Ethical communication in Functional Neurological Disorder (FND) care begins with recognizing that symptoms are real, distressing, and not “all in the mind.” Clinicians need to clearly convey that FND is a genuine disorder of nervous system functioning, while avoiding language that implies blame, exaggeration, or intentional control of symptoms. This foundation respects patient autonomy, validates lived experience, and sets the stage for meaningful collaboration. When a person with FND senses doubt, dismissal, or stigma, their willingness to engage in assessment and treatment often diminishes, and opportunities for recovery can be harmed.
A core principle is honesty combined with sensitivity. Patients deserve accurate, age-appropriate information about diagnosis, uncertainty, prognosis, and treatment options. At the same time, honesty should be delivered in a way that is hopeful, non-alarming, and paced according to the person’s emotional readiness. Instead of either minimizing difficulties or making overly definitive claims, clinicians can acknowledge the limits of current knowledge about FND while explaining what is known and what can be done next. This balanced approach supports informed consent, reduces fear, and reinforces the patient’s right to ask questions and seek clarification at any time.
Respect for autonomy in FND care requires more than offering choices; it involves helping patients understand those choices well enough to make decisions that align with their values, priorities, and circumstances. Many people with FND arrive after long, complex diagnostic journeys, feeling confused by conflicting explanations or previous negative encounters. Clear, empathetic communication that revisits prior experiences, translates technical terms into everyday language, and checks understanding is essential. Rather than assuming comprehension, clinicians should invite patients to explain the diagnosis and plan in their own words, gently correcting misunderstandings as needed.
Another principle is non-maleficence: avoiding psychological or emotional harm that can arise from poorly chosen words or attitudes. Language that implies “nothing is wrong,” “it’s just stress,” or “you’re doing this to yourself” can be deeply damaging. Similarly, insisting that FND is “purely psychological” or “purely physical” oversimplifies a complex condition and may invalidate parts of the patient’s experience. Ethical communication instead frames FND as a disorder where brain and body functioning, life experiences, and current stressors can interact, emphasizing that symptoms are involuntary and that improvement is possible with appropriate support.
Beneficence, the commitment to act in the patient’s best interest, calls for communication that is actively supportive and empowering. This includes acknowledging the courage it often takes to seek help, highlighting strengths and coping skills, and emphasizing areas where the patient has agency in their own care. In practice, this might mean collaboratively identifying achievable goals, such as gradually increasing activity levels or practicing specific therapeutic strategies. By focusing on what the patient can do, rather than solely on what they cannot, clinicians foster hope and a sense of progress.
Justice is another ethical pillar that shapes communication in FND care. People with FND frequently face inequities in healthcare access, diagnostic delays, and skepticism from professionals. Ethical practice requires striving for fairness in the time, attention, and resources offered, regardless of how complex or challenging the presentation may be. This may involve advocating within healthcare systems for appropriate referrals, rehabilitation services, or mental health support, as well as recognizing and challenging personal or institutional biases that might influence how FND is perceived and discussed.
Trust is central to any therapeutic relationship, but in FND it is often fragile at the outset. Many patients and families have experienced previous encounters where they felt dismissed, accused of faking symptoms, or shuffled between services without clear explanations. Rebuilding trust requires consistent, transparent, and predictable communication. Clinicians should be explicit about what they will do next, what information will be shared with whom, and when follow-up will occur. Following through on these commitments, or clearly explaining when plans need to change, demonstrates reliability and respects the patient’s need for stability.
Ethical communication in FND care is also grounded in shared decision making. Instead of presenting a single “correct” plan, clinicians can outline reasonable options, describe potential benefits and risks, and explore the patient’s preferences and concerns. For example, when discussing physical therapy, psychotherapy, or medication, patients should be invited to express what feels acceptable or worrying to them. Together, clinician and patient weigh options, considering both clinical evidence and the person’s life context, such as caregiving responsibilities, work, cultural beliefs, and financial constraints. This collaborative style not only upholds ethics but can enhance adherence and outcomes.
Attending to emotional responses is essential. Discussions about FND can evoke fear, relief, anger, grief, or shame. Ethical communication makes space for these reactions by acknowledging feelings without judgment: “Many people feel frustrated or relieved when they first hear this diagnosis; how is it for you?” This approach validates the emotional impact of living with FND and invites open expression of concerns. When strong emotions arise, slowing down, pausing to listen, and temporarily shifting away from detailed explanations toward emotional support can be more helpful than pushing through a predetermined agenda.
Cultural humility is another important principle. Experiences and expressions of symptoms, beliefs about illness, and expectations of healthcare differ across cultures, languages, and communities. Ethical practice involves asking patients about their own explanations for symptoms, their family’s views, and any spiritual or cultural frameworks that matter to them. Rather than imposing a single narrative about FND, clinicians can look for ways to integrate medical understanding with the patient’s own story, while gently correcting misconceptions that might impede effective care. Using interpreters when needed and avoiding jargon further supports equity and respect.
