Evidence-Based Psychotherapy Shared Decision-Making Toolkit for Mental Health Providers Bradley E. Karlin, PhD, ABPP | Amy Wenzel, PhD, ABPP I SECTION 2: SHARED DECISION-MAKING AND EVIDENCE-BASED PSYCHOTHERAPY Suggested Citation: Karlin, B. E., & Wenzel, A. (2018). Evidence-based psychotherapy shared decision-making toolkit for mental health providers. Waltham, MA: Education Development Center, Inc. The views and opinions expressed in this toolkit represent the opinions of the authors and do not necessarily reflect those of the U.S. Department of Veterans Affairs. Specific resources identified herein are provided for information purposes and do not represent an endorsement of any individual resource. EVIDENCE-BASED PSYCHOTHERAPY SHARED DECISION-MAKING TOOLKIT FOR MENTAL HEALTH PROVIDERS Table of Contents LIST OF TABLES AND FIGURES ...........................................................................V ACKNOWLEDGEMENTS ...................................................................................VII PREFACE ..........................................................................................................VIII INTRODUCTION TO THE TOOLKIT .....................................................................1 SECTION 1: INTRODUCTION TO SHARED DECISION-MAKING ........................4 1.1. SDM Models ................................................................................. 6 1.2. Empirical Support for SDM ......................................................... 14 SECTION 2: SHARED DECISION-MAKING AND EVIDENCE-BASED PSYCHOTHERAPY ..............................................................................16 2.1. The SDM Session ........................................................................ 20 2.1.1. Connect: Establish Initial Trust and Interpersonal Connection ....................................................................... 22 2.1.2. Motivate: Assess and Promote Motivation for Treatment .................................................................... 30 2.1.3. Educate: Educate Veteran about EBPs and Other Treatment Options ................................................. 39 2.1.4. Explore: Explore Values and Preferences ......................... 44 2.1.5. Set Goals: Identify Potential Treatment Goals ................. 50 2.1.6. Choose: Select Treatment or Determine Next Steps ....... 55 2.2. Putting SDM into Practice: Practical and Logistical Guidelines and Considerations ..................................................................... 67 SECTION 3: PROMOTING ONGOING ENGAGEMENT .....................................78 3.1. Therapeutic Alliance ................................................................... 79 3.1.1. Assessment of the Therapeutic Alliance .......................... 81 3.1.2. Enhancement of the Therapeutic Alliance ....................... 88 3.2. Measurement-Based Care......................................................... 100 3.2.1. Assessment of Patient Outcomes .................................. 104 I TABLE OF CONTENTS CONCLUSION..................................................................................................120 REFERENCES ...................................................................................................122 ABOUT THE AUTHORS....................................................................................137 APPENDIX .......................................................................................................139 A1. Preparatory Skills Building to Increase Treatment Readiness ... 140 A2. Preparatory Skills Building Provider Tip Sheets ........................ 174 A3. Preparatory Skills Building Patient Handouts ........................... 200 A4. Shared Decision-Making Session Provider Checklist ................ 206 A5. Shared Decision-Making Session Facility Implementation Checklist ......................................................... 214 A6. Shared Decision-Making Session Documentation Template .... 220 II EVIDENCE-BASED PSYCHOTHERAPY SHARED DECISION-MAKING TOOLKIT FOR MENTAL HEALTH PROVIDERS LIST OF TABLES AND FIGURES SECTION 1: INTRODUCTION TO SHARED DECISION-MAKING ........................4 Table 1.1. Domains and Core Concepts in SDM Conceptual Models.... 7 Table 1.2. Comparison of SDM Models .............................................. 9 Table 1.3. Elwyn et al. (2012) Shared Decision-Making Model: Goals and Provider Actions .............................................. 12 SECTION 2: SHARED DECISION-MAKING AND EVIDENCE-BASED PSYCHOTHERAPY .........................................................................16 Table 2.1. Skills to Promote Interpersonal Connection..................... 23 Table 2.2. Steps and Considerations for Initiating the SDM Session .... 