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Shared Decision Making: Activation of Patient/Prov ...
Presentation Q&A
Presentation Q&A
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Video Transcription
Patrick, I'm wondering if you might be able to answer our first question here, which is how does shared decision-making benefit the clinician in providing treatment? You focused a lot on the benefits for patients. What's the benefit for the clinician? Well, actually, the benefit for the clinician is the fact that the clinician's purpose and goals in their work is to improve the outcomes for the individual, and so that they have a feeling that the treatment that they're providing is having the desired effects on an individual's life and health. When they enter into this type of equal partnership relationship and the person begins to take ownership of their treatment plan and feel like they're an equal participant in making those important decisions, therefore, they follow through with the treatment plan much more, and we see that people do better. I think that is the goal that any clinician has, is to see that a person's life improves. If we're providing treatment and people's lives are not getting better, then we're not doing what we need to be focusing on. I think this type of relationship is very advantageous and makes a clinician feel that they're really in touch with their work and able to help people at the highest level. Great. We have another question around how people can access resources for shared decision-making. Somebody asked if we could show the slide again that you had provided with the website. That was for lessismoremedicine.com. I'll just let everyone know that in the GoToWebinar platform, you can actually download the slides. There's a link to the PDF there. Are there other websites that you would recommend as having good shared decision-making resources related to mental health? Actually, I don't have them in front of me, so I really can't say what the name of the sites are. In working with the shared decision-making process for a number of years now, probably more than 10 years that I've been utilizing it in my work, there have been just this really quickly growing availability of decision-making tools on the internet. If you just look under decision-making aids and tools, if you Google it, you'll come up with many, many different options. And if you explore them, you'll see the ones that I think you'll feel may work best in your practice. Great. Thank you. I'll just mention to folks as well, SAMHSA has a few on their website, I think, related to medication-assisted treatment and antipsychotic use. So not kind of tangential to our discussion around SMI, but there are some resources there as well that are pretty easy to find on Google. Let's take another question. The writer states, paternalistic approaches have been used because of the feeling that patients are not able to make good choices at times based on their illness. Are there patients for whom shared decision-making should not be used? And is it an all or nothing? It's not an all or nothing. And that's really the point. That goes to the heart of that idea of meeting a person where they are in that given moment. As I was talking about with somebody in a crisis unit, they may not be at that point able to join into decision-making or even fully take in the information that they need to make medication decisions. But there are some types of decisions that they can make. And by encouraging people to make decisions, and again, it may be simple decisions about whether or not they want to eat lunch on a crisis unit, whether or not they want to sit quietly and not engage in conversation with staff at a particular time, or they don't like to be physically touched during a crisis, or they do like to be physically touched. By getting people to make those kinds of decisions and working with them enough so that you understand where they are and encouraging them to make those decisions, you're already beginning the process. And so you're giving that person self-agency at the very most critical time. And that just expands as you move forward with that clinical relationship. And so eventually, the person is fully engaged with the clinician on all levels of their treatment and well-informed about the possibilities of positive outcomes or negative outcomes moving forward in any course of treatment. Another viewer writes in, is it helpful to have support figures involved in shared decision making along with the patient SMI? So I guess that's what's the role of family members, peers, others in an individual's life. You know, there's a very big role for many, many people. One of the issues that happens is, as I said, when people are perhaps not at a good point of making decisions or not feeling sure about themselves, sure enough about themselves to interject their own thoughts, it can be very advantageous to have a family member who you the person feels comfortable with to participate, to go with them to a clinical meeting, a treatment session. It may be also very appropriate to have a peer support group or a peer specialist who's developed a trusting relationship with the individual. And sometimes that can be just having the person in the room gives them the confidence they need. And sometimes they might need the individuals who've accompanied them to the meetings to help translate their thoughts into a way that the clinician can understand what they're trying to achieve. And so, again, this goes back to, you know, we can begin to participate in making decisions at almost any point. And that's by starting at the very beginning, making the most basic decisions, utilizing whatever supports are available to us to be effective in making those decisions, allows us to really eventually begin to activate that self-management that we all look for. We have another viewer question. It says, I'm an employment specialist working in an evidence-based program proven to have success getting people with SMI back to work. Part of the model involves integration of employment services with mental health treatment teams. What are some best practices around shared decision-making involving provider teams? Well, I have to think about that to a degree. I think, you know, it's essentially the same thing. I think when people are working and there's a team approach to providing their services, the individual has to be brought into those team decisions. However that is done, it may be through a one-on-one with one member of the team that they have a particular trusting relationship with, or it may be in group discussions. You know, frequently, like if we look at the ACT model, Assertive Community Treatment Teams model, which is, you know, the most intensive outpatient treatment, I believe, that's a team approach. But there's still a place in that for shared decision-making. And again, it may be done one-on-one with the treating psychiatrist, or it might be with the employment coach, you know, supported employment person. It may be done with a nurse, or it may be done by bringing the person into a joint discussion. And again, we try not to impose too much of a burden on the person where they feel overwhelmed by the choices that are presented to them. So we try to let them determine where is the place where they can begin to make decisions that they feel comfortable with. And I don't think that a team makes a very big difference in that, other than just the dynamics of how you involve the team, or you have the input from the individual to the team decision-making process. I don't know if that answers the question, but I think so. We have a multi-part question from a viewer, which I'll try to synthesize down. It asks about using shared decision-making in an acute inpatient setting where the patient needs medication for acute psychosis or mania, but