Clarity about roles and boundaries is part of ethical communication in FND care. Patients should understand who is responsible for which aspects of their treatment, how different professionals (such as neurologists, psychiatrists, psychologists, physiotherapists, and occupational therapists) collaborate, and how information is shared within the team. Unclear roles can lead to confusion, duplication, or gaps in care, which may reinforce feelings of abandonment or mistrust. Explicitly explaining the rationale for multidisciplinary involvement helps patients feel that their condition is being taken seriously and comprehensively addressed.
Ethical practice also involves continuity and consistency of messaging. When different clinicians provide conflicting explanations or use stigmatizing language, it undermines the patient’s confidence in the diagnosis and treatment plan. Teams working with people with FND should strive for shared frameworks and common terminology, so that messages about the nature of FND and its management are coherent across settings. When differences in perspective do arise, these should be discussed respectfully with the patient, acknowledging that there can be multiple ways to understand and approach FND without invalidating their experience.
Ethical communication is an ongoing process rather than a one-time event. Understanding, readiness to change, and information needs evolve over time. As patients move through phases of diagnosis, treatment, and potential relapse or recovery, clinicians should regularly revisit explanations, check for new questions, and adapt the level of detail. This iterative approach respects the dynamic nature of trust and consent in FND care and recognizes that what felt overwhelming or unacceptable at one stage may become more acceptable later, once trust has deepened and the person feels more supported.
Building trust and rapport with patients and families
Building an effective therapeutic relationship in Functional Neurological Disorder care begins with slowing down enough to meet the person and their family where they are, rather than where the service timetable expects them to be. Many arrive carrying grief, anger, or exhaustion from long diagnostic journeys, repeated investigations, and disbelief from others. Opening consultations by inviting their story—“Can you tell me what this has been like for you so far?”—signals that their experience matters, not just their test results. Active listening, reflected back in plain language, helps establish that the clinician has truly heard them: “So you’ve seen several specialists, had lots of tests, and still felt like no one could explain what was happening. That sounds incredibly draining.” This kind of communication validates distress without prematurely reframing or correcting, laying the groundwork for trust.
Consistency and reliability are central to repairing trust that may have been eroded by previous encounters. Saying what will happen next and then doing it—whether it is sending a letter, arranging a referral, or scheduling follow-up—communicates respect and reliability more powerfully than reassurance alone. When plans change or delays occur, explaining the reasons and apologizing for the impact maintains rapport. Simple statements such as “I did say I would call last week and I wasn’t able to; I’m sorry for that, and here is what I’m doing now” support transparency and contribute to ethical practice by demonstrating accountability.
Rapport also depends on the subtle cues of day-to-day interaction. Sitting at eye level, minimizing interruptions, and avoiding hurried body language convey that the person is worth unhurried attention. Avoiding excessive typing or screen-gazing while the patient shares sensitive information helps them feel they are not competing with the computer. Using names correctly, checking preferred pronouns, and asking permission before physical examination or movement-based assessments reinforces autonomy and consent in small but meaningful ways. Over time, these practices signal that the clinical space is one where the patient and family are treated as partners rather than problems to be solved.
Many people with FND and their families arrive with strong pre-existing beliefs or fears about the diagnosis, often shaped by internet searches, social media, or previous clinicians. Trust grows not from dismissing these beliefs, but from exploring them with curiosity. Asking, “What have you heard about FND so far?” or “What are you most worried this might be?” invites disclosure of concerns that might otherwise remain unspoken. Responding without ridicule or defensiveness, and acknowledging the emotional weight of those fears, builds a safe foundation for later education. When misunderstandings are corrected gently—“Some websites say this means you’re making it up; that’s not accurate, and I want to be clear that we do not see your symptoms as under your voluntary control”—patients and families are more likely to accept the clinician’s expertise.
Family members often hold critical information about triggers, patterns, and the impact of symptoms, as well as their own distress and confusion. Ethical communication involves actively inviting their perspective while respecting the patient’s boundaries. Asking the patient, “Is it okay if I ask your partner/parent about what they’ve noticed?” models respect for confidentiality and autonomy. Involving families in a structured way—such as asking what changes they have seen, how they try to help, and what they find most difficult—can transform them from bystanders or critics into allies in care. When families feel heard and not blamed, they are more likely to support rehabilitation strategies and to avoid inadvertently reinforcing disabling patterns.
Trust is also strengthened when clinicians acknowledge uncertainties rather than overpromising. In FND, prognosis and response to treatment can be variable. It is more trustworthy to say, “We know many people improve with the right help, but it can take time and effort, and we may need to adjust our plan as we go,” than to offer guarantees. This honest, measured optimism respects the person’s need for realistic expectations. It also opens the door to shared decision making, in which patients and families can weigh the effort and potential benefits of interventions like physiotherapy, psychotherapy, or occupational therapy in light of their own goals and capacities.
