Shared decision making: clear focus and shared goals

Consultant Clinical Psychologist Dr Duncan Law has used shared decision making in his work with children and young people for six years. He believes that the approach enables patients and clinicians to work more effectively together from the start.

What does shared decision making mean to you?

It’s about being in a room with a young person and their family and finding ways to share our joint expertise. I have experience around evidence-based interventions; the young person and their family have a different set of expertise – what they’ve already tried that has worked or failed and the context around any difficulties, anxieties or worries. 

I’ll give my understanding of the difficulties from what I’ve heard and offer a range of suggestions about what I think might help and, together with the young person, we will pick the best way to work together. Of course I have to share my expertise in keeping with the young person’s developmental age and what they can take in. We try to get lots of feedback from the young people on whether we’re getting it right. 

How has practice changed?

Our first appointment with a young person is now a ‘Choice appointment’ in which we look at wishes, goals and the range of choices. And we’ve got a goals-based outcome measure that enables us to rate progress together during the course of the intervention.

In the past we focused more on deciding if young people had a mental health problem. If we felt they did, we would agree to ‘treat’ them in the way we thought best. We learnt that even with the best evidence-based intervention, unless we worked closely with and really focused on what young people and families wanted, the work took longer or people dropped out. What professionals feel people need is often very different from what they really want.

Is it making a difference?

It is over six years since we introduced this approach and our service has had no waiting list ever since – previously it was 10 months. This is, I’m sure, due to the shared decision making together with some sophisticated use of demand and capacity theory (CAPA – the Choice and Partnership Approach). It gives us a clear focus right from the start and an understanding that helps us to work together. Because we’re starting on the right track and goals are agreed we can work quicker than if I was aiming for one thing and the young person another.

But one size doesn’t fit all. Our Closing the Gap project on shared decision making involves four services working in very different contexts and conditions and what works for one might not work for a team down the road. But what I am sure of is that we can all use the learning as a starting point to further improve shared decision making in our own settings.

And the next challenge?

How to share more complex information about the evidence base for interventions so that young people and families can make better informed decisions about what might be best, and fit best, for them. And we want to get better and better feedback at every step to ensure things are on track. 

Making decisions about progress together requires very close collaboration. It’s fairly straightforward when things are going well but really challenging to work together to get back on track if things start to ‘go wrong’. Clinicians need to encourage service users to give constructively critical feedback and help them to find ways to communicate it. The work is ongoing.