‘Shared Steps & Checks’: A Shared Decision Making Model for Mental Health Care

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Grootens, Doris Verwijmeren This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3820707/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Although shared decision making (SDM) is the preferred choice in mental health care, the literature shows this patient-clinician communication approach is not widely implemented in this field of medicine. To promote its use in clinical practice and training, we introduce an SDM model that allows for all field-specific demands and teaching purposes. Methods We developed an elementary framework for sharing decisions during psychiatric consultations through an iterative process. After reviewing the literature on existing SDM models and assessing their appropriateness for further enrichment to meet the needs of mental health services, we integrated all requirements in our model, paying special attention to didactic aspects in communication courses. The resulting model was finetuned in a focus group- approach involving five different panels of health-care professionals, clients, informal caregivers and medical students. Results We chose to expand the initial 3-step models and later adaptations by Elwyn et al. and to devise a linear step model to meet clinical and requirement and didactic usability. The model incorporates aspects that are typical to mental health care such as explicit goal setting, setting up a ‘decision team’, assessing decision capacity and risk deliberation. As psychiatric care demands a stable and trustful therapeutic relationship, we added the element of the explicit pursuit of three core values: Be curious, collaborative and connected. Conclusions Comprising six steps and periodical core value checks, the Shared Steps & Checks approach presented here offers a pragmatic SDM framework for mental health practice and training serving all stakeholders involved in this complex, multidisciplinary field. Figures Figure 1 1. Backgound Shared decision making (SDM) is a communication and collaboration process in which the patient and clinician together try to reach optimal care decisions ( 1 , 2 , 3 ). Good SDM requires a trustful and participatory relationship allowing the values and preferences of the patient and the knowledge and expertise of the health professional to come together. Many different SDM models have been designed to serve as a guide for clinicians in specific clinical situations ( 4 , 5 ). One of the most often cited communication models and the starting point for many subsequent paradigms is the one by Elwyn et al., which distinguishes three phases: the team/choice talk, the option talk and the decision talk ( 6 ). In their earlier SDM model, Makoul and Clayman make a distinction between ‘essential elements’ structuring the conversation (observable behaviour, e.g. presenting options), ‘ideal elements’ (e.g. unbiased information, mutual agreement) and ‘general qualities’ ( e.g. partnership, respect) ( 7 ). Arguably, in the mental health context a good patient-clinician partnership is perhaps even more crucial for successful SDM ( 8 ). Although SDM is often considered the most preferable means of decision making in mental health care, the literature shows that in this field of medicine proper implementation of the approach is very challenging ( 1 , 9 ). One of the critical issues is the physician’s option of coercive treatment and admission, which is in direct conflict with the SDM principle of reducing the power asymmetry between clinician and patient ( 10 ). Still, SDM can help overcome the traditional power imbalance when it comes to treatment decisions and enhance the patient-doctor relationship ( 11 ), creating the potential for better patient-centred and recovery-oriented care ( 12 ). Adequate communicative skills in the SDM process may help define equipoise options and facilitate highly preference-sensitive decisions ( 13 ). SDM models for mental health care are scarce, with some specifically addressing the more conceptual issues of SDM in this field of medicine and few describing how to achieve SDM in clinical practice ( 12 , 14 , 15 , 16 , 17 ). Being teachers and clinician-researchers in this field, we felt the need for a practice-based framework that would provide hands-on guidance for trainees and residents for use in the consulting room, facilitating the integration of the cognitive and emotional aspects of SDM. In this study we present such an SDM framework for the clinical practice of mental health care and for teaching and communication training purposes. In developing our ‘Shared Steps & Checks’ paradigm, we built upon existing models and experiences of the various stakeholders, while adding elements to meet the demands specific of the mental health context. 2. Methods We opted for an iterative process to develop a SDM model for psychiatric consultations in co-creation with all stakeholders. 2.1 Literature search and didactic usability First, we performed a narrative search of the literature to identify existing SDM models that we deemed suitable for our purposes. Second, we searched the literature looking for specific elements and challenges of SDM in severe mental health care. The results of this review (including the search strategy used) have been described elsewhere ( 9 ). From this overview, we derived the communication aspects that were not sufficiently addressed in the existing models that needed augmentation. Finally, we optimised specific didactic aspects for our model based on our own clinical and teaching experiences. 2.2 Focus groups Next, we had our (initial versions of) our model evaluated in a survey involving health professionals, patients, informal caregivers and medical students and made the necessary modifications to achieve consensus on the final version ( 18 ). The panellists, all living in the Netherlands, discussed SDM in their practice and our model in detail in five live 1–1,5 hour live meetings and were invited to comment on them, or make (spoken or written) suggestions for adjustments. In addition, they were invited to reflect on important themes and values of the SDM process, their personal experiences and best practices. The written and oral suggestions and recorded discussions were gathered and thematically coded by author DV, and then discussed and incorporated in the developing model by both authors in consensus. The draft of the final version was presented by e-mail, with the panellists being once more invited to comment on it or give their go ahead. As to the five group discussions, we can share that one comprised a mixed group of 25 multidisciplinary health professionals, clients, students and policy makers, another seven psychiatrists working with adult and older in-and outpatients in general hospital settings, a third five psychiatrists working in outreach programmes for adults with severe mental health issues. All members of panels 2 and 3 were active and experienced supervisors in residency training programmes. The last two focus groups consisted of five patient representatives and 5 informal caregiver representatives who all spoke from personal experience and were also active as representatives in mental health institutions. 