Community Ment Health J DOI 10.1007/s10597-015-9871-7
BRIEF COMMUNICATION
Caregiver Perceptions of Clinical Decision-Making for the Treatment of Children Brian Allen1 • Alberto Varela2
Received: 23 December 2014 / Accepted: 24 March 2015 Springer Science+Business Media New York 2015
Abstract Many sources of information impact one’s clinical decision-making (CDM) (e.g. clinical intuition, previous experience, research results). Relatively little is known about the clients’ perspectives of these factors. The current study is an examination of perceptions of the favorability of various CDM influences held by caregivers of children presenting for mental health treatment (n = 371). Responses to a questionnaire showed that caregivers overwhelmingly favored a treatment decision based on current scientific research, with one’s clinical experience being the second most favored influence. Other influences, such as colleague consultation and clinical intuition, were less favorable. Keywords Evidence-based practice Clinical decision making Child and caregiver participation Informed consent Evidence-based medicine
Introduction Clinical decision-making (CDM) can be informed by a number of different sources, including: colleagues; previous clinical work; intuition; and empirical literature. However, there is a significant debate within the profession about how treatment decisions should be made. Some
& Brian Allen [email protected] 1
Center for the Protection of Children, Penn State Hershey Children’s Hospital, 500 University Drive, Hershey, PA 17033, USA
2
Department of Educational Psychology, University of Utah, Salt Lake City, UT, USA
believe scientific evidence should be at the forefront of CDM (Baker et al. 2009); others place higher importance on variables such as intuition (Gaudiano et al. 2011), clinical experience (Stewart and Chambless 2007), or consultation from colleagues (Cook et al. 2009). In addition, practice recommendations from the American Psychological Association (APA 2006) suggest that treatment decisions should be made in collaboration with the client. The multitude of factors that might influence CDM gives rise to a debate regarding which influences should take precedence and how these factors might be integrated to arrive at the best possible plan for treatment. For instance, the APA (2006) policy on evidence-based practice stresses the integration of clinical experience, client characteristics, and best available evidence; however, the clinician him or herself is designated as the arbiter of how to integrate these factors and determines what constitutes ‘‘best available evidence.’’ Some suggest that this clinicianfocused approach represents a rather unscientific view to practice as clinicians may be likely to rely more on their intuition and experience than research knowledge or statistical reasoning when making treatment decisions (Baker et al. 2009). This contention appears to have some merit. For instance, Cook et al. (2009) found that empirical support for an intervention did not have a strong influence on clinicians’ decisions to implement the treatment; rather, discussions with colleagues was a greater determinant of current practice. Stewart and Chambless (2007) found clinicians strongly agreed that their prior clinical experiences were important in making treatment decisions and were less interested in empirical research informing treatment decisions. In fact, participants in their study rated prior clinical experience significantly higher than empirical research and discussions with colleagues. Lucock et al. (2006) surveyed 164 psychotherapists and reported that
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clinical intuition was rated higher in the CDM process than evidence from research. What is rarely considered in this debate is the perspective of the client. Oftentimes clinical practice involves providing treatment recommendations to the client, and discussing why a recommended treatment might work. Barring any significant concerns, the treatment is then implemented. Presumably, it is rare that a clinician asks a client about the factors upon which he or she would like the recommendation to be made, or his or her perception of how such recommendations are made. Only one study was identified that specifically asked clients about their perceptions of CDM (O’Donohue et al. 1989). Results suggested fairly comparable ratings of favorability among the two highest scoring factors: (1) a clinician’s personal experience with a given treatment approach and (2) the results of empirical research. The O’Donohue et al. study focused on adults receiving services for themselves and no identified studies exist examining the perceptions of caregivers in the context of psychotherapy for children and adolescents. Understanding the desired form of CDM from the perspective of the client/caregiver may have significant ramifications. For instance, Foster and Mash (1999) discuss the clinical importance of ‘‘social validity,’’ which is the larger social context’s agreement with the goals of treatment, treatment procedures, and/or desired clinical outcomes. The implication is that more socially valid interventions may result in greater client participation and, ultimately, improved outcomes. For instance, Tiano et al. (2013) examined differences between mothers and fathers in the acceptability of a parent-training intervention. One finding was that fathers were much less receptive to a group-based model than were mothers, but generally found individual treatment acceptable. This suggests that group parent-training may be less likely to yield the desired participation from fathers. Such social validity processes may also apply to issues of CDM, with client-therapist match regarding the importance of various factors determining issues such as treatment participation. Significantly greater public awareness regarding the role of science in mental health treatment has developed in recent years, with numerous news stories, magazine articles, and other forms of dissemination touting the advent of evidence-based treatments. As such, caregivers may view treatment rationales based on empirical research as more socially valid than other forms of CDM. The purpose of the current study was twofold: (1) to examine caregiver perceptions of different CDM methods and (2) to understand caregiver preferences for therapists’ methods of CDM. Essentially, this study was concerned with not only understanding what caregivers thought was
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the best CDM method, but if given a choice, what method they would prefer.