Establishing rapport requires particular care when discussing the role of psychological factors, trauma, or stress. Many patients have previously experienced suggestions that their symptoms are “just anxiety” or “all in their head,” and may fear that any mention of mood or stress implies disbelief. Building trust here relies on carefully framing these discussions as part of a whole-person understanding rather than an either-or explanation. Phrases such as “We know FND is about how the nervous system is functioning, and that can be influenced by many things, including previous experiences, current stress, and how the brain patterns movement and sensation” help integrate psychological and physical aspects without implying fault. Inviting patient and family input—“Does any of this fit with your experience?”—keeps the conversation collaborative.
Rapport deepens when clinicians actively recognize the strengths and coping strategies that patients and families already have. Many people with FND have demonstrated remarkable resilience in adapting to life changes, advocating for themselves, or supporting others despite their own symptoms. Naming these strengths—“You’ve found ways to keep working part-time and caring for your children even with these symptoms; that shows a lot of determination”—shifts the narrative away from deficit and helplessness. Building on existing strengths to set achievable, patient-led goals helps transform the relationship from one focused solely on symptom elimination to one focused on function, meaning, and quality of life.
Practical collaboration is a powerful tool for building rapport. Instead of imposing rigid treatment plans, clinicians can co-create a stepwise approach that feels manageable and aligned with the patient’s life context. Asking, “Looking at everything we’ve discussed, what feels like a realistic first step for you?” invites ownership and respects autonomy. When patients see that their preferences and limits are taken seriously—for example, adapting therapy schedules around caregiving duties or pacing exposure to feared movements—they are more likely to engage actively. This collaborative style reinforces ethics in action, translating respect and beneficence into concrete decisions that the person helped shape.
In pediatric and adolescent FND, the dynamics of trust and rapport extend to parents, guardians, and sometimes schools. Young people may feel caught between adults’ explanations and their own experience of symptoms. Taking time to speak both with the young person alone (when appropriate) and with the family together allows each voice to be heard. Validating the child’s or teenager’s perspective—“You’re the expert on what this feels like in your body”—and explaining things in age-appropriate language fosters a sense of control and safety. Meanwhile, acknowledging parents’ worries about the future, education, and safety shows respect for their responsibilities and opens pathways to coordinated support.
Cultural, linguistic, and socioeconomic factors shape how trust is formed and maintained. Some patients come from communities with a history of discrimination or neglect in healthcare, leading to understandable skepticism. Others may frame symptoms within spiritual or cultural narratives that differ from biomedical explanations. Clinicians build rapport not by challenging these beliefs outright, but by listening and seeking points of connection: “In your tradition, how are these kinds of symptoms usually understood?” Using professional interpreters when needed, providing written information in accessible language, and checking for understanding without condescension—“I’ve given you a lot of information; what parts feel clear and what parts are confusing?”—demonstrate respect and enhance communication.
Building and sustaining trust often depends on how clinicians respond when things do not go as hoped. Symptom relapses, missed appointments, or difficulty following recommendations are common in FND and can evoke frustration on both sides. Approaching these situations with curiosity rather than judgment—“It seems it’s been hard to keep up with the exercises; can you help me understand what’s getting in the way?”—keeps the relationship collaborative. Acknowledging the inherent challenges of behavior change and adapting the plan together sends a clear message: the patient is not being abandoned for struggling, and their efforts are recognized even when progress is uneven. Over time, this flexible, compassionate approach can turn a fragile initial connection into a durable therapeutic alliance that supports ongoing consent and engagement in care.
Ensuring informed and ongoing consent in clinical encounters
Ensuring that consent is genuinely informed begins with recognizing how complex and emotionally loaded information about Functional Neurological Disorder can be. People often arrive after years of investigations, conflicting explanations, and at times perceived disbelief. In this context, “Do you consent?” cannot be reduced to a quick yes-or-no question. Clinicians need to create space for careful, paced communication that covers the nature of FND, the aims and limits of proposed assessments or treatments, and realistic expectations of benefit and risk. This involves not only explaining the medical aspects but also acknowledging how emotions, prior experiences, and family pressures may influence decisions. When clinicians recognize this complexity and slow the process, consent becomes an ethical conversation rather than a formality.
For consent to be informed, patients must understand what FND is, what it is not, and how the proposed intervention fits within their overall care. Clear, jargon-free language is essential. Instead of saying, “We recommend a multidisciplinary biopsychosocial rehabilitation program,” it may be more helpful to say, “We’re suggesting a program where a team will work with you on movement, daily activities, and how stress affects your nervous system, with the goal of helping your body move and function more reliably.” Using concrete examples—such as describing what will typically happen in a physical therapy session or a psychological consultation—helps the person imagine the experience and weigh whether it feels acceptable. Checking understanding by asking, “Can you tell me in your own words what you understand about this plan?” allows the clinician to correct misunderstandings before a decision is made.