3. Results 3.1 Literature review Below we summarise the existing models on which we based our model with an emphasis on the aspects that we explicitly incorporated or elaborated on. 3.1.1 General SDM models Often designed for specific clinical situations or diseases, there is a large variety of SDM models ( 4 , 7 ). Many of them are based on the original concept of the stepwise three-talk model of Elwyn et al. who subdivided the dialogue into a ‘team talk’, ‘option talk’ and ‘decision talk’ ( 6 ), which they later adapted to a non-linear framework ( 19 ). Other authors enriched the model, adding a preparation phase and follow-up phase for long-term clinical contexts (beyond one-time decisions) such as chronic diseases and the care for the elderly ( 16 , 20 ), which are certainly also highly relevant for the mental health context ( 21 ). We incorporated the two phases since they help structure the conversations also by facilitating the integration of decision aids, and allowing clear appointment scheduling and task setting. A very interesting development is the goal-oriented approach to SDM, where three categories are distinguished: fundamental, functional and symptom-related goals ( 22 , 23 ). Working with such clearly defined, long-term goals at various levels of care is highly suited for the SDM approach in psychiatry, especially in community-based services ( 24 ). 3.1.2 Psychiatry-specific elements Few SDM models were specifically designed for the mental health setting ( 12 , 14 , 15 , 16 , 17 ). Several authors did put forward essential aspects that should be taken into account in psychiatric SDM, with many stressing the need of a trustful and ongoing relationship when (important) mental-health decisions are to be made ( 8 , 12 ), especially since patients may be more familiar with a more directive decision-making style or have even experienced coercive care in the past. Moreover, long-term psychiatric SDM is never a static and dyadic doctor-patient process. Typically, care is provided by a multidisciplinary team ( 25 ), while also multiple people close to and/or representing the patient may be involved. Although any medical decision is never made single-handedly or one-sidedly but rather by a range of people in conjunction ( 26 ), this holds even more true in mental health care where, as a rule, patients, health professionals and partners/family/caregivers decide together in a triad ( 27 ). Another typical feature within psychiatry is the effect of symptoms on decision capacity , combined with the subsequent consideration to overrule a patient’s decision preference. But also in the absence of this complicating factor, there often is patient-provider incongruence in the interpretation of the current state or progression of symptoms. Despite its clinical relevance, none of the existing SDM models for mental health incorporated the need to assess decisional capacity or incongruence ( 28 ), although in a model targeting patients with frailty, Van der Pol et al. did stress the importance of the assessment of legal (in)capacity ( 20 ). A clear view on decision capacity helps to define the roles and responsibility of participants in a decision process. Another major topic in the consulting rooms is non-adherence to and discontinuation of medication. This does not chance the essence of the decision process, but it does affects the character of the SDM, as the process revolves around and the balancing of risks and questions of responsibility ( 29 ). Taking all the above together, we concluded that a model for psychiatric SDM should explicitly address the therapeutic working alliance. Building upon the three steps of the Elwyn-models, we thus included a preparation and a follow-up step, added an extra step for explicit goal setting, and incorporated regular checks of decision capacity together with risk assessments, where the question to be answered reads: Is a shared decision possible at all at this point in time? 3.2 Didactic usability Striving to keep the model simple and pragmatic , we devised a succinct and easy-to-use overview of our paradigm, put in simple and non-directive language. Our experience is that most young professionals prefer recognizable linear, stepwise approaches , which can be particularly useful when explaining complex decision situations with multiple stakeholders. Also there is a ‘ chronological order’ that supports our stepwise paradigm, where the early recognition of changes in decision capacity will affect the ‘team building’ phase, while it is vital to identify the existence of non-shared goals before one can initiate the options phase and so on. Conversely, we are quite aware that SDM is a dynamic process and that not all steps will always occur in the same, fixed order. Still, for teaching, a solid blueprint with steps in handsome order has its purpose. With a good patient-provider working alliance being key to successful psychiatric SDM, clinicians will need to develop more than a sixth sense for what the essence of this partnership is. For both young and experienced health professionals consciously and regularly checking the state of the participatory alliance and ensuring to display both cognitive and emotional empathy will help foster and preserve their relationship with their patients. Also, in more complex or extensive consultations (e.g. multidisciplinary issues with multiple formal and informal caregivers), it is recommended to explicitly check that non-consensual outcomes are avoided. To capture core values of patient-doctor communication in SDM, i.e. the need to be warm, involved, and to show both cognitive and emotional empathy, we introduce the three Cs in a single motto: ‘Be Curious, Collaborative and Connected’. ‘Curious’ covers cognitive communication and entails promoting a genuine interest in the other, with both patients and clinicians adopting an active listening attitude. With ‘Collaborative’ we emphasize the equal partnership in the contacts between patient and professional, as well as the need for pleasant cooperation. ‘Connected’ concerns emotional communication where a sense of mutual trust and respect is to be created or upheld, with the health professional explicitly also paying attention to the nonverbal communications and emotional responses of their patient and other parties. Note that these working alliance features concern all stakeholders, with all being asked to uphold the values discussed and to keep the power differential as low as possible. In other words, patients, health professionals and caregivers alike should try and be curious to learn about all the options that are put forward by the other participants. Arguably, in severe mental health care, SDM is not always feasible, where, over time, either a (temporarily) paternalistic or informed-choice decision style may need to prevail. For clarity, our model is solely about sharing decisions, which is why we decided not to incorporate other communication techniques (e.g. motivational interviewing) or additional decision options (e.g. coercive forms of care). The shared checks we propose will help identify meaningful shifts in the therapeutic relationship over time and the need to change communication strategies. SDM can just be a series of single decision talks but it may also be a continuous decision journey where every now and then consensus needs to be re-established ( 12 , 21 ). To avoid becoming too abstract, and because the model should be seen as a blueprint, at different stages some phases can be skipped, where simply asking “Do we still agree that our shared goal is to …” may suffice. 