APPROVED AS MODIFIED
08/06/2015 BHRC IRB
Portland Psychotherapy Clinic, Research, and Training Center
RESEARCH CONSENT FORM
CONSENT TO PARTICIPATE IN RESEARCH: Perspective Taking and Theory of Mind
INTRODUCTION: You are invited to participate in a research study conducted by Paul Guinther, Ph.D., Jason Luoma,
Ph.D., and colleagues from the Portland Psychotherapy Clinic, Research, and Training Center. The results of this study
will contribute to a research project. You were identified as a possible volunteer in the study because you expressed
interest in the topic of this study. Please take as much time as you need to look over this form and ask questions so that
you can make an informed decision about whether to participate in this research.
ABOUT CONSENT: We have an ethical obligation to ensure that you have understood information relevant to making an
informed, voluntary decision to participate in research. After you read this form and ask any questions you may have,
we will ask you questions to ensure your understanding. If you are unable to show that you understand what is involved
in the study, you will not be allowed to participate in the study.
PURPOSE OF THE STUDY: We are studying how people learn to empathize and take the perspective of other people.
PROCEDURES AND ACTIVITIES: If you decide to participate in this study, we will ask you to tell us some basic
demographic information about yourself (i.e., your age, gender, race, and number of years of education). You will then
spend the next two hours completing computerized surveys and problem solving tasks involving social and spatial
perspective taking. You will learn how to solve computerized spatial puzzles using feedback (e.g., if you make a correct
selection on a learning trial you will be shown a happy face, but if you make an incorrect selection you will be shown a
sad face). There will also be some problems for which you will not receive any feedback, even though there are correct
answers. You will also be asked to identify emotions from pictures of faces, and answer questions about your general
thoughts and feelings about yourself and your relationships with other people.
POTENTIAL RISKS AND DISCOMFORTS: We do not expect you will experience negative physical effects from
participating in the study, except for possible eye-strain and discomfort from sitting. You may experience boredom,
frustration, or fatigue as a result of concentrating on the computerized tasks. Your level of discomfort from these tasks is
not expected to be any greater than what you might experience while studying for an exam, and you can stretch or take
breaks as needed. You are free to stop participation at any time without penalty.
POTENTIAL BENEFITS TO PARTICIPANTS AND/OR TO SOCIETY: Participants will not receive any direct benefit from
participating in this study. Participants may benefit indirectly from experiential learning and from the opportunity to
contribute to society. We hope that this research will help develop a better science of behavior, and ultimately help
develop more effective psychological therapies. There are no financial costs to you for participating in this research
study.
COMPENSATION: We will give you a $20 Target gift card for completing this study at the end of your study participation.
Those participants who require help with transportation costs can trade one used Trimet public transportation ticket for
two new tickets.
CONFIDENTIALITY: We will keep confidential any information obtained in connection with this study and will disclose it
only with your permission, as required by law, as required by ethical considerations (for example, if someone is at
imminent risk of harm to self or others), or for authorized oversight of the research study. We will keep a record of your
contact information and a signed copy of this consent form, but your identifying information will not be linked to the
data we collect. If you are being seen for therapy at Portland Psychotherapy, your therapist may be a member of the
research team and therefore know if you are participating in this research; your therapist will not otherwise be involved
in data collection and will not know what data is yours. All information gathered will be securely stored in locked filing
cabinets and password protected computers at the research center, or on secured internet servers. All of your
personally identifying information will be destroyed 7 years after study completion.
APPROVED AS MODIFIED
08/06/2015 BHRC IRB
PARTICIPATION AND WITHDRAWAL: You can choose whether to participate in this study or not. Whether you choose to
participate in this study will have no bearing on psychotherapy services you may be receiving or wish to receive through
Portland Psychotherapy. If you choose not to participate, there will be no penalty or loss of benefits to which you might
otherwise be entitled. If you volunteer to participate, you may withdraw at any time without penalty or loss of benefits
to which you might otherwise be entitled. Your participation in this study may be stopped at any time by the study staff or
the sponsor without your consent if it is in your best interest, if you do not consent to continue in the study after being told
of changes in the research that may affect you, or for any other reason. By signing this consent form you are not waiving
any legal claims, rights, or remedies because of your participation in this research study.
TREATMENT CONSIDERATIONS: This study is an experimental investigation, and is not intended as a treatment for any
medical or mental health concerns. No advantageous alternative procedures are available as a part of this study. You are
free to pursue any medical or mental health treatments that may be appropriate for you while participating in this
study.
IDENTIFICATION OF INVESTIGATORS AND INSTITUTIONAL REVIEW BOARD (IRB): General questions about this study
can be addressed by our research assistants by calling (503) 985-8805 or writing perspective.ppcresearch@gmail.com. If
you have any pressing questions or concerns about the study, please feel free to contact the lead investigator Paul
Guinther, Ph.D. at the Research Lab at Portland Psychotherapy, 3700 N. Williams Avenue, Portland, OR 97227, (503)
281-4852 ext. 16.
If you have questions about your rights as a research participant or if you have questions, concerns, or complaints about
the research, you may contact:
Behavioral Health Research Collective (BHRC) IRB
Attn: Travis L. Osborne, Ph.D., Chair
1200 5th Avenue, Suite 800 Seattle WA, 98101
(206) 374-0109
BHRC IRB is a group of people who perform independent review of research. BHRC IRB will not be able to answer some
study-specific questions. However, you may contact BHRC IRB if the research staff cannot be reached or if you wish to
talk to someone other than the research staff.
SIGNATURE OF RESEARCH PARTICIPANT
I understand the procedures described above. My questions have been answered to my satisfaction, and I agree to
participate in this study. I confirm that I am at least 18 years of age, can read English in 12 point font from a computer
screen, do not have any major cognitive or memory deficits, that I have not participated in this study before, and that I
am able to provide informed consent. I have been provided with a copy of the research consent form.
___________________________________ ___________________________________ ________________
Printed Name of Participant
Signature of Participant
Date
SIGNATURE OF INVESTIGATOR
In my judgment the participant is voluntarily and knowingly providing informed consent and possesses the
legal capacity to give informed consent to participate in this research study.
___________________________________ ___________________________________ ________________
Printed Name of Researcher
Signature of Researcher
Date