Shared Decision Making – with Families – Yields Better Treatment Outcomes

Alison M. Heru, M.D.
Professor of Psychiatry, University
of Colorado Denver

In the NES
Program at University of Colorado Health, a six-month program
combining neurology and psychiatry treatment for non-epileptic or
non-electrical seizures, psychiatrist Dr. Alison Heru makes shared
decision making an integral part of practice.

In my experience,
shared decision making yields the best results in treatment. When
patients feel like they have participated in choosing the treatment
and are able to ask questions and weigh alternatives, they are more
likely to feel they have selected the treatment that is the best for
them and have a stronger stake in the outcome.

At the NES program
(addressing non-electrical seizures), there’s not clear evidence
for which treatment approach will be best for each patient. It’s my
role, then, to make sure we make the correct diagnosis, provide
information about the treatment modalities available, and decide
together with the patient (and the patient’s family, unless not
available) on the treatment plan. I won’t tell the patient what to
do or to force a choice on them, but I will offer my opinion.

The first
appointment starts with an interview through which I learn about
symptoms and ask questions in order to get to know the person and
make a diagnosis. It is usually helpful to have a family member in
with the patient on the first appointment. I tend to include family
members, as they can provide me with more information than the
patient alone. Having a family member present also helps my
assessment of whether family treatment is indicated.

Whether I’m
teaching residents, seeing patients in my private clinical practice,
or treating medically ill patients in the hospital, I like to include
family members in the care plan. My presumption is that if a family
member is in the room, they have a role in the care, and the process
becomes more collaborative.

Families need
information, education, and often therapy when addressing mental
health issues. I refer to the family as the doctor’s eyes and ears,
as they provide information I might need and might not otherwise get,
whether at the time of diagnosis or in monitoring the progress of
treatment. In clinical practice, I see several roles for family
members and their involvement in shared decision making.

First, by
understanding the diagnosis and the treatment options, especially the
relative importance of medication for the particular condition, as
well as the person’s level of functioning and their values, family
members can help the person with the mood disorder make decisions
about care and treatment. Knowing what the psychiatrist is thinking
assists family members so they can support the person with the mood
disorder (e.g., taking them to the pharmacy, monitoring side effects,
setting up the pill minder) and help them to become more functional.

Second, an agreement between the person with the mood disorder and family members about their role reinforces the progression toward wellness. For example, if there’s agreement that the family member will be highly involved for a limited period of time – such as, for 6 weeks following discharge from the hospital, the family member reminds the person with the mood disorder to get out of bed, take regular meals, and so on – then when the time has passed, the family member will step back as the person with the mood disorder takes more charge of their own life. It’s a recurring problem that families get stuck in caregiving mode; without an agreement, there’s no event that causes them to step back, and they don’t know how to negotiate change when the patient gets better.

Third, one of the
most crucial roles for family members is in creating the advance
directive for care. Knowing the conditions in which the person will
go to the hospital–and what each person’s role is in that
situation (e.g., taking care of the children)–allows people to
proceed to care without there being chaos and hurried decisions made
under pressure.

Shared decision
making builds more honest relationships and engenders trust. Although
all physicians will say they are committed to shared decision making,
it may not be consciously emphasized at the relevant points of
diagnosis and treatment. They don’t often want to be in the
position of having to be ambivalent, admit the lack of evidence, or
not be seen as an expert. But I’ve found that patients appreciate
honesty, even when a doctor says she doesn’t know which would be
the best treatment for that person. I often tell patients to call me
if the treatment is not going well; each person is unique and
different, and I don’t know if this is the right treatment unless
they let me know that it’s not. Patients with a stake in the
decision believe that they have made the right choice to help them to
be well.

Editor’s Note:
We are reprinting this post, previously published on August 16, 2016,
as we continue our exploration of patient-centered care, of which
shared decision making is an essential component. Stay tuned!

What do you think?

  • What has been your
    experience with shared decision making for your (or your loved one’s)
    mental health treatment? In what ways did – or would have –
    shared decision making affect the treatment process and outcomes?

M. Heru, MD, Professor of Psychiatry at the University of Colorado
Denver, practices psychiatry in the NES (non-epileptic or
non-electrical seizures) program at University of Colorado. She is
the author of several books: Working
with Families of Psychiatric Inpatients
(with Laura
Drury); Couples
and Family Therapy in Clinical Practice, 5th
. (with Ira Glick, Douglas Rait, and Michael
Ascher); Clinical
Manual of Couples and Family Therapy
(with Gabor
Keitner and Ira Glick); and Working
with Families in Medical Settings: A Multidisciplinary Guide for
Psychiatrists and Other Health Professionals
Dr. Heru is treasurer of the Association
of Family Psychiatrists

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