Staff Perspective: Who Makes the Decisions Around Here?

Staff Perspective: Who Makes the Decisions Around Here?

Sharon Birman, Psy.D.

Various theories of psychotherapy have long highlighted the importance of developing individualized treatment plans developed to meet the idiographic needs of the individual person. Decades of research have also supported the positive impact of patient-provider collaboration, which has yielded benefits to include increased sense of empowerment, autonomy, and satisfaction with treatment (Slade, 2017). Collaboration in treatment has led to improved treatment compliance and engagement, thereby producing enhanced treatment outcomes (Patel et al., 2008).

In 2006, the American Psychological Association defined Evidence-Based Practice in Psychotherapy (EBPP) as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (p.280). This definition establishes Shared Decision Making (SDM) as an element of EBPP. SDM is a process whereby treatment decisions are made collaboratively through dialogue, deliberation, and agreement. The fundamental tenet of SDM is the shared expertise in the therapy room. Providers impart their expertise in scientific practice, while patients engage the process through their intimate knowledge of their lived experience (Fukui et al., 2015; Kon, 2010).

SDM has demonstrated great efficacy with medical patients, showing improved communication, identification of presenting problem, decision satisfaction, and health management. SDM has also demonstrated efficacy in the field of mental health (Department of Veterans Affairs & Department of Defense, 2017). Loh and colleagues (2007) conducted a cluster randomized control trial (RCT) of SDM in the treatment of Major Depressive Disorder in a primary care setting and found evidence of improved quality of care. In another RCT of a SDM intervention for prevention of depression relapse in primary care, Ludman and colleagues (2003) found improved monitoring of symptoms, increased use of coping and enhanced self-efficacy. In the first longitudinal outcome study of SDM for patients with a primary diagnosis of schizophrenia, Hamann and colleagues (2007) demonstrated a positive correlation between SDM and reduced hospitalization rates. Lastly, SDM has demonstrated increased patient commitment to participation in evidence-based treatment and lower drop-out rates in Veterans with Post Traumatic Stress Disorder (Mott et al., 2014; Watts, 2015).

Despite widespread acceptance of collaborative treatment efficacy, complete adoption this process seems challenging for providers. Research has revealed low levels of practice implementation of SDM in mental health, characterizing provider participation as a “cautious willingness” (Brooks et al., 2017). Candid discussions are hindered by both patient and provider misconceptions about one another. On one hand, patients report the belief that providers are dismissive of barriers to treatment and they fear being judged by their providers. Providers, on the other hand, have concerns about patients’ insight and competence to make decisions about treatment. Specifically, providers express concerns about the ethical responsibility of beneficence. For example, clinicians have conveyed concerns about patients’ selection of the “best” treatment available (Brooks et al., 2017).

The reluctant adoption of SDM is surprising given the work by Wennberg and Gittelsohn (1973), which documented the wide variance of provider treatment decisions regarding comparable cases. This variance was often accounted for by training and geographic location. They used the term the “practice variation phenomenon” to describe the pervasive divergence in treatment decisions and suggested that the subjective process in treatment was grounded in providers’ personal value systems at the expense of patient preferences.

Integrating patient preferences is vital for SDM and congruent with EBPP. SDM is particularly applicable to mental health treatment, stressing the value of incorporating patient values and preferences. Nevertheless, transitioning these values and theories into practice remains challenging. As a result, continued advancement of the research, dissemination and implementation of SDM in mental health care settings is paramount for the increased patient care effectiveness.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Sharon Birman, Psy.D., is a CBT trainer working with the Military Training Programs at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.


Brooks, H., Harris, K., Bee, P., Lovell, K., Rogers, A., & Drake, R. (2017). Exploring the potential implementation of a tool to enhance shared decision making (SDM) in mental health services in the United Kingdom: A qualitative exploration of the views of service users, carers and professionals. International Journal of Mental Health Systems, 11. doi:10.1186/s13033-017-0149-z

Department of Veterans Affairs & Department of Defense. (2017). VA/DoD Clinical Practice Guideline for Management of Post Traumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD). Retrieved from https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal082...

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Slade, M. (2017). Implementing shared decision making in routine mental health care. World Psychiatry, 16(2), 146-153. doi:10.1002/wps.20412

Watts, B. V., Schnurr, P. P., Zayed, M., Young-Xu, Y., Stender, P., & Llewellyn-Thomas, H. (2015). A randomized controlled clinical trial of a patient decision aid for posttraumatic stress disorder. Psychiatric Services, 66(2), 149-154. doi:10.1176/appi.ps.201400062

Wennberg, J., & Gittelsohn, A. (1973). Small area variations in health care delivery. Science, 182, 1102–1108.

Staff Perspective: Who Makes the Decisions Around Here? | Center for Deployment Psychology


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