3.3 Focus groups According to our panellists, a key element in SDM is the broader, social context of a decision. In a triadic approach the involvement of informal caregivers is essential but it may, at the same time, complicate the consensus process. In the panel discussions the idea developed to use the term decision team , a simpler and more neutral term than ‘triad’ or ‘ network’, supporting the notion that SDM involves various stakeholders. The patients and caregivers underlined the need to be explicit about the roles a caregiver has in the decision process, and the need to give tailored information to the patient’s needs. Many panellists deemed a preparation phase important for various reasons, of which choosing and using the right decision aids and an adequate support team composition were two. Especially psychiatrists working in community care services and the patient representatives stressed the importance of selecting the right caregiver network for the deciding process. The panel of hospital psychiatrists unequivocally agreed on the necessity of adequate preparation, the anticipation of a (temporarily) lowered decision capacity and the potential of non-shared aspects and inviting the right support . Goal sharing was put forward by many panellists as a helpful and explicit step in the early stages of the conversation since it fits a recovery-oriented approach where not only symptoms are discussed but multiple areas of life . In addition, community psychiatrists endorsed a non-directive approach when building the decision team and setting up a ‘shared agenda’ and the use of inclusive language. All panellists underscored the importance of the therapeutic alliance between service user and provider, validating the statement “[..] not simply as a prerequisite for shared decision making, but as a necessary component that frames the context in which shared decision making occurs” ( 8 ). Many clinicians emphasised that a clear and well-organised follow-up is helpful to deal with fluctuating adherence and should be part of the dynamic SDM process. This would also be the right moment for meta-communication and an invitation to reflect on the working alliance and the decision process itself. The caregiver panel underlined the need of tailoring information to the needs of the patient and his/her caregivers as the information need will vary among people. 3.4. Shared Steps & Checks In Fig. 1 we present our SDM model for use by the ‘decision team’ of patients, clinicians and informal caregivers in routine clinical mental health practice. As described above, the decision process is founded on three core values that are ‘checked’ regularly (i.e. curiousness, collaborativeness and connectedness) and comprises six separate steps of information exchange. The text boxes describe issues to be addressed that are typical for the mental health context: assessing decision capacity, inviting and involving others and setting up a ‘decision team’, deliberating risks (e.g. discontinuation of medication), defining goals on multiple domains, incorporating decision aids and allowing room for meta-communication. 4. Discussion In this study, we have presented a pragmatic SDM model for the complex mental health setting. Suitable for the clinical practice and education and training, the model, which we have named ‘Sharing Steps & Checks,’ contains six steps and periodical core value checks to monitor the therapeutic relationship. Having both participatory and information exchange components, the model covers both emotional and cognitive care aspects ( 30 ). We think the strength of the model lies in its clinical recognisability and the fact that it allows for both types of care in a relatively compact and understandable paradigm. The steps we propose follow the pioneering work by Charles and Elwyn and subsequent authors and also comprise an additional preparation and follow-up phase as well as an explicit step dedicated to the (re-)sharing of goals ( 3 , 16 , 19 , 20 , 22 ). In addition, the model challenges the users to check the partnership regularly throughout the treatment, an important aspect given that consensus cannot always be assumed but is be strived for, a dynamic process that is to be monitored and re-evaluated regularly ( 21 ). How and how often patient-doctor consensus is to be re-assessed is case-specific and up to the stakeholders. Conscious but ‘silent’ checks are an option, but, from our experience with residency training programs, we would advise to teach residents to do this explicitly and to not merely rely on a developing consciousness or a ‘sixth sense’ when it comes to these important relational aspects. Rather, they should be asking explicit questions such as ‘Do you feel you have told me what is most important to you at this stage?’ or ‘Before we go ahead, I’d like to know whether we are still on the right track?’ Sometimes, one may combine the consensus checks with in-between summaries expressing curiosity and empathy, such as in ‘I take it that we agree that (… and …) are our options, or are we missing something?’; ‘So, am I right in concluding that our common goal is that, in order for you to be able to resume work, we need to treat your depression? And, that for you and your partner it is very important that medication side effects like weight gain or drowsiness are to be avoided?’ Conversely, the patient might raise the confidence issue by asking ‘I don’t really know whether you still agree with my goal to (…)?’ Clearly, we do not see the clinician as the single actor in our SDM model but propose to also ‘train’ both patients and their informal caregivers in SDM and familiarise them with the steps and checks by neutrally outlining that all involved will be looking for joint goals and joining efforts to attain these in every stage of the treatment. In addition, in our model we have avoided jargon and use plain terms, looking for a shared language. Most often, the clinician has a double role, being both the medical expert and the ‘process operator’, but in the triadic and multidisciplinary context of mental health care other (health) professionals are often also involved, where conflicting opinions may arise. Here, the model can serve as an objective process support tool, with any party or neutral operator, such as a case manager or experience expert, taking the lead when opportune. Besides as a strength for cap reasons, the model’s simplicity can also be viewed as a weakness. We recognise that the wealth of therapeutic skills and actions cannot be summarised with the citation of three core values and six succinctly defined steps and instructions. What it does offer, is an elementary framework that must come to life with the aid of skilled teachers and with growing clinical experience. Another innovative aspect was the broad co-creation with multidisciplinary health professionals, patients, informal caregivers and psychiatry/psychology students. The psychiatrists participating in the study were all active clinicians working in either a psychiatric or general hospital or in community (outreach) care since decision processes and communication demands can differ widely in various settings ( 31 ). Nevertheless, our study may still be biased to some extent since all our panellists and we as researchers are from the Netherlands, a rather liberal European country with a recovery-oriented care culture ( 32 ) and a national policy promoting SDM. Clearly, follow-up research is needed to show the feasibility of the model both in residency programs and in daily mental health practice. Optimal implementation of SDM in the mental health context will remain challenging given the many none-shared decisions that may be necessary in this complex field of medicine ( 9 , 29 ). Still, we think that ours can be a unifying model and can serve as the ‘default mode’ to engage in any decision process in most areas of mental health care. Conclusion With our Shared Steps & Checks model, a stepwise approach to SDM with in-built reflection on the client-clinician relationship, we aim to bring and keep patients, informal and formal caregivers and treating clinicians on board and make decision making ‘as much shared as possible’. Declarations Ethics approval and consent : The study protocol was approved by Reineir van Arkel Research ethics Board. Informed consent was obtained from all participants. Consent: All athors approve the manuscript in its current form. Availability of data and materials: Not applicable. We do not have consent from participants to share raw interview data. Competing interests: The authors declare none. Funding: This research received no specific grant from any funding agency, commercial or not-for-profit sectors. Contribution: Author KG and DW designed the study and wrote the protocol, KG and DW undertook the focus group study and deisgned the final model. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3820707","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":266570454,"identity":"6aa33354-adb4-4b8b-abba-0d449c0e4f23","order_by":0,"name":"Koen P. Grootens","email":"data:image/png;base64,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","orcid":"","institution":"Tilburg University","correspondingAuthor":true,"prefix":"","firstName":"Koen","middleName":"P.","lastName":"Grootens","suffix":""},{"id":266570455,"identity":"bea35330-9c94-4321-9684-1ea189c9eb15","order_by":1,"name":"Doris Verwijmeren","email":"","orcid":"","institution":"Tilburg University","correspondingAuthor":false,"prefix":"","firstName":"Doris","middleName":"","lastName":"Verwijmeren","suffix":""}],"badges":[],"createdAt":"2023-12-29 10:04:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3820707/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3820707/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49547327,"identity":"588d63eb-b216-4bf8-9113-fd1dfaf8be77","added_by":"auto","created_at":"2024-01-12 19:20:33","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":903032,"visible":true,"origin":"","legend":"\u003cp\u003e‘Shared Steps \u0026amp; Checks’: A framework for shared decision making in mental health care.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3820707/v1/6636b53eacc932f578eaa7ed.jpeg"},{"id":51235849,"identity":"37d1cb19-0390-4bc6-89a2-001f6c15675c","added_by":"auto","created_at":"2024-02-16 16:30:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":347858,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3820707/v1/ae80bb51-877c-448f-92aa-772948dec9d9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"‘Shared Steps \u0026 Checks’: A Shared Decision Making Model for Mental Health Care","fulltext":[{"header":"1. Backgound","content":"\u003cp\u003eShared decision making (SDM) is a communication and collaboration process in which the patient and clinician together try to reach optimal care decisions (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e). Good SDM requires a trustful and participatory relationship allowing the values and preferences of the patient and the knowledge and expertise of the health professional to come together.\u003c/p\u003e\n\u003cp\u003eMany different SDM models have been designed to serve as a guide for clinicians in specific clinical situations (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e). One of the most often cited communication models and the starting point for many subsequent paradigms is the one by Elwyn et al., which distinguishes three phases: the team/choice talk, the option talk and the decision talk (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e). In their earlier SDM model, Makoul and Clayman make a distinction between \u0026lsquo;essential elements\u0026rsquo; structuring the conversation (observable behaviour, e.g. presenting options), \u0026lsquo;ideal elements\u0026rsquo; (e.g. unbiased information, mutual agreement) and \u0026lsquo;general qualities\u0026rsquo; ( e.g. partnership, respect) (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e). Arguably, in the mental health context a good patient-clinician partnership is perhaps even more crucial for successful SDM (\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eAlthough SDM is often considered the most preferable means of decision making in mental health care, the literature shows that in this field of medicine proper implementation of the approach is very challenging (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e). One of the critical issues is the physician\u0026rsquo;s option of coercive treatment and admission, which is in direct conflict with the SDM principle of reducing the power asymmetry between clinician and patient (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e). Still, SDM can help overcome the traditional power imbalance when it comes to treatment decisions and enhance the patient-doctor relationship (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e), creating the potential for better patient-centred and recovery-oriented care (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e). Adequate communicative skills in the SDM process may help define equipoise options and facilitate highly preference-sensitive decisions (\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eSDM models for mental health care are scarce, with some specifically addressing the more conceptual issues of SDM in this field of medicine and few describing \u003cem\u003ehow\u003c/em\u003e to achieve SDM in clinical practice (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e). Being teachers and clinician-researchers in this field, we felt the need for a practice-based framework that would provide hands-on guidance for trainees and residents for use in the consulting room, facilitating the integration of the cognitive and emotional aspects of SDM. In this study we present such an SDM framework for the clinical practice of mental health care and for teaching and communication training purposes. In developing our \u0026lsquo;Shared Steps \u0026amp; Checks\u0026rsquo; paradigm, we built upon existing models and experiences of the various stakeholders, while adding elements to meet the demands specific of the mental health context.\u003c/p\u003e"},{"header":"2.\tMethods","content":"\u003cp\u003eWe opted for an iterative process to develop a SDM model for psychiatric consultations in co-creation with all stakeholders.\u003c/p\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003e2.1 Literature search and didactic usability\u003c/h2\u003e\n\u003cp\u003eFirst, we performed a narrative search of the literature to identify existing SDM models that we deemed suitable for our purposes. Second, we searched the literature looking for specific elements and challenges of SDM in severe mental health care. The results of this review (including the search strategy used) have been described elsewhere (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e). From this overview, we derived the communication aspects that were not sufficiently addressed in the existing models that needed augmentation. Finally, we optimised specific didactic aspects for our model based on our own clinical and teaching experiences.