TIPS
For Mental Health
Service Providers
Using Shared Decision
Making in Your Practice
Adapted from various materials from
SAMHSA on Shared Decision Making for
BHH Learning Session on June 25, 2015.
www.samhsa.gov • 1-877-SAMHSA-7 (1-877-726-4727)
Your Role as a Helper
Making decisions independently is an important part of mental health recovery. People have the
right to make and take responsibility for personal decisions in their lives. But people make their
best decisions when they have good information, consider the input of others, and take time to
think through what is most important to them.
As a peer, family member, friend, or mental health provider, there are many ways you can help
others make informed and thoughtful decisions.
Here are some examples:
• Support emotions. Recognize that decision making is not always logical and rational,
but can be messy, complicated, and emotional. Provide support for emotions, not just
the process. Affirm that it is natural to feel stressed, uncertain, or confused when faced
with a difficult decision. Sometimes people are afraid to even begin the process of decision
making. Ask people about their concerns about making a decision and offer ways to
address them. Suggest that people talk with others who have faced similar decisions.
•
Match your support to the person’s preferences. Recognize that people might not want
your help. Offer help with the recognition that your offer might not be accepted. Ask people
what type of help would be useful, such as emotional support or practical information.
• Helponlywhenneeded.Noteveryoneneedshelpwiththewholedecisionmakingprocess.
Apersonmaybestuckononlyoneortwosteps.Helpwiththetroublingstepsonly.They
maywantyourideasaboutoptions, but make the decision on their own.
• Beflexiblewithpace.Respectthepaceatwhichpeoplewanttomakedecisions,while
help-ingthemfocusonany deadlines.Itisokaytostopandrestartas needed.Somesteps,
like”Research”(page9),mayrequireconsiderabletime.
• Simplify.Presentanystructureddecisionmakingapproachashelpfultools ratherthanas
aprocessthatmustbefollowedtotheletter.Breakcomplicateddecisions intosmaller
decisions.Thegoalistomakeinformeddecisionsthatfit.
• Avoid taking over. Focus on the person’s thoughts and feelings and do not impose your
own. This can be challenging, especially if you have a strong opinion or feel you have a
stake in the decision the person makes. Avoid leading questions such as “Wouldn’t you
prefer to…”
2
You also help them develop their decision making skills. It is important to keep the dialogue
open, because, in the end, people make their own decisions, either actively or passively (by
avoiding or not following through on a decision).
People generally make choices that they believe are right for them at the time. You may not
necessarily agree with their choice. Sometimes people make a decision and then find that it
did not work out the way they expected. Part of the process is to revisit a decision and see how
it is working.
TIP
To Avoid Taking Over
Use open-ended questions about
a person’s priorities.
What do you think is the best way to…
Reflect what the person says.
So what is important to you is…
Ask for permission before
presenting your opinions.
Do you want to know what I think?
Present your opinions as opinions,
not as facts or advice.
In my opinion, your best option is…
Acknowledge any conflict of interest.
Of course, I would be better off if you….
Stay open to any idea the
person suggests.
That is an interesting idea! Add it to
your brainstorm list.
Talk About It!
Shared decision making communication skills for providers and helpers
Shared decision making is more than asking someone what is important to him or her. Combining these communication skills with information resources, structured decision aids, and decision support tools can result in a productive
and satisfying shared decision making experience. It also empowers individuals and encourages their involvement.
Skill
Example Conversation Starter
BEFORE decision making
1.
Recognize that a need 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.
State there is more than one way
to deal with the need.
There may be several options for you to deal with this situation.
3.
Identify ideas and expectations.
What are your ideas for dealing with this situation?
4.
Discuss concerns and worries
about the decision.
What worries you most about making this decision?
5.
Find out how the person wants
YOU involved in the decision.
Is this a decision you want to make by 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.
Find out how the 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 decision making
7.
Respect the person’s pace and
preferences for your involvement.
You said you wanted to make this decision yourself. Let me
know if and how I can help. I’d like to check in to see how it’s
going. Is that OK?
8.
Find out how the 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.
Check to see if the person
understands information.
Let’s talk about what you found out from [our conversation, your
reading, the video….]
10.
Clarify steps and use tools to help
make a decision.
Let’s work through this together, step-by-step. OR here is a
step-by-step worksheet to help guide you.
11.
Identify options.
Let’s make a list of all the possible ways to handle this situation.
12.
Explore pros and cons of each option.
What would happen if you chose this option?
13.
Offer opportunities for asking
questions.
What questions do you have?
14.
Indicate 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 decision making
15.
Revisit and review the decision.
You made a decision to….. How did that go for you?
Culture Counts!
Enhancing the Shared Decision Making Process
Creating Dialogue
Promoting Choice
Supporting Recovery
Cultural factors influence how people come to view, understand, and experience
the world. Likewise, a person’s cultural beliefs, values, and preferences play an
important role in health and mental health care decision making. For shared
decision making to be truly effective, an individual’s cultural background and
relevant beliefs must be considered throughout the decision making process.
Factors to consider include the following:
• The role of culture in health and mental health care decision making.
• The impact of cultural beliefs on treatment and service decisions.
• Strategies for incorporating culture in the shared decision making process.
Providers can understand
and bridge the cultural
differences that influence
clinical relationships and
decision making.
– Anna Napoles-Springer
Health Expectations, 2005
vol. 8, p. 4-17
Shared decision making is an emerging best practice in health care and has been specifically
recommended by the Institute of Medicine (IOM, 2005). It helps improve communication
between service providers and people who use their services. Incorporating full information
and decision making tools, it helps balance information about mental health conditions
and treatment options with an individual’s preferences, goals, and cultural values and beliefs.
Used effectively, shared decision making can make communication more productive,
efficient, and empowering for both the person using services and those providing them.