Autonomy is central to ethical consent, but autonomy is not the same as being left alone to make decisions without support. Many people with FND are fatigued, overwhelmed, or cognitively slowed by symptoms, which can affect how they process information. Ethical practice involves scaffolding autonomy by breaking information into manageable chunks, allowing time between explanations and decisions when possible, and offering written or visual materials that the person can review later. Asking what decision-making style the person prefers—“Some people like to decide quickly, others like time to think or to talk things through with family; what works best for you?”—respects individual differences. Where cognitive difficulties or communication impairments are present, involving speech and language therapists, occupational therapists, or neuropsychologists can support the person’s ability to participate meaningfully in decisions.
Shared decision making is particularly important in FND because there is rarely a single, clearly superior treatment path. Interventions often involve significant effort, behavioral change, and emotional work, even when medical risks are low. Presenting options side by side—such as different intensities of rehabilitation, individual versus group therapy, or in-person versus telehealth formats—invites genuine choice. Clinicians can outline likely benefits, possible discomforts, and uncertainties: “This approach has helped many people improve function, but it can be challenging at times, especially early on. Some people notice an initial increase in symptoms as they start to move differently.” Inviting the patient’s values and goals into the discussion—“Given your priorities around work, caring responsibilities, or pain levels, which option fits best for now?”—helps align plans with what matters most to the person.
In FND care, consent should be seen as an ongoing process rather than a one-time event at the beginning of treatment. Symptoms can change, life circumstances shift, and new information becomes available. A plan that felt acceptable at the start may later feel too demanding or no longer aligned with the person’s priorities. Regularly revisiting consent—“We’ve been working with this program for six weeks now; does it still feel right for you? Are there parts you’d like to change, pause, or stop?”—maintains respect for autonomy and reinforces trust. This is especially significant when treatment involves graded exposure to feared or avoided movements, intensive exercise, or emotionally challenging psychological work; patients must know that they can renegotiate pace, format, or even the overall plan without fear of being blamed or abandoned.
Ongoing consent also applies to diagnostic assessments and investigations. People with FND may be offered additional tests to clarify other conditions, to reassure about serious disease, or to support functional diagnoses. Each test should be accompanied by clear explanation of its purpose, what results might show, and what would happen based on different outcomes. Ethically, clinicians should avoid ordering investigations primarily to placate anxiety or external pressure when the clinical value is minimal, as this can inadvertently reinforce fear and medicalizes symptoms further. Explaining why certain tests are not recommended—“Based on your story and examination, further scans are unlikely to help us and may even cause more worry; instead, I’d like to focus on treatments that can actually change how your body functions”—is part of informed consent, even when the decision is not to investigate.
Communication about risks and discomforts requires particular care. Even when medical risk is low, interventions can be emotionally or physically demanding. For example, participation in physiotherapy may temporarily increase fatigue or pain, and psychotherapy might bring up distressing memories or feelings. Ethical consent involves being upfront about these possibilities while framing them within a supportive, hopeful narrative: “Some people notice more fatigue at first as they start moving differently; we’ll monitor this together and adjust your plan if it becomes too much.” Minimizing or omitting discussion of these challenges may secure quick agreement but risks later rupture of trust if patients feel they were not adequately prepared.
Special consideration is needed when the person’s capacity to consent is in question, whether due to severe cognitive impairment, dissociation, intense distress, or coexisting psychiatric or neurological conditions. In such situations, ethics and law often require a structured capacity assessment and the involvement of substitute decision makers or legal guardians, depending on jurisdiction. Even when formal capacity is limited, it is important to involve the person as much as possible in line with their abilities—seeking their preferences, explaining options in simplified form, and attending carefully to verbal and nonverbal responses. This approach respects their dignity and preserves autonomy to the greatest extent possible, rather than collapsing into a paternalistic model where others decide entirely on their behalf.
Family members, caregivers, and partners frequently play an important role in both consent and treatment adherence. However, their involvement must not override the patient’s wishes. Clinicians should clarify at the outset how information will be shared and who is authorized to participate in decisions. Asking explicit permission—“Are you comfortable with me discussing these options with your family here?”—reinforces the patient’s control over who is present for sensitive discussions. Involving families ethically means balancing their perspectives with the patient’s voice, noticing if the patient appears pressured into agreeing, and providing opportunities for private conversation when needed. Where minors are concerned, clinicians must navigate the dual responsibility to respect the young person’s developing autonomy while ensuring that parents or guardians receive sufficient information to fulfill their caregiving responsibilities.
Because many people with FND have a history of feeling disbelieved or coerced into certain paths, transparency about the voluntary nature of interventions is crucial. Statements such as, “This is a recommended option, but it is your choice whether to take it, and you can change your mind later,” help counter prior experiences of feeling pushed or judged. At the same time, clinicians can explain potential consequences of different choices without using fear or moral pressure: “If we don’t start therapy now, it may be harder to address some of these patterns later, but we can revisit the timing if now doesn’t feel right for you.” This openness signals that consent is respected even when the patient’s decisions differ from the clinician’s preference.