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003ch2\u003e2.2 Focus groups\u003c/h2\u003e\n\u003cp\u003eNext, we had our (initial versions of) our model evaluated in a survey involving health professionals, patients, informal caregivers and medical students and made the necessary modifications to achieve consensus on the final version (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e). The panellists, all living in the Netherlands, discussed SDM in their practice and our model in detail in five live 1\u0026ndash;1,5 hour live meetings and were invited to comment on them, or make (spoken or written) suggestions for adjustments. In addition, they were invited to reflect on important themes and values of the SDM process, their personal experiences and best practices. The written and oral suggestions and recorded discussions were gathered and thematically coded by author DV, and then discussed and incorporated in the developing model by both authors in consensus. The draft of the final version was presented by e-mail, with the panellists being once more invited to comment on it or give their go ahead. As to the five group discussions, we can share that one comprised a mixed group of 25 multidisciplinary health professionals, clients, students and policy makers, another seven psychiatrists working with adult and older in-and outpatients in general hospital settings, a third five psychiatrists working in outreach programmes for adults with severe mental health issues. All members of panels 2 and 3 were active and experienced supervisors in residency training programmes. The last two focus groups consisted of five patient representatives and 5 informal caregiver representatives who all spoke from personal experience and were also active as representatives in mental health institutions.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003e3.1 Literature review\u003c/h2\u003e\n\u003cp\u003eBelow we summarise the existing models on which we based our model with an emphasis on the aspects that we explicitly incorporated or elaborated on.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n\u003ch2\u003e3.1.1 General SDM models\u003c/h2\u003e\n\u003cp\u003eOften designed for specific clinical situations or diseases, there is a large variety of SDM models (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e). Many of them are based on the original concept of the stepwise \u003cspan class=\"Underline\"\u003ethree-talk model\u003c/span\u003e of Elwyn et al. who subdivided the dialogue into a \u0026lsquo;team talk\u0026rsquo;, \u0026lsquo;option talk\u0026rsquo; and \u0026lsquo;decision talk\u0026rsquo; (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e), which they later adapted to a non-linear framework (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e). Other authors enriched the model, adding a \u003cspan class=\"Underline\"\u003epreparation phase\u003c/span\u003e and \u003cspan class=\"Underline\"\u003efollow-up phase\u003c/span\u003e for long-term clinical contexts (beyond one-time decisions) such as chronic diseases and the care for the elderly (\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e), which are certainly also highly relevant for the mental health context (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e). We incorporated the two phases since they help structure the conversations also by facilitating the integration of decision aids, and allowing clear appointment scheduling and task setting.\u003c/p\u003e\n\u003cp\u003eA very interesting development is the \u003cspan class=\"Underline\"\u003egoal-oriented approach\u003c/span\u003e to SDM, where three categories are distinguished: fundamental, functional and symptom-related goals (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e). Working with such clearly defined, long-term goals at various levels of care is highly suited for the SDM approach in psychiatry, especially in community-based services (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n\u003ch2\u003e3.1.2 Psychiatry-specific elements\u003c/h2\u003e\n\u003cp\u003eFew SDM models were specifically designed for the mental health setting (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e). Several authors did put forward essential aspects that should be taken into account in psychiatric SDM, with many stressing the need of a \u003cspan class=\"Underline\"\u003etrustful and ongoing relationship\u003c/span\u003e when (important) mental-health decisions are to be made (\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e), especially since patients may be more familiar with a more directive decision-making style or have even experienced coercive care in the past.\u003c/p\u003e\n\u003cp\u003eMoreover, long-term psychiatric SDM is never a static and dyadic doctor-patient process. Typically, care is provided by a multidisciplinary team (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e), while also multiple people close to and/or representing the patient may be involved. Although any medical decision is never made single-handedly or one-sidedly but rather by a range of people in conjunction (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e), this holds even more true in mental health care where, as a rule, patients, health professionals and partners/family/caregivers decide together in a \u003cspan class=\"Underline\"\u003etriad\u003c/span\u003e (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eAnother typical feature within psychiatry is the effect of symptoms on \u003cspan class=\"Underline\"\u003edecision capacity\u003c/span\u003e, combined with the subsequent consideration to overrule a patient\u0026rsquo;s decision preference. But also in the absence of this complicating factor, there often is patient-provider incongruence in the interpretation of the current state or progression of symptoms. Despite its clinical relevance, none of the existing SDM models for mental health incorporated the need to assess decisional capacity or incongruence (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e), although in a model targeting patients with frailty, Van der Pol et al. did stress the importance of the assessment of legal (in)capacity (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e). A clear view on decision capacity helps to define the roles and responsibility of participants in a decision process. Another major topic in the consulting rooms is non-adherence to and discontinuation of medication. This does not chance the essence of the decision process, but it does affects the character of the SDM, as the process revolves around and the balancing of \u003cspan class=\"Underline\"\u003erisks\u003c/span\u003e and questions of responsibility (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eTaking all the above together, we concluded that a model for psychiatric SDM should explicitly address the therapeutic working alliance. Building upon the three steps of the Elwyn-models, we thus included a preparation and a follow-up step, added an extra step for explicit goal setting, and incorporated regular checks of decision capacity together with risk assessments, where the question to be answered reads: Is a shared decision possible at all at this point in time?\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n\u003ch2\u003e3.2 Didactic usability\u003c/h2\u003e\n\u003cp\u003eStriving to keep the model \u003cspan class=\"Underline\"\u003esimple and pragmatic\u003c/span\u003e, we devised a succinct and easy-to-use overview of our paradigm, put in simple and non-directive language. Our experience is that most young professionals prefer recognizable linear, \u003cspan class=\"Underline\"\u003estepwise approaches\u003c/span\u003e, which can be particularly useful when explaining complex decision situations with multiple stakeholders. Also there is a \u0026lsquo;\u003cspan class=\"Underline\"\u003echronological order\u0026rsquo;\u003c/span\u003e that supports our stepwise paradigm, where the early recognition of changes in decision capacity will affect the \u0026lsquo;team building\u0026rsquo; phase, while it is vital to identify the existence of non-shared goals before one can initiate the options phase and so on. Conversely, we are quite aware that SDM is a dynamic process and that not all steps will always occur in the same, fixed order. Still, for teaching, a solid blueprint with steps in handsome order has its purpose.