Method Procedure Two different child-serving mental health clinics within the Rocky Mountain region (USA) participated in this project. The study’s questionnaire was sent to potential participants along with standard intake forms following the caregiver contacting the clinics to schedule initial assessments for the child. The questionnaires were then completed and returned to the clinics during the initial assessment appointment. This process eliminated the potential for any tainting of the caregivers’ responses as a result of discussions with a clinician. An informed consent form was included with the questionnaire notifying caregivers that participation was voluntary and, if they did not wish to participate, to simply disregard the questionnaire in the packet. All data were collected anonymously and all procedures were approved by an applicable Institutional Review Board. Questionnaire The structure of the questionnaire was modeled on that used by O’Donohue et al. (1989). Minor revisions were made to the items to reflect that one was providing responses regarding treatment for their child as opposed to themselves. Caregivers were presented with the following written scenario: Imagine that you take your child to a mental health therapist to seek help for a certain problem. After you explain your child’s problem to the therapist, s/he recommends a certain method for treating your child’s problem. You then ask the therapist, ‘‘Why did you decide to use this particular method to treat my child’s problem?’’ Suppose the therapist says… The caregivers were then presented with five methods of CDM. To minimize the influence of possible order effects, the presentation of the items was counterbalanced using a Latin square design. In addition, all items were written in such a way that the influence of other potential factors was minimized. The CDM methods were presented in the following manner: Clinical Experience: ‘‘I’m not sure if other therapists have used this treatment method in the past, but I have used this method in the past with success, and for that reason I think it will work again.’’
Community Ment Health J
Research Supported: ‘‘Because I have looked at scientific research regarding this problem. The research data indicate that the method I’m recommending will work.’’ Clinical Intuition: ‘‘I just have a gut feeling—an intuition—that this treatment method will work.’’ Colleague Consultation/Hearsay: ‘‘I have heard from other therapists at this agency that they have used this treatment method with success, and for that reason I think this treatment method will work.’’ No Rationale- ‘‘I have no reason or rationale. I just decided, based on no real reason, that this treatment method will work.’’ (It should be noted that although this item does not convey the use of any actual method of CDM, it does provide a baseline for evaluating how favorable the caregiver views other methods when compared to no rationale or reason for one’s decision.) After each presentation of a CDM method, participants were asked to ‘‘Rate how good you think this approach to making a treatment decision is’’ and to respond on a 5-point Likert-type scale (1 = this is a terrible way to make a treatment decision; 2 = this is a bad way to make a treatment decision; 3 = this is neither a bad nor a good way to make a treatment decision; 4 = this is a good way to make a treatment decision; 5 = this is an excellent way to make a treatment decision). After completing this first section of the questionnaire, caregivers were presented with a new section that was not presented in the O’Donohue et al. study. In this section, caregivers were presented with the following instructions: Of the different methods to making a treatment decision described above, which would you most prefer to hear your child’s therapist say? Put a ‘‘1’’ next to your most preferred option, a ‘‘2’’ next to the second most preferred option, and so forth. Please rank each of the five options. Participants were then presented with the five CDM methods in the same counterbalanced order presented in the first section. Participants Approximately 890 questionnaires were mailed to potential participants during the 12 month recruitment period. A total of 371 caregivers returned the questionnaire to the clinics for a response rate of nearly 42 %. The mean age of the participant caregivers was 37.9 years (SD = 7.3, range 22–70) and the caregivers were overwhelmingly female (n = 326; 87.9 %), of European descent (n = 318; 85.7 %), and currently married (n = 271; 73 %). The
caregivers had a mean of 14.2 years of education (SD = 3.3; range 1–22). The children of the caregiver participants were equally split in terms of gender (female: n = 183; 49.3 %) and were an average of 9.9 years of age (SD = 3.66; range 2–17). Like the caregivers, the children were overwhelmingly from a European ethnic group (n = 296; 79.8 %). Of the caregivers completing the questionnaire, 174 (46.9 %) endorsed previous mental health system involvement for either themselves or a child under their care. Of the total returned questionnaires, 52 of the caregivers failed to complete the second section assessing rank-ordered preferences. Analyses did not suggest any demographic differences between those caregivers who did and did not complete the second section. As such, analyses of the first section of the questionnaire utilize all 371 responses, and analyses examining the second section make use of the 319 completed questionnaires. Analytic Plan First, demographic analyses were completed to examine whether these factors may have influenced scores on the ratings of the five CDM methods. Next, a series of pairedsamples t-tests were performed to examine differences between caregivers’ ratings of the CDM methods. Comparisons between all CDM methods were performed to determine whether a hierarchy emerged of preferred caregiver methods and, if so, the ordering of those methods. Last, descriptive data are provided on rankings of the five CDM methods to reveal patterns in the rankings.