Digital technologies introduce additional layers of consent in FND care. Telehealth consultations, remote monitoring, and digital exercise or symptom-tracking apps all require clear explanation about confidentiality, data storage, and who will have access to information. Patients should understand what is recorded, how long it is kept, and their right to opt out or revoke permission. For some, video recording of movements or episodes may be suggested for diagnostic or therapeutic purposes; clinicians should explain why recordings are helpful, how they will be used, and that the person can decline or request that specific recordings be deleted. Maintaining high standards for privacy and data protection reinforces trust and aligns digital innovation with core ethics.
Ongoing consent also extends to the ways in which FND is discussed in team meetings, teaching, or research. With appropriate safeguards and permissions, anonymized case discussions can improve care and professional education, but patients should be informed when their information may be used beyond direct clinical care. Obtaining explicit consent for research participation or for using de-identified clinical material for teaching honors patient autonomy and ensures that contributions to wider knowledge are genuinely voluntary. When declining such use does not affect their access to care, this should be clearly stated to avoid any sense of obligation or subtle coercion.
In everyday clinical practice, maintaining consent as an ongoing process often comes down to repeated micro-questions that reinforce agency: “Is it okay if I move your arm now?”, “Would you like to take a break?”, “Are you comfortable trying that exercise today, or shall we plan it for next time?” These seemingly small inquiries accumulate into a pattern that communicates respect, helps prevent re-traumatization (especially for those with trauma histories), and makes it more likely that patients will speak up when something feels wrong. Over time, these practices support not only legal compliance but a culture in which consent, trust, and collaboration are woven into the fabric of FND care.
Addressing power imbalances and patient vulnerability
Power imbalances are woven into almost every clinical interaction, but in the care of people with Functional Neurological Disorder they are often intensified by prior experiences of disbelief, stigma, and dependence on health and social systems. Patients may feel they have little control over what happens in consultations, which specialists they see, or how their symptoms are interpreted. They may also worry that if they question recommendations, they will be labeled “difficult” or risk losing access to care. Ethical communication requires clinicians to recognize these structural and relational imbalances and to take deliberate steps to soften their impact, using their professional power to promote safety, dignity, and autonomy rather than compliance.
One of the most visible aspects of power is control over the narrative: who gets to define what is “really” happening. People with FND commonly report that previous clinicians have framed their symptoms as “psychogenic,” “not neurological,” or “all in the mind,” often without meaningful discussion. This can leave them feeling erased from their own story, as if the professional explanation has replaced their lived reality. To address this, clinicians can explicitly invite the patient’s account as a legitimate source of knowledge: “You are the expert on what these symptoms feel like day to day; I bring expertise about how the nervous system works. Let’s put those together.” By treating the patient’s story as data, not as a barrier to diagnosis, clinicians redistribute epistemic power and create conditions for shared decision making.
Language has a powerful role in either reinforcing or reducing vulnerability. Technical jargon, unexplained abbreviations, or offhand remarks made to colleagues in front of the patient can signal exclusion and hierarchy. Conversely, careful attention to words can foster connection and trust. Choosing phrases that emphasize involuntariness and legitimacy—“Your nervous system is misfiring,” “These movements are not under your conscious control”—helps counter internalized blame. Avoiding terms that imply malingering, exaggeration, or personality weakness is essential, not only in direct conversation but in documentation that may later be read by other professionals or by the patient. Where potentially stigmatizing language must be used for coding or administrative purposes, clinicians can explain this openly and reassure the person that such terms do not reflect moral judgment.
Power imbalances also appear in how time is distributed. Clinicians usually control the agenda, the length of appointments, and what counts as “relevant” information. People with FND often have complex, fluctuating symptoms that do not fit neatly into short consultations. When they are rushed or repeatedly interrupted, they may feel that only parts of their experience are allowed in the room. Where possible, building flexibility into appointments for FND—such as slightly longer initial consultations, or follow-up visits focused solely on questions and concerns—signals that the person’s full experience matters. Even when time is constrained, explicitly acknowledging the limitation and offering another slot to address unanswered issues can mitigate the feeling of being silenced.
Another dimension of vulnerability relates to bodily exposure and control during examination and treatment. Many people with FND have histories of trauma, including physical or sexual assault, medical trauma, or experiences of being restrained during severe episodes. Standard neurological examinations, physiotherapy maneuvers, or emergency responses to seizures and dissociative episodes can unintentionally echo earlier violations. To reduce this risk, clinicians should consistently seek explicit, moment-to-moment consent: “Is it okay if I touch your leg now?”, “I’m going to stand behind you to support your balance; does that feel all right?” Offering choices—such as whether a support person is present, whether a gown is needed, or whether certain tests can be paused or modified—restores a measure of bodily autonomy and can prevent re-traumatization.
