Shared Decision-Making

in Mental Health and Behavioral Healthcare

National Grantee Conference
on the Mental Health Block Grant and Data
Washington, DC
June 18, 2009

Presenters:

Melody Riefer Laurie Curtis

Pat Deegan & Associates, Inc. Project Director
Shared Decision-Making Project SAMHSA’s Shared Decision-Making
Atlanta Office in Mental Health Project
2392 Cardinal Way Advocates for Human Potential
Tucker, GA 20084 2 E-Comm Square
heymelody@gmail.com 324 Broadway
Albany, NY 12207
lcurtis@ahpnet.com

Moderator:
Stacey Lesko
Contract Officer
Office of Consumer Affairs
Center for Mental Health Services (CMHS)
Substance Abuse and Mental Health Services Administration (SAMHSA)
1 Choke Cherry road, Room 2-1012
Rockville, MD 20857
stacey.lesko@samhsa.hhs.gov
Shared Decision-Making (SDM):
Making Recovery Real in Mental Health Care
Substance Abuse and Mental Health Services Administration (SAMHSA)
Center for Mental Health Services (CMHS)

About Shared Decision-Making

• Shared decision-making is an interactive and collaborative process between individuals and their health care
practitioners about decisions pertinent to the individual’s treatment, services, and ultimately their personal
recovery. The practitioner brings expertise about disorders, treatment options, risks and benefits. Individuals
bring their lived experience, knowledge, values, and preferences.
• An optimal decision is one that is informed, consistent with personal values, and acted upon. Participants are
satisfied with the process used to make the decision.

• Shared decision-making is particularly relevant when there is uncertainty about a particular decision.
Uncertainty may stem from multiple or competing options each with advantages and disadvantages,
incomplete or inconclusive scientific outcome evidence, or individual factors such as personal values and
beliefs, a limited knowledge about the options, or lack of support to make a clear choice.

• Effective shared decision-making requires both informed and involved consumers, and practitioners who are
willing to enter into meaningful dialogue with the person about the decision to be made.

• In general health care, people are increasingly recognized as key decision-makers about their own healthcare.
For example, the Institute of Medicine (IOM) Report, Crossing the Quality Chasm, calls for health care to be
patient-centered with individual preferences, needs, and values guiding clinical decisions. The IOM’s follow-up
report, Improving the Quality of Health Care for Mental and Substance Abuse Conditions, expands the
principles of informed, patient-centered treatment, and shared decision-making to mental health and
substance abuse treatment services.

Decision Aids and Decision Support

• Decision aids are tools that help provide information and provide a structured process for making decisions
about a particular concern. They may be presented in any number of formats, such as paper-pencil,
audio/visual, computer-assisted or web-based interactive technologies. Regardless of format, decision aids
contain four primary elements: (1) Information; (2) Values clarification; (3) Recognition of social pressures on
decision-maker; and (4) Resources required to act on decision.

• Decision Support: Processes for helping individuals gather information, assess risks/benefits, and use decision
aids and other resources to come to a decision that aligns with personal values and goals. May include
preparation for communicating and implementing a decision.

• The Ottawa Health Research Institute maintains the Ottawa Health Decision Centre (http://www.decisionaid.ohri.ca)
which has an inventory of many decision aides for physical health care, many of which are available on line.
The Dartmouth-Hitchcock Medical Center Decision Support Center, with funding from the Foundation for
Informed Medical Decision Making and Health Dialog, Inc., has established an on-site decision-support center
for patients and also provides limited on-line resources (http://www.dhmc.org).
About Shared Decision-Making in Mental Health
SAMHSA/CMHS is interested in promoting and supporting SDM in mental health for a number of reasons
o SDM is consistent with recovery-based transformation and the foundation values of choice, self-
determination, and empowerment.
o SDM is a means of enhancing involvement of consumers in mental health care, which has recognized
benefits for positive treatment outcomes.
o Mental health consumers have an active desire to participate in decisions about their care and are
capable of doing so.
• To promote these interests and objectives, SAMHS/CMHS has initiated and funded this project.
• There is growing understanding and interest in how approaches to shared decision-making emerging in the
physical health arena may be adapted to mental health field. Currently there is very little research and few
decision-aides or other materials on shared decision-making specific to the mental health context.
• Dr. Patricia Deegan has pioneered an innovative approach to helping mental health consumers to participate
in shared decision-making about the use of psychiatric medication. This program, “Common Ground” is one
example of decision support and includes peer-to-peer workshops, an interactive software program available
to patients in a clinical waiting-room setting, and training for practitioners to help clients navigate decisional
conflict related to medication use. Dr. Deegan is a lead member of the SAMHSA/CMHS SDM project.