\u003c/p\u003e\n\u003cp\u003eWith a good patient-provider working alliance being key to successful psychiatric SDM, clinicians will need to develop more than a sixth sense for what the essence of this partnership is. For both young and experienced health professionals consciously and regularly \u003cspan class=\"Underline\"\u003echecking the state of the participatory alliance\u003c/span\u003e and ensuring to display both cognitive and emotional empathy will help foster and preserve their relationship with their patients. Also, in more complex or extensive consultations (e.g. multidisciplinary issues with multiple formal and informal caregivers), it is recommended to explicitly check that non-consensual outcomes are avoided.\u003c/p\u003e\n\u003cp\u003eTo capture core values of patient-doctor communication in SDM, i.e. the need to be warm, involved, and to show both cognitive and emotional empathy, we introduce the three Cs in a single motto: \u0026lsquo;Be Curious, Collaborative and Connected\u0026rsquo;. \u0026lsquo;Curious\u0026rsquo; covers cognitive communication and entails promoting a genuine interest in the other, with both patients and clinicians adopting an active listening attitude. With \u0026lsquo;Collaborative\u0026rsquo; we emphasize the equal partnership in the contacts between patient and professional, as well as the need for pleasant cooperation. \u0026lsquo;Connected\u0026rsquo; concerns emotional communication where a sense of mutual trust and respect is to be created or upheld, with the health professional explicitly also paying attention to the nonverbal communications and emotional responses of their patient and other parties. Note that these working alliance features concern all stakeholders, with all being asked to uphold the values discussed and to keep the power differential as low as possible. In other words, patients, health professionals and caregivers alike should try and be curious to learn about all the options that are put forward by the other participants. Arguably, in severe mental health care, SDM is not always feasible, where, over time, either a (temporarily) paternalistic or informed-choice decision style may need to prevail.\u003c/p\u003e\n\u003cp\u003eFor clarity, our model is solely about sharing decisions, which is why we decided not to incorporate other communication techniques (e.g. motivational interviewing) or additional decision options (e.g. coercive forms of care). The shared checks we propose will help identify meaningful shifts in the therapeutic relationship over time and the need to change communication strategies. SDM can just be a series of single decision talks but it may also be a continuous decision \u003cem\u003ejourney\u003c/em\u003e where every now and then consensus needs to be re-established (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e). To avoid becoming too abstract, and because the model should be seen as a blueprint, at different stages some phases can be skipped, where simply asking \u0026ldquo;Do we still agree that our shared goal is to \u0026hellip;\u0026rdquo; may suffice.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n\u003ch2\u003e3.3 Focus groups\u003c/h2\u003e\n\u003cp\u003eAccording to our panellists, a key element in SDM is the broader, social context of a decision. In a triadic approach the involvement of informal caregivers is essential but it may, at the same time, complicate the consensus process. In the panel discussions the idea developed to use the term \u003cspan class=\"Underline\"\u003edecision team\u003c/span\u003e, a simpler and more neutral term than \u0026lsquo;triad\u0026rsquo; or \u0026lsquo; network\u0026rsquo;, supporting the notion that SDM involves various stakeholders. The patients and caregivers underlined the need to be explicit about the \u003cspan class=\"Underline\"\u003eroles\u003c/span\u003e a caregiver has in the decision process, and the need to give \u003cspan class=\"Underline\"\u003etailored information\u003c/span\u003e to the patient\u0026rsquo;s needs.\u003c/p\u003e\n\u003cp\u003eMany panellists deemed a \u003cspan class=\"Underline\"\u003epreparation phase\u003c/span\u003e important for various reasons, of which choosing and using the right decision aids and an adequate support team composition were two. Especially psychiatrists working in community care services and the patient representatives stressed the importance of selecting the right caregiver network for the deciding process. The panel of hospital psychiatrists unequivocally agreed on the necessity of adequate preparation, the anticipation of a (temporarily) lowered \u003cspan class=\"Underline\"\u003edecision capacity\u003c/span\u003e and the potential of \u003cspan class=\"Underline\"\u003enon-shared aspects\u003c/span\u003e and inviting the \u003cspan class=\"Underline\"\u003eright support\u003c/span\u003e. \u003cspan class=\"Underline\"\u003eGoal sharing\u003c/span\u003e was put forward by many panellists as a helpful and explicit step in the early stages of the conversation since it fits a recovery-oriented approach where not only symptoms are discussed but \u003cspan class=\"Underline\"\u003emultiple areas of life\u003c/span\u003e. In addition, community psychiatrists endorsed a \u003cspan class=\"Underline\"\u003enon-directive approach\u003c/span\u003e when building the decision team and setting up a \u0026lsquo;shared agenda\u0026rsquo; and the use of inclusive language.\u003c/p\u003e\n\u003cp\u003eAll panellists underscored the importance of the \u003cspan class=\"Underline\"\u003etherapeutic alliance\u003c/span\u003e between service user and provider, validating the statement \u0026ldquo;[..] not simply as a prerequisite for shared decision making, but as a necessary component that frames the context in which shared decision making occurs\u0026rdquo; (\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e). Many clinicians emphasised that a clear and well-organised \u003cspan class=\"Underline\"\u003efollow-up\u003c/span\u003e is helpful to deal with fluctuating adherence and should be part of the dynamic SDM process. This would also be the right moment for \u003cspan class=\"Underline\"\u003emeta-communication\u003c/span\u003e and an invitation to reflect on the working alliance and the decision process itself. The caregiver panel underlined the need of tailoring information to the needs of the patient and his/her caregivers as the information need will vary among people.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n\u003ch2\u003e3.4. Shared Steps \u0026amp; Checks\u003c/h2\u003e\n\u003cp\u003eIn Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e we present our SDM model for use by the \u0026lsquo;decision team\u0026rsquo; of patients, clinicians and informal caregivers in routine clinical mental health practice. As described above, the decision process is founded on three core values that are \u0026lsquo;checked\u0026rsquo; regularly (i.e. curiousness, collaborativeness and connectedness) and comprises six separate steps of information exchange. The text boxes describe issues to be addressed that are typical for the mental health context: assessing decision capacity, inviting and involving others and setting up a \u0026lsquo;decision team\u0026rsquo;, deliberating risks (e.g. discontinuation of medication), defining goals on multiple domains, incorporating decision aids and allowing room for meta-communication.