Nonverbal communication significantly shapes how power is experienced. Standing over a seated patient, remaining near the door, or maintaining a stern expression can convey authority and distance, especially when the person already feels scrutinized or judged. Simple adjustments—sitting at eye level, adopting an open posture, allowing silences, and showing visible curiosity rather than skepticism—can help level the interaction. For individuals with functional seizures or episodes that may emerge during assessment, calmly staying present, speaking in a steady tone, and avoiding unnecessary crowding by staff can transform what might otherwise feel like a loss of control into an experience of being safely accompanied.
Institutional settings can amplify hierarchies. In emergency departments or inpatient wards, rapid decisions, rotating staff, and limited privacy may leave people with FND feeling particularly powerless. They may be moved between teams, subjected to repeated examinations, or discussed at the bedside without being addressed directly. Intentional practices can buffer this: introducing oneself and one’s role each time; briefly summarizing what has happened so far; asking what the person already knows; and explicitly inviting questions. When staff changeover occurs, handing over not just medical details but also the agreed communication approach—such as preferred language about FND, known triggers, or prior trauma—demonstrates respect and continuity, even within a high-pressure environment.
Socioeconomic, cultural, and linguistic factors further shape vulnerability. Patients from marginalized communities may face additional barriers, including racism, ableism, or immigration-related fears. They may worry that expressing pain or distress will lead to being labeled “hysterical” or “non-compliant,” or that declining certain interventions will jeopardize benefits, visas, or school support. Ethical practice requires clinicians to be alert to these broader forces and to avoid interpreting guardedness or apparent passivity as lack of interest. Asking open questions—“Are there any concerns about how this plan might affect your work, benefits, or family situation?”—creates space for hidden pressures to emerge. When interpreters are needed, addressing the patient directly rather than the interpreter and checking understanding in simple language redistribute communicative power back toward the person whose care is at stake.
Power imbalances are particularly salient when discussing psychological formulations, trauma histories, or coexisting mental health conditions. Patients may fear that disclosing trauma will cause professionals to dismiss physical symptoms, or that agreeing to psychological therapy will be taken as proof that symptoms are “not real.” Clinicians can reduce this vulnerability by carefully explaining why such topics are relevant: “Understanding what your nervous system has been through helps us make sense of why it is reacting this way now; it doesn’t mean we think you are imagining your symptoms.” Offering clear options and consent processes for psychological assessment, and reassuring patients that they can set limits on what they share and at what pace, helps prevent coercion and supports a sense of control.
In multidisciplinary teams, power dynamics can appear both between professionals and between the team and the patient. Different disciplines may carry varying prestige or influence within the service, and patients can feel confused or intimidated when opinions diverge. To manage this ethically, teams should strive to present a unified, respectful framework for understanding FND, while openly acknowledging areas of legitimate difference without undermining one another. When discussing options with patients, it is helpful to clarify that they are not being “handed off” because one team does not believe them, but rather that different professionals address different aspects of the same condition. Inviting the patient into these decisions—“We could start with physiotherapy and review later, or begin with psychological support if that feels more manageable; what fits best for you?”—makes team power a shared resource rather than an invisible authority.
Episodes of acute behavioral or emotional escalation pose special challenges. A person who becomes highly distressed, dissociative, or physically agitated may be at risk of being managed in a coercive or punitive manner, particularly if staff feel overwhelmed or interpret behaviors as deliberate. Training in de-escalation, trauma-informed care, and the specifics of FND can help clinicians respond with calm containment rather than control. Speaking slowly, offering clear choices (“Would you like the light dimmed or left as it is?”), and explaining every step if physical support is required reduce the sense of being overpowered. After the episode, debriefing with the patient—asking how they experienced staff responses and what might help them feel safer next time—invites their expertise and converts a potentially disempowering event into an opportunity for collaborative learning.
Documentation practices can either entrench or challenge power disparities. Records that describe the patient as “demanding,” “attention-seeking,” or “manipulative” not only carry moral judgment but can bias future clinicians before they even meet the person. In contrast, notes that focus on observable behaviors, contextual factors, and patient perspectives promote fairness and reduce stigma. For instance, instead of writing “refuses physiotherapy,” clinicians might note “expressed fear that exercises will worsen symptoms; discussed pacing strategies and agreed to revisit plan next session.” Recognizing that patients may later access their records under data protection laws, professionals should write in a way they would be prepared to read aloud to the person, which can be a practical check on respectful, balanced documentation.
People with FND may also feel vulnerable in relation to systems that determine benefits, insurance coverage, employment accommodations, or school support. Clinicians’ reports can have major consequences for eligibility and long-term livelihood. It is therefore crucial to separate the therapeutic role from the role of gatekeeper as far as possible, and to be transparent when those roles overlap. Explaining what can and cannot be included in reports, inviting the patient to describe how symptoms impact function, and checking that descriptions are accurate and non-stigmatizing represent important ethical safeguards. When asked to provide opinions that fall outside their expertise or may be used in adversarial legal processes, clinicians should proceed cautiously, stating the limits of their knowledge and avoiding speculation that might harm the patient.