Results Demographic analyses were completed to determine if any given demographic variables significantly related to the ratings of each CDM method. Only one statistically significant relationship was found: participants with more education had a slightly better perception of clinical intuition (r = .11, p = .03). All t test analyses were significant (all ts [ 5.77, all ps \ .001), suggesting significant separation in caregiver favorability of the various CDM methods. The highest rated CDM method was the Research Supported item with a mean rating of 3.9 (SD = .83), corresponding approximately to the ‘‘good way to make a treatment decision’’ anchor. Clinical Experience was the second highest rated CDM method (M = 3.58, SD = .80) with a score mid-way between the ‘‘neither good nor bad way’’ and ‘‘good way’’ anchors. Although the difference in scores between Research Supported and Clinical Experience methods was .32 points, the obtained effect size was roughly medium in strength (t = 5.78, d = .39; Cohen
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1992), suggesting a clear hierarchy in the caregivers’ ratings. The third highest ranked method was Colleague Consultation (M = 3.26, SD = .88), followed by Clinical Intuition (M = 2.3, SD = .99). The lowest rated method, understandably, was No Rationale (M = 1.24, SD = .58), which closely approximated a ‘‘terrible’’ way to make a decision. Next, we examined caregivers’ rank-ordered preferences for CDM methods. The Research Supported method was the clear favorite, receiving the top ranking from the majority of caregivers (n = 174, 54.5 %; 2nd place votes = 61, 19.1 %). Clinical Experience received the second most top rankings (n = 100, 31.3 %) and received the most second-place endorsements (n = 126, 39.5 %). These findings clearly suggest that caregivers tend to view the Research Supported method of CDM as the most favorable and preferred way of deriving a treatment recommendation. However, Clinical Experience was also viewed favorably and was clearly deemed to be the second best option of CDM methods. Mirroring the results of the ratings discussed above, Colleague Consultation was the third most preferred method (1st place votes = 36; 2nd place votes = 117), followed by Clinical Intuition (1st place votes = 7; 2nd place votes = 14), and finally No Rationale (1st place votes = 1; 2nd place votes = 1).
Discussion These data help inform the current debate regarding the role of research, clinical experience, and other factors in the CDM process. Most obvious of conclusions from these data is that clinicians should not assume that their perspective of appropriate CDM methods is shared by a caregiver. In an ongoing effort to engage caregivers, as well as other involved practitioners (e.g., social workers, physicians), greater specification of the reasoning behind one’s clinical decisions may improve communication and service delivery. In addition, clearly specifying one’s reasoning with a caregiver and clarifying any misunderstandings or misconceptions may improve caregiver involvement in the treatment process and encourage attempts to continually engage and inform caregivers throughout the treatment process. The current study also raises a significant ethical concern related to the issue of informed consent to treatment procedures. Results of the current study clearly indicate that caregivers prefer a research-based approach to CDM. Consequently, it may be expected that many caregivers assume that the mental health clinician is basing his or her treatment recommendation on the current empirical knowledge. Unfortunately, substantial evidence exists to suggest that many clinicians do not utilize evidence-based
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treatments (Allen et al. 2012; Sharp et al. 2008). However, little is known about how much information is being conveyed to the client/caregiver about the CDM process prior to obtaining consent. This creates the potential for a significant ethical concern. A clinician may make a treatment recommendation based on his or her judgment, or colleague recommendation, for instance, while the caregiver assumes the recommendation is based on some other factor (e.g., the current research base) and subsequently provides consent to treat the child. In this situation, it is difficult to assert that ‘‘informed’’ consent occurred. It is advisable that clinicians explicitly state the rationale for selecting a specific treatment and provide information about the various aspects of the CDM process. For