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eIn this study, we have presented a pragmatic SDM model for the complex mental health setting. Suitable for the clinical practice and education and training, the model, which we have named \u0026lsquo;Sharing Steps \u0026amp; Checks,\u0026rsquo; contains six steps and periodical core value checks to monitor the therapeutic relationship. Having both participatory and information exchange components, the model covers both emotional and cognitive care aspects (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). We think the strength of the model lies in its clinical recognisability and the fact that it allows for both types of care in a relatively compact and understandable paradigm.\u003c/p\u003e \u003cp\u003eThe steps we propose follow the pioneering work by Charles and Elwyn and subsequent authors and also comprise an additional preparation and follow-up phase as well as an explicit step dedicated to the (re-)sharing of goals (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In addition, the model challenges the users to check the partnership regularly throughout the treatment, an important aspect given that consensus cannot always be assumed but is be strived for, a dynamic process that is to be monitored and re-evaluated regularly (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). How and how often patient-doctor consensus is to be re-assessed is case-specific and up to the stakeholders. Conscious but \u0026lsquo;silent\u0026rsquo; checks are an option, but, from our experience with residency training programs, we would advise to teach residents to do this explicitly and to not merely rely on a developing consciousness or a \u0026lsquo;sixth sense\u0026rsquo; when it comes to these important relational aspects. Rather, they should be asking explicit questions such as \u0026lsquo;Do you feel you have told me what is most important to you at this stage?\u0026rsquo; or \u0026lsquo;Before we go ahead, I\u0026rsquo;d like to know whether we are still on the right track?\u0026rsquo; Sometimes, one may combine the consensus checks with in-between summaries expressing curiosity and empathy, such as in \u0026lsquo;I take it that we agree that (\u0026hellip; and \u0026hellip;) are our options, or are we missing something?\u0026rsquo;; \u0026lsquo;So, am I right in concluding that our common goal is that, in order for you to be able to resume work, we need to treat your depression? And, that for you and your partner it is very important that medication side effects like weight gain or drowsiness are to be avoided?\u0026rsquo; Conversely, the patient might raise the confidence issue by asking \u0026lsquo;I don\u0026rsquo;t really know whether you still agree with my goal to (\u0026hellip;)?\u0026rsquo;\u003c/p\u003e \u003cp\u003eClearly, we do not see the clinician as the single actor in our SDM model but propose to also \u0026lsquo;train\u0026rsquo; both patients and their informal caregivers in SDM and familiarise them with the steps and checks by neutrally outlining that all involved will be looking for joint goals and joining efforts to attain these in every stage of the treatment. In addition, in our model we have avoided jargon and use plain terms, looking for a shared language. Most often, the clinician has a double role, being both the medical expert and the \u0026lsquo;process operator\u0026rsquo;, but in the triadic and multidisciplinary context of mental health care other (health) professionals are often also involved, where conflicting opinions may arise. Here, the model can serve as an objective process support tool, with any party or neutral operator, such as a case manager or experience expert, taking the lead when opportune.\u003c/p\u003e \u003cp\u003eBesides as a strength for cap reasons, the model\u0026rsquo;s simplicity can also be viewed as a weakness. We recognise that the wealth of therapeutic skills and actions cannot be summarised with the citation of three core values and six succinctly defined steps and instructions. What it does offer, is an elementary framework that must come to life with the aid of skilled teachers and with growing clinical experience.\u003c/p\u003e \u003cp\u003eAnother innovative aspect was the broad co-creation with multidisciplinary health professionals, patients, informal caregivers and psychiatry/psychology students. The psychiatrists participating in the study were all active clinicians working in either a psychiatric or general hospital or in community (outreach) care since decision processes and communication demands can differ widely in various settings (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Nevertheless, our study may still be biased to some extent since all our panellists and we as researchers are from the Netherlands, a rather liberal European country with a recovery-oriented care culture (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) and a national policy promoting SDM. Clearly, follow-up research is needed to show the feasibility of the model both in residency programs and in daily mental health practice.\u003c/p\u003e \u003cp\u003eOptimal implementation of SDM in the mental health context will remain challenging given the many none-shared decisions that may be necessary in this complex field of medicine (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Still, we think that ours can be a unifying model and can serve as the \u0026lsquo;default mode\u0026rsquo; to engage in any decision process in most areas of mental health care.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWith our Shared Steps \u0026amp; Checks model, a stepwise approach to SDM with in-built reflection on the client-clinician relationship, we aim to bring and keep patients, informal and formal caregivers and treating clinicians on board and make decision making \u0026lsquo;as much shared as possible\u0026rsquo;.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent :\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by Reineir van Arkel Research ethics Board. Informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll athors approve the manuscript in its current form.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. We do not have consent from participants to share raw interview data.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare none.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency, commercial or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eContribution:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthor KG and DW designed the study and wrote the protocol, KG and DW undertook the focus group study and deisgned the final model. Author KG wrote the first draft of the manuscript. Both authors contributed to and have approved the final manuscript.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgement:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank Marcel van Dijk for the graphic design of the model.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSlade M. Implementing shared decision making in routine mental health care. World Psychiatry. 2017;16(2):146-53.\u003c/li\u003e\n\u003cli\u003eKon AA. The shared decision-making continuum. JAMA. 2010;304(8):903-4.\u003c/li\u003e\n\u003cli\u003eCharles C, Gafni A, Whelan T. Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med. 1999;49(5):651-61.\u003c/li\u003e\n\u003cli\u003eBomhof-Roordink H, Gartner FR, Stiggelbout AM, Pieterse AH. Key components of shared decision making models: a systematic review. BMJ Open. 2019;9(12):e031763.\u003c/li\u003e\n\u003cli\u003eCharles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med. 1997;44(5):681-92.\u003c/li\u003e\n\u003cli\u003eElwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361-7.\u003c/li\u003e\n\u003cli\u003eMakoul G, Clayman ML. An integrative model of shared decision making in medical encounters. Patient Educ Couns. 2006;60(3):301-12.\u003c/li\u003e\n\u003cli\u003eEliacin J, Salyers MP, Kukla M, Matthias MS. Patients\u0026apos; understanding of shared decision making in a mental health setting. Qual Health Res. 2015;25(5):668-78.