Children and adolescents with FND occupy a particularly complex position of dependency and vulnerability. They may be caught between parents, schools, and health professionals, each with their own theories and expectations. Young people can feel that decisions are made about them rather than with them, especially when adults disagree. To address this, clinicians should consistently include the child in discussions at a developmentally appropriate level, asking for their perspective on symptoms, goals, and fears. Phrases like “You know your body best; what do you notice?” or “What would make school feel safer for you?” affirm their voice. At the same time, working collaboratively with parents and schools, and acknowledging the real constraints on families, helps ensure that the young person is not left carrying the burden of conflicting demands.
Because of previous negative experiences, many people with FND test new clinicians, consciously or unconsciously, to see whether they will be believed and treated fairly. This can involve challenging questions, expressions of anger, or apparent disengagement. Rather than interpreting such responses as “resistance,” clinicians can view them as understandable strategies for self-protection in an unequal relationship. Responding with steadiness—“It sounds like you’ve been badly let down in the past; I want us to talk openly about your concerns”—acknowledges the history of harm without becoming defensive. Over time, consistent follow-through on promises, openness to feedback, and willingness to apologize when mistakes occur slowly recalibrate the power balance and deepen trust.
Ultimately, addressing power imbalances in FND care means embedding autonomy and consent into the fabric of everyday practice. This involves not only explicit conversations about choices but also an ongoing stance of collaboration: asking rather than assuming, inviting rather than directing, and viewing the patient as a partner in expertise. When clinicians use their authority to create space for the patient’s voice, protect against stigma, and advocate within systems that may otherwise disadvantage people with FND, professional power becomes a tool for ethical care rather than domination. In this way, vulnerability is not denied but met with structures of safety, respect, and shared responsibility for decisions.
Documenting, reflecting on, and improving consent practices
Documenting consent in Functional Neurological Disorder care is not simply a legal safeguard; it is part of ethical communication and continuity of treatment. Clear, thorough notes demonstrate that the person’s autonomy was taken seriously, that options were discussed, and that decisions were made through shared decision making rather than implied agreement. At a minimum, documentation should record what information was provided (including key explanations about FND and the proposed intervention), the options that were offered (including reasonable alternatives and the option to decline), the patient’s questions and concerns, and the decision reached at that time. Where relevant, including the patient’s own words about their understanding or priorities can make the record more meaningful and better reflect the nuance of the conversation.
In practice, it is useful to structure documentation of consent as a narrative rather than a checklist. Instead of writing “consent obtained,” clinicians might record: “Discussed diagnosis of FND, explained rationale for physiotherapy focusing on retraining movement patterns; outlined possible temporary increase in fatigue; patient stated they wished to proceed, aiming to improve ability to walk to local shop, and understands they can pause or stop if it becomes overwhelming.” This level of detail captures the ethical dimensions of the encounter: how risks and benefits were framed, how the plan aligns with the person’s goals, and how the option to withdraw consent was made explicit. Such notes support continuity, so that other team members can see what has already been covered and avoid repeating or undermining earlier conversations.
Because FND care often involves multiple disciplines, shared documentation systems are crucial for maintaining coherent consent practices. When neurologists, psychologists, physiotherapists, occupational therapists, and nurses all have access to a unified record, they can see how the diagnosis was explained, which metaphors or educational materials were used, and what boundaries or preferences the patient expressed. Recording these elements—“Patient prefers that episodes are described as ‘functional seizures’ rather than ‘non-epileptic attacks’” or “Requested that trauma history not be discussed in front of partner”—helps the team maintain consistent language and respect previously negotiated limits. This consistency, in turn, reinforces trust, as patients experience the service as coordinated rather than fragmented or contradictory.
Documentation should also track the evolving nature of consent over time. As treatment progresses, the person’s understanding, readiness, and circumstances may change. Brief entries such as “Reviewed ongoing therapy after three weeks; patient reports increased confidence, wishes to continue at current intensity” or “Explored option of group program; patient currently declines due to anxiety about groups, agreed to revisit in two months” show that consent is being revisited rather than presumed. When a patient withdraws from a particular intervention, notes should emphasize their reasons and any alternative plans agreed, rather than implying noncompliance. For example: “Patient stopped attending sessions due to flare in caregiving responsibilities; discussed home-based strategies and plan to re-contact service when able” avoids stigmatizing language and respects the person’s context.