instance, telling a caregiver that a certain treatment is the most research-supported, but that the clinician lacks experience in the model are both important pieces of information for the caregiver to consider. In such an instance, the caregiver may decide to select an alternative treatment with which the clinician does have experience or seek out a different clinician with experience in the more empiricallysupported model. However, advising the selection of a treatment based on clinician judgment while either not discussing the research base or providing a skewed perspective of the research in order to support the implementation of a preferred approach crosses into an ethical quandary regarding whether true ‘‘informed consent’’ can be provided. With the advent of the internet, one must consider the vast amount of information available to caregivers pertaining to mental health treatment. Information provided by clinicians can be readily verified or challenged by savvy caregivers. Indeed, it is not uncommon for a caregiver to specifically request a branded treatment program when attending an assessment session. This treatment may or may not be indicated based on numerous factors. Although clinicians are never obligated to provide a treatment requested by a caregiver, obtaining informed consent in such a situation may be challenging and require an in depth discussion of the various CDM methods, including exploration of why the caregiver is interested in the treatment and where the information was obtained. The current study must be evaluated in light of its limitations. First, the sample composition was overwhelming from a White/European ethnicity. Although these demographic characteristics were similar to the broader population where the data were obtained, it makes it difficult to examine potential cultural differences in the favorability of various forms of CDM. In addition, the average number of years of education was 14.2, suggesting the average respondent had some post-secondary education. Although the impact of this level of education on the results was not significant for most forms of CDM, the
Community Ment Health J
question of generalizability remains. Second, the questionnaire used for this project was study-specific; there are no indices of reliability or validity currently available for the metric. Lastly, the scenario created for the caregiver when responding was artificial and the hypothetical clinician responses were written in a concise manner. There are an infinite number of ways that a clinician might respond when asked to justify his or her treatment decision, and no study could capture all contingencies. Most visible in this concern is the likelihood that multiple methods of CDM are employed when developing a treatment plan. For practical purposes of evaluation, each method of CDM in this study was presented to the caregiver in isolation; it is likely the case that the most preferred manner of CDM involves the confluence of multiple sources of information. Some directions for future research are indicated. First, it would be advantageous to study the informed consent process that clinicians typically employ to determine how treatment recommendations are conveyed to caregivers. Clinicians receiving training in evidence-based treatments are typically instructed to discuss with clients the results of clinical trials and what evidence supports the intervention, at least in an abbreviated form. This is typically done to obtain buy-in from the caregivers. However, such an approach seems unlikely with other treatment programs that lack a similarly developed research base. It seems plausible that in these instances a discussion of CDM is more likely to focus on clinical judgment and intuition. Second, caregiver perceptions of how these various CDM methods combine to provide a treatment recommendation are a fruitful area for research. An ideal situation occurs if research support, clinical experience, and colleague consultations all converge on the treatment recommendation. In many cases, however, a caregiver’s non-preferred method of CDM may be used to offer a treatment recommendation, especially if a number of these methods are converging. In such a situation, it is valuable to know how this CDM process, even though eventually agreed to by the caregiver, impacts caregiver perceptions of treatment planning, as well as treatment participation and success.
Acknowledgments This study was approved by the Institutional Review Board of Intermountain Healthcare, Salt Lake City, Utah, USA.