The Federal Substance Abuse and Mental Health Services Administration (SAMHSA)
supports the use of shared decision making as a routine part of mental health services.
This issue brief is part of a set of materials designed to help make this possible.
Culture is defined as “an integrated pattern of behavior that includes
language, thoughts, communications, customs, beliefs, values, and
institutions of racial, ethnic, and cultural groups” (DHHS, 2001).
Strategies for Incorporating Culture
in the Shared Decision Making Process
A shared decision making process may provide new opportunities to explore and discuss cultural beliefs about health
and healing. Alegria and colleagues (2008) found that a shared decision making approach can help increase participation
in mental health services by people from non-white cultures. When people who use services discuss what is important to
them, it may lead to increased trust, engagement, and decisions that fit their beliefs, values, and preferences. Further,
provider awareness of an individual’s cultural values and other information can help minimize bias and stereotypic beliefs.
Here are some key strategies for incorporating culture in the shared decision making process.
Strategy
Why Important
1. Take extra time to explain the value of shared decision
making for individuals who often rely on authority, narrative
talk, or negotiation to make decisions.
Such discussions can help individuals feel comfortable about
becoming more involved in decisions and with using shared
decision making materials.
2. Ask how decisions are made in a person’s life and family.
Are particular family or community members typically
consulted on key decisions? Is the person interested in
using shared decision making tools with this person?
If desired, a family member or other important person participating in the decision making process can help increase
engagement into care. This may help a person make a more
culturally informed decision.
3. Ask about how the person thinks about his or her problem
or situation. Is there a particular name or term used within
their family, community or cultural group to describe what
he or she is going through?
This discussion can increase a provider’s understanding
of culturally specific beliefs about health, illness, and healing.
It can help providers find treatment approaches that respect
cultural beliefs and preferences.
4. Ask about spiritual, religious, family, or other cultural
beliefs associated with the use of medication and other
Western medicine treatments. Also ask about the use of
herbs, roots, or other complementary or alternative medicine.
Individual spiritual or cultural beliefs may not support the
use of medication. Talking about this may yield information
about treatment practices that are culturally acceptable.
5. Ask about customs or rituals the person is using or would
like to use to promote health and healing.
Discussion and use of culturally specific customs and rituals,
along with formal treatment recommendations, can lead to
increased trust, engagement, and treatment follow-through.
6. Ask about family or community beliefs associated with the
decision the individual is trying to make.
Understanding influences on decision making can help a
person place his or her own beliefs and values into a broader
social and cultural context.
7. Ask about whether activities included as part of shared
decision making resources address culturally relevant values.
Should other values clarification areas be explored?
This communicates respect, cultural sensitivity, and the
understanding that there may be culturally specific values
impacting a person’s preferences.
8. Facilitate translation of shared decision making materials
and discussions into the person’s preferred language.
Reading and speaking one’s primary language allows for
more complete understanding of information and processing
of emotions or ideas that do not translate directly to English.
9. Examine your own beliefs, values, and assumptions.
Training in cultural competency can help with this process.
Personal beliefs and bias can affect how you view options
and make recommendations. Awareness and training can
help reduce their impact in shared decision making.
Conversation Starters
Talking about culture and health in shared decision making
A person’s cultural beliefs, values, and practices can play an important role in his or her decision making. The
shared decision making process can provide opportunities to explore and discuss cultural aspects of health and
healing. Provider awareness of these beliefs can help bridge differences that influence relationships and decision
making. Here are conversation starters for addressing culture in shared decision making.
Content area
for exploration
1.
2.
3.
4.
5.
6.
Language preferences
Decision making in a person’s
life and family
Beliefs about one’s problem
or situation
Family or community beliefs
associated with the decision
the individual is trying to
make
Spiritual, religious, or family
beliefs about the use of medication and other Western
medicine treatments
Herbs, supplements, and
other complementary or
alternative medicine
Sample conversation starters
•
•
•
What language do you speak at home?
•
How are decisions typically made in your family?
In your community?
•
Are there particular family members that are consulted
on important decisions?
•
Would you like to complete or share this tool with
this person?
•
•
How do you describe or understand your situation?
•
•
•
Are your family members aware of your situation?
•
How have you responded?
•
How is using medication viewed within your family?
Within your faith community?
•
How is Western medicine viewed within your family?
Your faith community?
•
What alternatives are used instead of medication?
•
Are there herbs, roots, or supplements that you use to
promote healing?
•
Are these remedies associated with religious or spiritual
beliefs? If so, how?
•
How have you felt using herbs or other alternative medicine
practices? What benefits have you experienced?
Any negative reactions?
What language would you like to speak here?
Would you prefer to use a translator?
Is there a particular name or term used in your family or
community to describe what you are experiencing?
What are their views about the decision you are weighing?
How about your community? Have you experienced pressure
from your family or community to decide one way or another?
turn page for more
Content area
for exploration
7.
8.
9.
10.
Customs or rituals the person
is using or would like to use to
promote health and healing
Cultural relevance of shared
decision making resources
Cross-cultural understanding
Coping with stress related to
decision making
Sample conversation starters
•
Are there customs or rituals that you use for health or healing?
That your family or faith community uses?
•
•
Are these rituals rooted in religious or family tradition? Explain.
•
How well has this decision making tool helped you address
concerns that are important to you?
•
Are there other areas that you would like to explore?
•
Are there other aspects of your culture or background that
are important for me to understand in order to be helpful?
•
Are there areas of your culture or background I may have
misunderstood?
•
What level of stress have you felt in trying to make this
decision?
•
•
•
What things have helped in the past with relieving stress?
Are there customs, rituals, or remedies you would like to try?
How have you coped with this stress?
What can you do to relieve some of this stress?