\u003c/li\u003e\n\u003cli\u003eVerwijmeren D, Grootens KP. Shifting Perspectives on the Challenges of Shared Decision Making in Mental Health Care. Community Ment Health J. 2023.\u003c/li\u003e\n\u003cli\u003eZisman-Ilani Y, Roth RM, Mistler LA. Time to Support Extensive Implementation of Shared Decision Making in Psychiatry. JAMA Psychiatry. 2021;78(11):1183-4.\u003c/li\u003e\n\u003cli\u003eAoki Y. Shared decision making for adults with severe mental illness: A concept analysis. Jpn J Nurs Sci. 2020;17(4):e12365.\u003c/li\u003e\n\u003cli\u003eGurtner C, Schols J, Lohrmann C, Halfens RJG, Hahn S. Conceptual understanding and applicability of shared decision-making in psychiatric care: An integrative review. J Psychiatr Ment Health Nurs. 2021;28(4):531-48.\u003c/li\u003e\n\u003cli\u003evan der Horst DEM, Garvelink MM, Bos WJW, Stiggelbout AM, Pieterse AH. For which decisions is Shared Decision Making considered appropriate? - A systematic review. Patient Educ Couns. 2023;106:3-16.\u003c/li\u003e\n\u003cli\u003eMorant N, Kaminskiy E, Ramon S. Shared decision making for psychiatric medication management: beyond the micro-social. Health Expect. 2016;19(5):1002-14.\u003c/li\u003e\n\u003cli\u003eHamann J, Heres S. Adapting shared decision making for individuals with severe mental illness. Psychiatr Serv. 2014;65(12):1483-6.\u003c/li\u003e\n\u003cli\u003eGrim K, Rosenberg D, Svedberg P, Schon UK. Shared decision-making in mental health care-A user perspective on decisional needs in community-based services. Int J Qual Stud Health Well-being. 2016;11:30563.\u003c/li\u003e\n\u003cli\u003eLanger DA, Jensen-Doss A. Shared Decision-Making in Youth Mental Health Care: Using the Evidence to Plan Treatments Collaboratively. J Clin Child Adolesc Psychol. 2018;47(5):821-31.\u003c/li\u003e\n\u003cli\u003eBoulkedid R, Abdoul H, Loustau M, Sibony O, Alberti C. Using and reporting the Delphi method for selecting healthcare quality indicators: a systematic review. PLoS One. 2011;6(6):e20476.\u003c/li\u003e\n\u003cli\u003eElwyn G, Durand MA, Song J, Aarts J, Barr PJ, Berger Z, et al. A three-talk model for shared decision making: multistage consultation process. BMJ. 2017;359:j4891.\u003c/li\u003e\n\u003cli\u003evan de Pol MH, Fluit CR, Lagro J, Slaats YH, Olde Rikkert MG, Lagro-Janssen AL. Expert and patient consensus on a dynamic model for shared decision-making in frail older patients. Patient Educ Couns. 2016;99(6):1069-77.\u003c/li\u003e\n\u003cli\u003eGrootens KP, Verwijmeren D. A shared decision journey to bridge the gap between treatment recommendation and low adherence? Eur Neuropsychopharmacol. 2023;69:77-8.\u003c/li\u003e\n\u003cli\u003eElwyn G, Vermunt N. Goal-Based Shared Decision-Making: Developing an Integrated Model. J Patient Exp. 2020;7(5):688-96.\u003c/li\u003e\n\u003cli\u003eVermunt N, Elwyn G, Westert G, Harmsen M, Olde Rikkert M, Meinders M. Goal setting is insufficiently recognised as an essential part of shared decision-making in the complex care of older patients: a framework analysis. BMC Fam Pract. 2019;20(1):76.\u003c/li\u003e\n\u003cli\u003eStewart V, McMillan SS, Hu J, Ng R, El-Den S, O\u0026apos;Reilly C, et al. Goal planning in mental health service delivery: A systematic integrative review. Front Psychiatry. 2022;13:1057915.\u003c/li\u003e\n\u003cli\u003eMontori VM, Kunneman M, Brito JP. Shared Decision Making and Improving Health Care: The Answer Is Not In. JAMA. 2017;318(7):617-8.\u003c/li\u003e\n\u003cli\u003eRapley T. Distributed decision making: the anatomy of decisions-in-action. Sociol Health Illn. 2008;30(3):429-44.\u003c/li\u003e\n\u003cli\u003eSchuster F, Holzhuter F, Heres S, Hamann J. \u0026apos;Triadic\u0026apos; shared decision making in mental health: Experiences and expectations of service users, caregivers and clinicians in Germany. Health Expect. 2021;24(2):507-15.\u003c/li\u003e\n\u003cli\u003eBeyene LS, Severinsson E, Hansen BS, Rortveit K. Shared Decision-Making-Balancing Between Power and Responsibility as Mental Health-Care Professionals in a Therapeutic Milieu. SAGE Open Nurs. 2018;4:2377960817752159.\u003c/li\u003e\n\u003cli\u003eZisman-Ilani Y, Lysaker PH, Hasson-Ohayon I. Shared Risk Taking: Shared Decision Making in Serious Mental Illness. Psychiatr Serv. 2021;72(4):461-3.\u003c/li\u003e\n\u003cli\u003eDi Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health outcomes: a systematic review. Lancet. 2001;357(9258):757-62.\u003c/li\u003e\n\u003cli\u003eFreidl M, Pesola F, Konrad J, Puschner B, Kovacs AI, De Rosa C, et al. Effects of Clinical Decision Topic on Patients\u0026apos; Involvement in and Satisfaction With Decisions and Their Subsequent Implementation. Psychiatr Serv. 2016;67(6):658-63.\u003c/li\u003e\n\u003cli\u003eStorm M, Edwards A. Models of user involvement in the mental health context: intentions and implementation challenges. Psychiatr Q. 2013;84(3):313-27.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-3820707/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3820707/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough\u003cstrong\u003e \u003c/strong\u003eshared decision making (SDM) is the preferred choice in mental health care, the literature shows this patient-clinician communication approach is not widely implemented in this field of medicine. To promote its use in clinical practice and training, we introduce an SDM model that allows for all field-specific demands and teaching purposes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe developed an elementary framework for sharing decisions during psychiatric consultations through an iterative process. After reviewing the literature on existing SDM models and assessing their appropriateness for further enrichment to meet the needs of mental health services, we integrated all requirements in our model, paying special attention to didactic aspects in communication courses. The resulting model was finetuned in a focus group- approach involving five different panels of health-care professionals, clients, informal caregivers and medical students.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe chose to expand the initial 3-step models and later adaptations by Elwyn et al. and to devise a linear step model to meet clinical and requirement and didactic usability. The model incorporates aspects that are typical to mental health care such as explicit goal setting, setting up a ‘decision team’, assessing decision capacity and risk deliberation. As psychiatric care demands a stable and trustful therapeutic relationship, we added the element of the explicit pursuit of three core values: Be curious, collaborative and connected.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComprising six steps and periodical core value checks, the Shared Steps \u0026amp; Checks approach presented here offers a pragmatic SDM framework for mental health practice and training serving all stakeholders involved in this complex, multidisciplinary field.\u003c/p\u003e","manuscriptTitle":"‘Shared Steps \u0026amp; Checks’: A Shared Decision Making Model for Mental Health Care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-12 19:20:28","doi":"10.21203/rs.3.rs-3820707/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7adb1bbb-6e85-472b-a151-25369333d29c","owner":[],"postedDate":"January 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-02-16T16:30:32+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-12 19:20:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3820707","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3820707","identity":"rs-3820707","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}