References Allen, B., Gharagozloo, L., & Johnson, J. C. (2012). Clinician knowledge and utilization of empirically-supported treatments for maltreated children. Child Maltreatment, 17, 11–21. American Psychological Association. (2006). Evidence-based practice in psychology. American Psychologist, 61(4), 271–285. Baker, T. B., McFall, R. M., & Shoham, V. (2009). Current status and future prospects of clinical psychology: Toward a scientifically principled approach to mental and behavioral health care. Psychological Science in The Public Interest, 9(2), 67–103. Cohen, J. (1992). A power primer. Psychological Bulletin, 112, 155–159. Cook, J. M., Schnurr, P. P., Biyanova, T., & Coyne, J. C. (2009). Apples don’t fall far from the tree: Influences on psychotherapists’ adoption and sustained use of new therapies. Psychiatric Services, 60(5), 671–676. Foster, S. L., & Mash, E. J. (1999). Assessing social validity in clinical treatment research: Issues and procedures. Journal of Consulting and Clinical Psychology, 67, 308–319. Gaudiano, B. A., Brown, L. A., & Miller, I. W. (2011). Let your intuition be your guide? Individual differences in the evidencebased practice attitudes of psychotherapists. Journal of Evaluation in Clinical Practice, 17(4), 628–634. Lucock, M. P., Hall, P., & Noble, R. (2006). A survey of influences on the practice of psychotherapists and clinical psychologists in training in the UK. Clinical Psychology & Psychotherapy, 13(2), 123–130. O’Donohue, W., Fisher, J. E., Plaud, J. J., & Link, W. (1989). What is a good treatment decision? The client’s perspective. Professional Psychology: Research and Practice, 20(6), 404–407. Sharp, L. R., Herbert, J. D., & Redding, R. E. (2008). The role of critical thinking skills in practicing clinical psychologists’ choice of intervention techniques. Scientific Review of Mental Health Practice, 6(1), 21–30. Stewart, R. E., & Chambless, D. L. (2007). Does psychotherapy research inform treatment decisions in private practice? Journal of Clinical Psychology, 63(3), 267–281. Tiano, J. D., Grate, R. M., & McNeil, C. B. (2013). Comparison of mothers’ and fathers’ opinions of parent-child interaction therapy. Child & Family Behavior Therapy, 35, 110–131.
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BRIEF COMMUNICATION
Caregiver Perceptions of Clinical Decision-Making for the Treatment of Children Brian Allen1 • Alberto Varela2
Received: 23 December 2014 / Accepted: 24 March 2015 Springer Science+Business Media New York 2015
Abstract Many sources of information impact one’s clinical decision-making (CDM) (e.g. clinical intuition, previous experience, research results). Relatively little is known about the clients’ perspectives of these factors. The current study is an examination of perceptions of the favorability of various CDM influences held by caregivers of children presenting for mental health treatment (n = 371). Responses to a questionnaire showed that caregivers overwhelmingly favored a treatment decision based on current scientific research, with one’s clinical experience being the second most favored influence. Other influences, such as colleague consultation and clinical intuition, were less favorable. Keywords Evidence-based practice Clinical decision making Child and caregiver participation Informed consent Evidence-based medicine
Introduction Clinical decision-making (CDM) can be informed by a number of different sources, including: colleagues; previous clinical work; intuition; and empirical literature. However, there is a significant debate within the profession about how treatment decisions should be made. Some
& Brian Allen [email protected] 1
Center for the Protection of Children, Penn State Hershey Children’s Hospital, 500 University Drive, Hershey, PA 17033, USA
2
Department of Educational Psychology, University of Utah, Salt Lake City, UT, USA
believe scientific evidence should be at the forefront of CDM (Baker et al. 2009); others place higher importance on variables such as intuition (Gaudiano et al. 2011), clinical experience (Stewart and Chambless 2007), or consultation from colleagues (Cook et al. 2009). In addition, practice recommendations from the American Psychological Association (APA 2006) suggest that treatment decisions should be made in collaboration with the client. The multitude of factors that might influence CDM gives rise to a debate regarding which influences should take precedence and how these factors might be integrated to arrive at the best possible plan for treatment. For instance, the APA (2006) policy on evidence-based practice stresses the integration of clinical experience, client characteristics, and best available evidence; however, the clinician him or herself is designated as the arbiter of how to integrate these factors and determines what constitutes ‘‘best available evidence.’’ Some suggest that this clinicianfocused approach represents a rather unscientific view to practice as clinicians may be likely to rely more on their intuition and experience than research knowledge or statistical reasoning when making treatment decisions (Baker et al. 2009). This contention appears to have some merit. For instance, Cook et al. (2009) found that empirical support for an intervention did not have a strong influence on clinicians’ decisions to implement the treatment; rather, discussions with colleagues was a greater determinant of current practice. Stewart and Chambless (2007) found clinicians strongly agreed that their prior clinical experiences were important in making treatment decisions and were less interested in empirical research informing treatment decisions. In fact, participants in their study rated prior clinical experience significantly higher than empirical research and discussions with colleagues. Lucock et al. (2006) surveyed 164 psychotherapists and reported that