doesn't at that time have insight into the need for medication. And the question basically boils down to, how do you change your shared decision-making approach as the patient develops insight through treatment? What do you think about that, Patrick? I think that's a very good question. And I think, again, you know, when a person is in that acute treatment point where they're not able to have the insight that they need, they still may have areas, you know, where they have really preferences that they can define. Sometimes they define them through advanced directives, and that's extremely helpful because that can also be part of shared decision-making. Now, when a person fills out an advanced psychiatric directive and they're at a point where perhaps they're nonverbal or they're easily distracted or confused and not able to make their preferences as clear as they might be at other times, we can turn to those advanced directives and see what their preferences for that point in their life are. And I've helped people fill out advanced directives before. And I've literally seen where, you know, a major preference for an individual might be that issue I brought up before of a person either liking to be touched or not liking to be touched when in crisis. So by making that choice early on, that's a step forward. But at the same time, I think, you know, even when a person is, you know, acutely ill and, you know, lacking in really clear insight, there are some things that they're able to communicate to the clinicians and the staff that are providing treatment and stabilization services. And again, it might be just, you know, being left alone at a particular time or being encouraged to talk at a particular time. And so that's, you know, that is the start of it. And then as people begin to, you know, find more clarity in their own thinking and are able to communicate that to the people providing services, then their ability to participate in decision making is increasing. And so the clinician needs to be really aware of where that person is at any given point. This is done really through discussion, through, you know, investigation by the clinician to really try to understand where the person is and continue that feeling of trust by honoring their wishes as best possible. Is that, do you think that gets close to where we're trying to answer? Yeah, I think that's great. And I would just add, you know, psychiatric advance directives is something that we're going to be talking a lot more about on SMI Advisor. SAMHSA actually released a practical guide to psychiatric advance directives earlier this week. And I'd encourage all of you who are interested in this topic to visit SAMHSA's Evidence-Based Practice Resource Center and download it. It has a number of helpful tools in it. And we will also be having broader discussions around psychiatric advance directives in future webinars. And I think it's a really important topic. And Patrick, I really like how you've connected it with shared decision making. I'm wondering for the last question here, if you can also connect shared decision making to one other approach that we commonly use in mental health, which is motivational interviewing and how those two, there are a lot of similarities in some ways, but also some distinct differences. And so I'm wondering if you can do a little bit of comparing and contrast shared decision making and MI. Sure. And, you know, that's one of the things that I talked about earlier during the presentation. Motivational interviewing is, you know, largely about getting people to the place where they can make meaningful choices about change. And in order to do shared decision making, again, people need to be at a point where they can make those kinds of choices when given the information. So you may, again, meet somebody where they're not at the point where they're willing to make a change. And I used the example of medication changes during the presentation. They may be really aware of a positive effect that the medication has had on their ability to think and communicate. But they may also be aware of very distressing side effects. And so they're ambivalent. They don't know which way to go. And, you know, the physician or clinician can provide them with all the information they can, but sometimes they need to move forward in a slightly different way. And this is where you can combine the techniques of motivational interviewing, where you, again, help a person by giving them the maximum amount of information, providing them with access to decision making tools, knowing that they have to go through a sequence of, you know, that pre-contemplation where they're beginning to feel change might be necessary, but they really haven't thought it through, moving them into the contemplation stage of change, and then eventually into the activation or active change part, and then maintenance eventually. And when you do that, you kind of just slide right into a shared decision making process. When you're helping a person by using the techniques of motivational interviewing, you're actually partnering with them from the beginning. You're trying to get them to feel that they have the ability to make choices. And something I said earlier, I think is really key to this, is that people at different points in treatment and at different points in, you know, the symptoms of what they're living with, have different abilities and different depths in their abilities to make important decisions, because their idea of what's available to them can be very limited by the experiences they're going through. And what I mean by that is, for instance, if you're in a crisis unit, and in your, you know, when you're in a hospitalization, you don't get to make a lot of very basic choices in your life. For instance, you know, a doctor may show up at six o'clock in the morning in your room. You don't really have a say in that in most cases. You may be told, you know, you have to eat breakfast at this particular time and lunch at this time, dinner at this time. You may have set hours where you can visit people. All of these things are very common. And so decisions are taken away from people. So we try to give, help them to find places where they can begin to make decisions. And then we just follow through with that. And by doing that, you move right into that trusting partnership kind of idea. Well, Patrick, thank you for such a great presentation and for really digging in on the questions and answers. We have reached the end of today's presentation.
Video Summary
The video transcript features a discussion on shared decision-making in healthcare. The speaker, Patrick, talks about the benefits of shared decision-making for clinicians, stating that it allows clinicians to improve outcomes for individuals and feel that their treatment is having a positive effect on patients' lives and health. By involving patients in the decision-making process and making them feel like equal participants, they are more likely to follow through with the treatment plan and experience better outcomes. Patrick also discusses the availability of resources for shared decision-making, mentioning a website called lessismoremedicine.com and recommending a Google search for decision-making aids and tools. He emphasizes the importance of meeting patients where they are in their treatment journey and involving support figures, such as family members and peers, in the decision-making process. Patrick also addresses questions about shared decision-making in acute inpatient settings and its connection to motivational interviewing, highlighting the similarities and benefits of combining the two approaches.
Keywords
shared decision-making
healthcare
clinicians
patient involvement
treatment outcomes
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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