Reflective practice is essential for improving consent processes in FND care. Individual clinicians and teams can regularly review challenging cases, asking not only whether the correct forms were signed but whether the spirit of ethics and autonomy was honored. Useful questions include: Did the patient have enough time and support to make this decision? Were language, cultural, or cognitive barriers adequately addressed? Did we inadvertently pressure the person toward a particular option? Were we transparent about uncertainties and potential discomforts? Structured debriefings—whether in supervision, multidisciplinary meetings, or informal case discussions—help identify patterns where consent may drift toward routine or tokenistic, especially in busy services.
People with FND themselves are invaluable partners in this reflective work. Inviting their feedback, both informally and through more structured mechanisms such as patient advisory groups or satisfaction surveys, can reveal blind spots in how consent is experienced from the patient perspective. Questions like “Did you feel you had a real choice about your treatment options?” or “Was there anything you agreed to because you felt you had no alternative?” can illuminate subtle pressures that may not be apparent to clinicians. When feedback identifies problems—such as feeling rushed into group programs, or confusion about why certain tests were or were not offered—teams can adjust their communication and documentation practices, closing the loop between experience and improvement.
Ethical reflection is particularly important in situations where capacity, distress, or crisis complicate consent. After an acute admission, for example, clinicians can revisit earlier decisions with the patient once they are more stable: “When you first came in, you were very distressed and we had to act quickly; I’d like us to go back over what happened and make sure you’re comfortable with the plan going forward.” Documenting these follow-up conversations provides evidence that initial consent was not treated as permanently binding and that the team is willing to renegotiate in light of the person’s preferences once they can participate more fully. This approach aligns with trauma-informed care and supports restoration of agency after a potentially disempowering event.
Written materials, consent forms, and information leaflets used in FND services also benefit from periodic review. Teams can examine whether forms are written in accessible language, whether they clearly state that participation is voluntary, and whether they explain how data will be used and who will have access. It may be necessary to revise standard templates borrowed from other areas of medicine that assume a purely biomedical intervention, adding explanations relevant to FND, such as the effort involved in behavioral and rehabilitation work or the potential for emotional activation in psychological therapies. Involving patients in co-designing or reviewing these documents can enhance clarity and make them more responsive to common questions and fears.
Another dimension of improvement involves auditing documentation and communication for implicit bias or stigmatizing patterns. Regularly sampling records of people with FND and comparing them with records of patients with other neurological conditions can reveal differences in tone, depth of explanation, or assumptions about reliability. For instance, if notes about FND patients more frequently include value-laden descriptors (“dramatic,” “overly focused on symptoms”) or vague phrases about consent (“agreed as discussed”) without detail, this may signal an area where ethics in documentation need strengthening. Sharing anonymized examples within the team—highlighting both good practice and problematic wording—can foster a culture of learning rather than blame.
Digital systems offer opportunities and risks for documenting consent. Electronic health records can prompt clinicians to record key elements of discussion, ensuring that important topics such as risks, alternatives, and patient preferences are not overlooked. However, overreliance on tick-box fields can obscure the richness of shared decision making. Balancing structured fields with free-text spaces allows clinicians to capture the narrative of how a decision was reached, including the emotional context, questions raised, and any unresolved ambivalence. When telehealth or email are used to obtain or confirm consent, clinicians should document the mode of communication, how identity was verified, and any limitations of that format (for example, difficulty reading nonverbal cues), as well as offering follow-up opportunities in person if needed.
Improving consent practices also requires attention to how information about FND care is shared beyond direct clinical work, such as in teaching, supervision, or research. When cases are presented at conferences, in academic articles, or in teaching sessions, consent for such use should be explicitly recorded, including what details can be shared and how anonymity will be protected. Reflecting on these processes in team meetings—asking whether requests for such consent might feel coercive in certain contexts and how to minimize that risk—helps keep ethics at the forefront. Where consent is not granted, documentation should clearly state that the patient declined and that this decision has no impact on their care, reinforcing that their voice carries real weight.
Self-reflection by individual clinicians is a vital complement to formal systems. After significant consent conversations, it can be useful to pause and consider personal reactions: Did I feel rushed, frustrated, overly persuasive, or overly cautious? Did my own beliefs about what is “best” for FND influence how I framed the options? Keeping brief reflective notes (separate from the medical record where appropriate) or bringing such reflections to supervision can reveal recurring themes. Over time, this introspective practice supports more balanced communication, allowing clinicians to recognize when they may be slipping into paternalism or, conversely, into a hands-off stance that leaves patients under-supported in complex decisions.
Teams can institutionalize improvement by embedding consent-related goals into service development and quality improvement projects. Examples include setting targets for offering every new patient a written summary of their diagnosis and treatment options, ensuring that consent for group programs is revisited after initial sessions, or developing checklists for discussing digital privacy when recommending symptom-tracking apps. Regular review of these initiatives, with input from patients and families, helps move consent from an individual clinician’s responsibility to a shared organizational commitment. In this way, documentation and reflection become tools for aligning everyday practice with the core values of respect, autonomy, and trust that underpin ethical care in FND.