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clinical intuition was rated higher in the CDM process than evidence from research. What is rarely considered in this debate is the perspective of the client. Oftentimes clinical practice involves providing treatment recommendations to the client, and discussing why a recommended treatment might work. Barring any significant concerns, the treatment is then implemented. Presumably, it is rare that a clinician asks a client about the factors upon which he or she would like the recommendation to be made, or his or her perception of how such recommendations are made. Only one study was identified that specifically asked clients about their perceptions of CDM (O’Donohue et al. 1989). Results suggested fairly comparable ratings of favorability among the two highest scoring factors: (1) a clinician’s personal experience with a given treatment approach and (2) the results of empirical research. The O’Donohue et al. study focused on adults receiving services for themselves and no identified studies exist examining the perceptions of caregivers in the context of psychotherapy for children and adolescents. Understanding the desired form of CDM from the perspective of the client/caregiver may have significant ramifications. For instance, Foster and Mash (1999) discuss the clinical importance of ‘‘social validity,’’ which is the larger social context’s agreement with the goals of treatment, treatment procedures, and/or desired clinical outcomes. The implication is that more socially valid interventions may result in greater client participation and, ultimately, improved outcomes. For instance, Tiano et al. (2013) examined differences between mothers and fathers in the acceptability of a parent-training intervention. One finding was that fathers were much less receptive to a group-based model than were mothers, but generally found individual treatment acceptable. This suggests that group parent-training may be less likely to yield the desired participation from fathers. Such social validity processes may also apply to issues of CDM, with client-therapist match regarding the importance of various factors determining issues such as treatment participation. Significantly greater public awareness regarding the role of science in mental health treatment has developed in recent years, with numerous news stories, magazine articles, and other forms of dissemination touting the advent of evidence-based treatments. As such, caregivers may view treatment rationales based on empirical research as more socially valid than other forms of CDM. The purpose of the current study was twofold: (1) to examine caregiver perceptions of different CDM methods and (2) to understand caregiver preferences for therapists’ methods of CDM. Essentially, this study was concerned with not only understanding what caregivers thought was
123
the best CDM method, but if given a choice, what method they would prefer.
Method Procedure Two different child-serving mental health clinics within the Rocky Mountain region (USA) participated in this project. The study’s questionnaire was sent to potential participants along with standard intake forms following the caregiver contacting the clinics to schedule initial assessments for the child. The questionnaires were then completed and returned to the clinics during the initial assessment appointment. This process eliminated the potential for any tainting of the caregivers’ responses as a result of discussions with a clinician. An informed consent form was included with the questionnaire notifying caregivers that participation was voluntary and, if they did not wish to participate, to simply disregard the questionnaire in the packet. All data were collected anonymously and all procedures were approved by an applicable Institutional Review Board. Questionnaire The structure of the questionnaire was modeled on that used by O’Donohue et al. (1989). Minor revisions were made to the items to reflect that one was providing responses regarding treatment for their child as opposed to themselves. Caregivers were presented with the following written scenario: Imagine that you take your child to a mental health therapist to seek help for a certain problem. After you explain your child’s problem to the therapist, s/he recommends a certain method for treating your child’s problem. You then ask the therapist, ‘‘Why did you decide to use this particular method to treat my child’s problem?’’ Suppose the therapist says… The caregivers were then presented with five methods of CDM. To minimize the influence of possible order effects, the presentation of the items was counterbalanced using a Latin square design. In addition, all items were written in such a way that the influence of other potential factors was minimized. The CDM methods were presented in the following manner: Clinical Experience: ‘‘I’m not sure if other therapists have used this treatment method in the past, but I have used this method in the past with success, and for that reason I think it will work again.’’
