Client Preferences and Shared Decision Making in Clinical Care

In a new article in Clinical Psychology Review, Lindhiem and colleagues describe a meta-analysis on the importance of client preferences for treatment satisfaction, completion rates, and clinical outcome. As the number of treatment options for different mental health conditions increases and clients have more resources available to learn about varying treatments, the idea of shared decision making has come to the forefront of the minds of many clinicians. Shared decision making enables the clinician and client to discuss different treatment options and decide together which option is most suited to the client’s unique situation. The study examined the effects of taking the client’s treatment preferences into account, and how this may impact treatment satisfaction, completion, and outcome.

In recent years, research has shown that up to 71% of patients demonstrate a treatment preference of some sort, compared to only 50% in 2000. Younger patients, increased patient education, and increased availability of information all likely contribute to this surge in shared decision making within clinical practice.The study reviewed the literature on several different types of client preferences, including active choice (letting the client actively choose treatment rather than simply assigning them to their preferred treatment), informed choice (providing education regarding the treatment), and ongoing choice vs. single-treatment choice, as well as whether providing the client with a choice may be more beneficial for some disorders than others. This study was novel in its examination of potential moderators of psychoeducation (informed vs. uninformed), setting (inpatient vs. outpatient), and type of randomization (client vs. provider). Thirty-four articles met criteria for inclusion and were included in the final analyses.

Results indicated that clients who were involved in shared decision making or who chose a treatment or even were just assigned to their preferred treatment were more satisfied with their treatment in general, were more likely to complete treatment, and had better clinical outcomes compared to those who were not provided a choice or opportunity to receive their preferred treatment, a finding with obvious implications for clinical work. Namely, this speaks to the importance of providing the client with options when two or more equally beneficial and effective treatment methods are available, in order to ensure the best clinical outcomes. When two treatment options are similarly effective, it is easier to provide the client with options; however, when one treatment has clearly been proven superior over others, it becomes more difficult to present the client with all options, without misleading or misguiding them to a less effective treatment. Therefore, it becomes a matter of clinical judgment, to know the options for the patient and provide them with complete and honest information about their choices.

Future research is needed to understand why client preferences are important in the successful treatment of mental illness or other medical disorders. While several theories have been proposed, one stands out from the rest as a possible explanation for observed findings: the therapeutic alliance, or the relationship between client and clinician. A strong alliance between client and clinician allows the patient to express their true views, feelings, and beliefs about treatment, which can only occur if there is mutual respect and understanding between the provider and client. Additionally, a strong therapeutic alliance has been found to be related to more positive expectancies regarding treatment. Research has shown that patients who have positive expectancies about their treatment have better outcomes and better adherence to treatment regimes. These positive expectancies are developed over time, as the therapist learns about the patient’s attitudes, expectations, and beliefs regarding therapy and learns to tailor therapy to the individual, rather than tailoring the individual to a particular treatment. Other proposed explanations for the current findings include physician-patient congruence and better communication; however, more research is need in these areas. For clinicians, the implications of the current findings are clear: in order to have the most successful treatment, a patient’s preference must be taken into account when deciding on treatments. This can be done by providing the patient with psychoeducation, engaging in a discussion about various treatment options, and finally, by providing the patient with a treatment choice when two or more equally effective treatments exist for a particular disorder or condition. In doing this, greater treatment satisfaction, better completion, and more positive outcomes will likely be observed. As clinicians, it is crucial that we begin to move in this direction, as more and more disorders have multiple equally effective treatments.

By guest blogger Caitlin McLear

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Discussion Questions:

  1. What are some ways in which we can move more towards the shared decision-making model of treatment?
  2. What implications may this move have for the future of clinical psychology?