potential risks and/or benefits. Table 2 provides a series of sample questions that practitioners can use during one-on-one dialogs with clients (or parents/guardians) to implement the principles of empowered and understood consent in practice.
Sample Questions for Different Types of Interventions
| Type of intervention | Sample questions |
|---|---|
| General questions about risks | • How do you feel about these risks? • What are your alternatives (choices or options other than the intervention)? • In your own words, how do you weigh your desire for achievement in your sport against the possible risks? |
| Sharing information with other staff | • Tell me in your own words what it means to share this information. • Can you give me examples of whom I can share this information with and whom I cannot share this information with? • Please tell me what you think will happen if I share this information with the people we agreed on. • What do you expect to gain by sharing this information? • What risks will you face by sharing this information? |
| Introducing goal setting (this can be viewed as a placeholder for other psychological skills, e.g., planning, game plan, evaluating performance) | • In your own words, what do you believe the benefits of goal setting could be in terms of your development? • Have you considered whether goal setting might pose risks to you or others? • Please tell me what you think might happen if we start working on your goal setting. • Can you tell me who might be involved in your goal setting? |
| Introducing a specific psychotherapy (e.g., REBT, ACT, CBT) | • In your own words, could you tell me what you believe our work with ACT might entail? • Could you give me an overview of your expectations regarding our upcoming work with REBT? • What do you expect to gain from working with something like CBT? • What do you expect to gain from taking a different course and switching from CBT to ACT? |
Note. CBT = cognitive behavioral therapy; ACT = acceptance and commitment therapy; REBT = rational emotive behavior therapy.
Pressing pause can create space for the client to reconnect with their reasoning and set their boundaries for the proposed intervention (Harris, 2019). It also enhances the client’s sense of mastery, which is hypothesized to be critical for a successful intervention (Stamoulos et al., 2016).Practitioner: Can I press pause for a second to make sure that we are on the same page in terms of sharing some of what you and I have discussed with your coach? Could you give me some examples of information you do not want me to share?
These principles fit into most approaches to applied sport psychology (e.g., rational emotive behavior therapy, cognitive behavioral therapy, acceptance and commitment therapy, motivational interviewing). However, implementing all the principles of empowered and understood consent in daily life in a sport environment can be challenging due to time scarcity (Andersen et al., 2001), professional boundaries (Williams & Andersen, 2012), and pressures to produce changes in athletes and staff (Gilmore et al., 2018). Adapting the consent process in the proposed way can provide an enhanced awareness of what is said, meant, and understood in relation to consent. Furthermore, giving athletes more autonomy or empowerment regarding the process can strengthen the therapeutic alliance, and, thus, the efficacy of interventions (Glouberman, 2008). Empowered consent is a step toward considering the duty of care of practitioners and organizations in a more comprehensive way. Embedding the principles and short questions into the client–practitioner collaboration can serve as a model for ethical best practice.
Potential Wider Implications and Future Research
This paper has focused on how sport psychology practitioners negotiate consent with their clients. However, the wider implications of empowered consent in talent development and elite sport could extend to sport-related issues surrounding sharing pictures of clients on social media, third-party interventions (Wachsmuth et al., 2020), and changes in training schedules involving training of increased intensity and duration. They could also extend to other sport sciences, such as physiotherapy (Copnell, 2018) and concussion management (Turner et al., 2021). In the case of concussion management, there may be cognitive deficits immediately after the injury (Turner et al., 2021), thus increasing the need for a timely intervention (see Principle 4, Table 1). Athletes with long-term injuries may be eager to return to play (Clement et al., 2015), potentially intensifying ethical challenges for medical staff, and making collective case formulation a critical step (Bickley et al., 2016).
It is also essential for sport psychology practitioners to assess how different age groups might respond to being asked to outline the potential risks or benefits of an intervention. Doing sport psychology with young people has specific developmental challenges (e.g., they are not miniature elite athletes; Henriksen et al., 2014). McCarthy et al. (2010) found that young people are less able to explain the meaning of psychological skills. Hence, using empowered consent could answer McCarthy at al.’s call to adapt interventions and psychoeducation to younger athletes. In the case of young athletes, it might be fruitful to limit technical language (e.g., references to acceptance and commitment therapy, rational emotive behavior therapy) and instead ask about their expectations related to working on mental skills. Asking such questions and thus empowering young athletes could enhance their psychological literacy by supporting their reflective thinking skills.
In the future, it would also be pertinent to consider how the questions the sport psychology practitioner asks are framed based on various identity markers (e.g., culture, race, religion, partnership status, disability). Regarding gender, the American Psychological Association produced its first guidelines for psychological practice with girls and women in 2007 (updated in 2018) and boys and men in 2018 (American Psychological Association, 2018a, 2018b). The practice guidelines show that there is an asymmetry in the mental challenges faced by different genders (i.e., men are more prone to externalizing disorders and women to internalizing disorders). Hence, focusing on open discussion could help practitioners understand how societal norms and unrealistic views influence their collaboration with men (e.g., being self-reliant and managing their own problems) or women (e.g., appearance-based social worth). This is especially important since such norms may be compounded by the bodily exposure that is prevalent in the sport environment and the hypercompetitive and hypermasculine sport culture. There are additional gender identities that face separate challenges; therefore, it is essential for sport psychology practitioners to use open discussion in the consent procedure to ascertain the potential influences of gender identities or minority stress. While the professional practice guidelines for different genders address some challenges, they also raise important issues regarding the influence of ethnicity, religion, language (is the practitioner–client collaboration carried out in first language), and other identity markers. Culturally competent and gender-sensitive consent procedures are just one of the future possibilities of empowered consent. Hence, future research should address how empowered consent can be adapted based on identity markers beyond gender.
The empowered consent approach must be adapted to fit the specific context of a practitioner–client collaboration (e.g., based on national culture, legal, and health systems). It will also need to be adapted over time as new challenges arise in response to changing societal norms and contextual constraints. The approach presented in this paper only provides general guidance to assist sport psychology practitioners in providing ethical, and suitable, best practice. Continuing a profession-wide discussion on ethical challenges will help ensure practitioner competencies, ethical practice, and better outcomes for clients in the future.
Acknowledgments
Thank you, to my colleagues Milla Saarinen, Rob Book, Dadi Rafnasson, and Lucy Piggott for providing valuable feedback during the development of this paper.
Note
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