Community Ment Health J
Research Supported: ‘‘Because I have looked at scientific research regarding this problem. The research data indicate that the method I’m recommending will work.’’ Clinical Intuition: ‘‘I just have a gut feeling—an intuition—that this treatment method will work.’’ Colleague Consultation/Hearsay: ‘‘I have heard from other therapists at this agency that they have used this treatment method with success, and for that reason I think this treatment method will work.’’ No Rationale- ‘‘I have no reason or rationale. I just decided, based on no real reason, that this treatment method will work.’’ (It should be noted that although this item does not convey the use of any actual method of CDM, it does provide a baseline for evaluating how favorable the caregiver views other methods when compared to no rationale or reason for one’s decision.) After each presentation of a CDM method, participants were asked to ‘‘Rate how good you think this approach to making a treatment decision is’’ and to respond on a 5-point Likert-type scale (1 = this is a terrible way to make a treatment decision; 2 = this is a bad way to make a treatment decision; 3 = this is neither a bad nor a good way to make a treatment decision; 4 = this is a good way to make a treatment decision; 5 = this is an excellent way to make a treatment decision). After completing this first section of the questionnaire, caregivers were presented with a new section that was not presented in the O’Donohue et al. study. In this section, caregivers were presented with the following instructions: Of the different methods to making a treatment decision described above, which would you most prefer to hear your child’s therapist say? Put a ‘‘1’’ next to your most preferred option, a ‘‘2’’ next to the second most preferred option, and so forth. Please rank each of the five options. Participants were then presented with the five CDM methods in the same counterbalanced order presented in the first section. Participants Approximately 890 questionnaires were mailed to potential participants during the 12 month recruitment period. A total of 371 caregivers returned the questionnaire to the clinics for a response rate of nearly 42 %. The mean age of the participant caregivers was 37.9 years (SD = 7.3, range 22–70) and the caregivers were overwhelmingly female (n = 326; 87.9 %), of European descent (n = 318; 85.7 %), and currently married (n = 271; 73 %). The
caregivers had a mean of 14.2 years of education (SD = 3.3; range 1–22). The children of the caregiver participants were equally split in terms of gender (female: n = 183; 49.3 %) and were an average of 9.9 years of age (SD = 3.66; range 2–17). Like the caregivers, the children were overwhelmingly from a European ethnic group (n = 296; 79.8 %). Of the caregivers completing the questionnaire, 174 (46.9 %) endorsed previous mental health system involvement for either themselves or a child under their care. Of the total returned questionnaires, 52 of the caregivers failed to complete the second section assessing rank-ordered preferences. Analyses did not suggest any demographic differences between those caregivers who did and did not complete the second section. As such, analyses of the first section of the questionnaire utilize all 371 responses, and analyses examining the second section make use of the 319 completed questionnaires. Analytic Plan First, demographic analyses were completed to examine whether these factors may have influenced scores on the ratings of the five CDM methods. Next, a series of pairedsamples t-tests were performed to examine differences between caregivers’ ratings of the CDM methods. Comparisons between all CDM methods were performed to determine whether a hierarchy emerged of preferred caregiver methods and, if so, the ordering of those methods. Last, descriptive data are provided on rankings of the five CDM methods to reveal patterns in the rankings.
Results Demographic analyses were completed to determine if any given demographic variables significantly related to the ratings of each CDM method. Only one statistically significant relationship was found: participants with more education had a slightly better perception of clinical intuition (r = .11, p = .03). All t test analyses were significant (all ts [ 5.77, all ps \ .001), suggesting significant separation in caregiver favorability of the various CDM methods. The highest rated CDM method was the Research Supported item with a mean rating of 3.9 (SD = .83), corresponding approximately to the ‘‘good way to make a treatment decision’’ anchor. Clinical Experience was the second highest rated CDM method (M = 3.58, SD = .80) with a score mid-way between the ‘‘neither good nor bad way’’ and ‘‘good way’’ anchors. Although the difference in scores between Research Supported and Clinical Experience methods was .32 points, the obtained effect size was roughly medium in strength (t = 5.78, d = .39; Cohen
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1992), suggesting a clear hierarchy in the caregivers’ ratings. The third highest ranked method was Colleague Consultation (M = 3.26, SD = .88), followed by Clinical Intuition (M = 2.3, SD = .99). The lowest rated method, understandably, was No Rationale (M = 1.24, SD = .58), which closely approximated a ‘‘terrible’’ way to make a decision. Next, we examined caregivers’ rank-ordered preferences for CDM methods. The Research Supported method was the clear favorite, receiving the top ranking from the majority of caregivers (n = 174, 54.5 %; 2nd place votes = 61, 19.1 %). Clinical Experience received the second most top rankings (n = 100, 31.3 %) and received the most second-place endorsements (n = 126, 39.5 %). These findings clearly suggest that caregivers tend to view the Research Supported method of CDM as the most favorable and preferred way of deriving a treatment recommendation. However, Clinical Experience was also viewed favorably and was clearly deemed to be the second best option of CDM methods. Mirroring the results of the ratings discussed above, Colleague Consultation was the third most preferred method (1st place votes = 36; 2nd place votes = 117), followed by Clinical Intuition (1st place votes = 7; 2nd place votes = 14), and finally No Rationale (1st place votes = 1; 2nd place votes = 1).