25 Figure 2.1. Sample Script for Introducing the SDM Session .............. 26 Table 2.3. Steps for Assessing Motivation for Treatment ................. 32 Table 2.4. Steps for Enhancing Motivation for Treatment ................ 33 Figure 2.2. Pros and Cons Exercise for Addressing Ambivalence about Treatment ............................................................... 35 Table 2.5. Steps for Considering Patient Values and Preferences .... 45 Table 2.6. Steps for Identifying Potential Treatment Goals .............. 51 Table 2.7. Examples of Potential Treatment Goals ........................... 52 Table 2.8. Steps for Selecting Treatment or Determining Next Steps ........................................................................ 56 Table 2.9. Outcomes of SDM Session ............................................... 58 Table 2.10. Barriers to Treatment Readiness and Pre-Treatment Strategies.......................................................................... 63 Figure 2.3. Inductive Process of the SDM Session ............................. 66 Table 2.11. Practical and Logistical Requirements for Implementing the SDM Session............................................................... 68 Figure 2.4. Example of Common Pathways to the SDM Session ....... 72 Figure 2.5. Sample Script for Introducing the Group SDM Session ... 75 III TABLE OF CONTENTS SECTION 3: PROMOTING ONGOING ENGAGEMENT .....................................78 Table 3.1. Measures of the Therapeutic Alliance .............................. 87 Figure 3.1. The Therapeutic Alliance—EBP Technique Continuum ... 89 Table 3.2. Focus on the Therapeutic Relationship During the EBP Treatment Process .............................................. 92 Table 3.3. Core EBP Competencies for Enhancing the Therapeutic Alliance ......................................................... 94 Table 3.4. Factors Contributing to Limited or Negative Treatment Response and Associated Indicators and Clinical Considerations ................................................................ 103 Table 3.5. Measures of Symptom Change ...................................... 111 Table 3.6. Measures of Functioning ................................................ 117 Table 3.7. Measures of Well-Being and Quality of Life ................... 119 IV EVIDENCE-BASED PSYCHOTHERAPY SHARED DECISION-MAKING TOOLKIT FOR MENTAL HEALTH PROVIDERS Acknowledgements We would like to acknowledge the leadership and staff of the Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) for Veteran Suicide Prevention for their support for this toolkit and for their commitment to advancing the principles and processes of shared decision-making to increase the uptake and delivery of evidence-based psychological treatments. This toolkit is part of an initiative sponsored by the Rocky Mountain MIRECC designed to promote patient engagement and empowerment for more fully realizing the potential of evidence-based psychological treatments among Veterans. We would like to specifically extend our appreciation to the following individuals for their support and assistance: Lisa Brenner, PhD, ABPP; Nazanin Bahraini, PhD; Claire Collie, PhD; Josephine DeMarce, PhD; Dominick DePhilippis, PhD; Joe Huggins, MSW, MSCIS; Heidi Kar, PhD, MHS; Bridget Matarazzo, PsyD; Robyn Walser, PhD; Leah Wendleton, MPH, MSW; and Hal Wortzel, MD. V ACKNOWLEDGEMENTS Preface Far too many Veterans and other individuals with mental health needs in the United States and throughout the world fail to receive treatment. For those who do get care, the treatments they receive frequently do not resemble treatments highly recommended by clinical experts for their condition. This is especially the case for evidence-based psychotherapies (EBPs)—psychotherapies shown to be efficacious in randomized controlled trials—which are recommended at the highest level and as first-line treatments for a number of mental and behavioral health conditions. These circumstances have resulted in innumerable missed opportunities for significant clinical and functional improvement and have created a gap in evidence-based treatment that is larger than in virtually any other health care context. At the same time, increasing data over the past decade have revealed that Veterans who receive EBPs often reap significant improvements in symptoms and quality of life. A number of these experiences include heartwarming stories in which treatment helped to greatly change key aspects and the trajectory of Veterans’ lives, sometimes after many years of suffering. Yet, relatively few Veterans who may benefit from these treatments receive them. Among the most significant and widely unrecognized barriers contributing to missed opportunities for EBPs are key patient factors, namely limited