About the SAMHSA/CMHS Project: Shared Decision-Making: Making Recovery Real in Mental Health
Purpose

• The project is intended to identify existing proven decision-making technologies from general healthcare or
other sources, and then adapt and pilot test them for use by mental health care practitioners and consumers.
• SDM is a very new approach for mental health services and it is expected that this project will develop interest
and provide a foundation for future development in the field.
• The intended audiences for shared decision-making materials developed through this project include mental
health consumers, practitioners, and family members.
Products under Development
Three different kinds of products are being developed under this project.
• Introductory materials for specific audiences such as consumers, providers, administrators, prescribers
• Decision support materials providing general structure and guidance for making any decisions
• An interactive, web-based decision aid focusing a decision relevant to antipsychotic medications
Method for Development

• The SAMHSA/CMHS SDM project is being developed under a contract with Advocates for Human Potential,
Inc. (AHP) and Westat, with an experienced team of staff, consultants, and subcontractors to design, develop
and pilot test SDM products.
• SDM project receives regular input and feedback from a Planning Team, an advisory group of researchers,
policy-makers, consumers, family members, and practitioners.
• All SDM products will undergo pre-development audience testing and field evaluation.

For further information contact:

Laurie Curtis, Project Director
Shared Decision-Making: Making Recovery Real in Mental Health Care
Advocates for Human Potential, Inc.
lcurtis@ahpnet.com
 Shared Decision-Making Conversation Skills for Providers
Talk about it!

Provider Skill Example Conversation Starter

OPENING
1. Recognizing that a problem exists and/or that a decision can be made. This is a situation where you can think about what is important to you and
make a decision.
2. Stating there is more than one way to deal with the problem. You may have several options for dealing with this situation.
3. Identifying ideas and expectations. What are your ideas for dealing with this situation?
4. Discussing concerns and worries about the decision. What worries you most about making this decision?
5. Finding out how person wants YOU involved in decision. Is this a decision want to make on yourself or do you want some help from me?
From someone else? You said you wanted some help from me. Let’s talk about
what would be most useful.
6. Finding out how person wants OTHERS involved in the decision. Do you want friends or family to help you think about or make this decision? If
so, who? How do you want them involved?
DURING
7. Respecting each person’s pace and preferences for your involvement. You said you wanted to take this on yourself. Let me know if and how I can help.
Stepping back. I’d like to check in to see how it’s going. Is that OK?
8. Finding out how person prefers to receive information. How do you want to get information about this? Talk it over with me or
someone else? Read? Watch a video? Use the internet?
9. Checking to see if person understands information. Let’s talk about what you found out from [our conversation, your reading, the
video….]
10. Clarifying steps and using tools. Let’s work through this together, step-by-step. OR here is a step-by-step
worksheet to help guide you.
11. Identifying options. Let’s make a list of all the possible ways to handle this situation.
12. Exploring pros and cons of each option. What do you think would happen if you chose this option?
13. Offering opportunities for asking questions. What questions do you have?
14. Indicating the need to decide or defer a decision. It’s time to make a decision about what should be done. OR You don’t have to
decide right now. You can think it over for a while.
AFTER
15. Revisiting and reviewing the decision. You made a decision to….. How did that go for you?

JUNE, 2009
DRAFT – NOT FOR DISBRIBUTION
 Developed by Pat Deegan PhD & Associates, LLC,
CommonGround™ is a web-based software application
that empowers those of us with psychiatric diagnoses to
communicate with psychiatrists and to arrive at shared
decisions about next steps in the management of long-term
psychiatric conditions. It was developed by and for people
diagnosed with psychiatric disabilities. The
CommonGround™ Approach is currently being used in clinics and hospitals in Kansas,
Pennsylvania and Massachusetts.

For the doctor: CommonGround creates efficiencies in the psychiatric consultation and
optimizes collaboration with the client in the management of long-term psychiatric
conditions. It identifies treatment adherence concerns upstream and generates
solutions for resolving decisional uncertainty about treatment. CommonGround
presents a holistic view of the patient-as-person, brings the individual to the center of
the clinical care team and helps medical practitioners focus on functional recovery
outcomes like getting back to work.

For the client: CommonGround amplifies the client's voice and brings concerns to the
center of the psychiatric care team. It empowers clients to talk with their doctors about
treatment concerns before nonadherence become an issue. CommonGround activates
clients in the disease management and wellness process by helping them identify
Personal Medicine or the things they can do to create wellness such as gardening,
walking and being with loved ones. It provides clients with the tools to create Power
Statement that communicate individualized, functional recovery goals such as going
back to work and parenting.

For Direct Service Staff: CommonGround provides peer staff with a unique career
track, set of skills and tools to support people in getting active and involved in their
psychiatric care. It also provides case managers and other direct service staff with
practical, recovery oriented strategies for supporting clients' recovery.

For the Mental Health Administrator: CommonGround is a risk management tool that
insures quality in the busy psychopharmacology consultation. It provides on-the-job
training in recovery oriented practice and helps to achieve transformation of services to
support recovery.

CommonGround can be used in peer centers, inpatient units and outpatient clinics.
Because it is a web based application, it can be used by mobile outreach teams and
Assertive Community Treatment teams.

After initial start-up costs, CommonGround is available to organizations at $2 per user

per month. Contact pat@patdeegan.com to learn more.

www.patdeegan.com/AboutCommonGround.html