Discussion These data help inform the current debate regarding the role of research, clinical experience, and other factors in the CDM process. Most obvious of conclusions from these data is that clinicians should not assume that their perspective of appropriate CDM methods is shared by a caregiver. In an ongoing effort to engage caregivers, as well as other involved practitioners (e.g., social workers, physicians), greater specification of the reasoning behind one’s clinical decisions may improve communication and service delivery. In addition, clearly specifying one’s reasoning with a caregiver and clarifying any misunderstandings or misconceptions may improve caregiver involvement in the treatment process and encourage attempts to continually engage and inform caregivers throughout the treatment process. The current study also raises a significant ethical concern related to the issue of informed consent to treatment procedures. Results of the current study clearly indicate that caregivers prefer a research-based approach to CDM. Consequently, it may be expected that many caregivers assume that the mental health clinician is basing his or her treatment recommendation on the current empirical knowledge. Unfortunately, substantial evidence exists to suggest that many clinicians do not utilize evidence-based
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treatments (Allen et al. 2012; Sharp et al. 2008). However, little is known about how much information is being conveyed to the client/caregiver about the CDM process prior to obtaining consent. This creates the potential for a significant ethical concern. A clinician may make a treatment recommendation based on his or her judgment, or colleague recommendation, for instance, while the caregiver assumes the recommendation is based on some other factor (e.g., the current research base) and subsequently provides consent to treat the child. In this situation, it is difficult to assert that ‘‘informed’’ consent occurred. It is advisable that clinicians explicitly state the rationale for selecting a specific treatment and provide information about the various aspects of the CDM process. For instance, telling a caregiver that a certain treatment is the most research-supported, but that the clinician lacks experience in the model are both important pieces of information for the caregiver to consider. In such an instance, the caregiver may decide to select an alternative treatment with which the clinician does have experience or seek out a different clinician with experience in the more empiricallysupported model. However, advising the selection of a treatment based on clinician judgment while either not discussing the research base or providing a skewed perspective of the research in order to support the implementation of a preferred approach crosses into an ethical quandary regarding whether true ‘‘informed consent’’ can be provided. With the advent of the internet, one must consider the vast amount of information available to caregivers pertaining to mental health treatment. Information provided by clinicians can be readily verified or challenged by savvy caregivers. Indeed, it is not uncommon for a caregiver to specifically request a branded treatment program when attending an assessment session. This treatment may or may not be indicated based on numerous factors. Although clinicians are never obligated to provide a treatment requested by a caregiver, obtaining informed consent in such a situation may be challenging and require an in depth discussion of the various CDM methods, including exploration of why the caregiver is interested in the treatment and where the information was obtained. The current study must be evaluated in light of its limitations. First, the sample composition was overwhelming from a White/European ethnicity. Although these demographic characteristics were similar to the broader population where the data were obtained, it makes it difficult to examine potential cultural differences in the favorability of various forms of CDM. In addition, the average number of years of education was 14.2, suggesting the average respondent had some post-secondary education. Although the impact of this level of education on the results was not significant for most forms of CDM, the
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question of generalizability remains. Second, the questionnaire used for this project was study-specific; there are no indices of reliability or validity currently available for the metric. Lastly, the scenario created for the caregiver when responding was artificial and the hypothetical clinician responses were written in a concise manner. There are an infinite number of ways that a clinician might respond when asked to justify his or her treatment decision, and no study could capture all contingencies. Most visible in this concern is the likelihood that multiple methods of CDM are employed when developing a treatment plan. For practical purposes of evaluation, each method of CDM in this study was presented to the caregiver in isolation; it is likely the case that the most preferred manner of CDM involves the confluence of multiple sources of information. Some directions for future research are indicated. First, it would be advantageous to study the informed consent process that clinicians typically employ to determine how treatment recommendations are conveyed to caregivers. Clinicians receiving training in evidence-based treatments are typically instructed to discuss with clients the results of clinical trials and what evidence supports the intervention, at least in an abbreviated form. This is typically done to obtain buy-in from the caregivers. However, such an approach seems unlikely with other treatment programs that lack a similarly developed research base. It seems plausible that in these instances a discussion of CDM is more likely to focus on clinical judgment and intuition. Second, caregiver perceptions of how these various CDM methods combine to provide a treatment recommendation are a fruitful area for research. An ideal situation occurs if research support, clinical experience, and colleague consultations all converge on the treatment recommendation. In many cases, however, a caregiver’s non-preferred method of CDM may be used to offer a treatment recommendation, especially if a number of these methods are converging. In such a situation, it is valuable to know how this CDM process, even though eventually agreed to by the caregiver, impacts caregiver perceptions of treatment planning, as well as treatment participation and success.
Acknowledgments This study was approved by the Institutional Review Board of Intermountain Healthcare, Salt Lake City, Utah, USA.
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