Benjamin Kearney, Ph.D.
Relationships Matter
June 20, 2013
Relationships Matter: Story
Building and the Brain
Benjamin Kearney, PhD
OhioGuidestone
Benjamin.kearney@OhioGuidestone.org
The Neurobiological Process of
Attachment
Genetic basis and epigenic factors :
•
Transcription function-- experience
determines which genes express themselves
via a process of protein synthesis.
•
Genotypes become phenotypes-environmental factors help determine which
genotypes are triggered into phenotypes and
thus developed and expressed as physical or
behavioral features of the personality.
•
Experience drives epigenic processess
Benjamin Kearney, Ph.D.
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Relationships Matter
June 20, 2013
The Neurobiological Process of
Attachment (cont.)
Memory• Implicit memory—present at birth and does not
require conscious processing during encoding
and retrieval
• Explicit memory -- a form of memory conscious
awareness for encoding, recall, sense of self
and time.
The Neurobiological Process of
Attachment (cont.)
EXPLICIT Memory Systems
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Benjamin Kearney, Ph.D.
Late Developing
Matures later with Hippocampus and Cortex
Cortical/Hippocampal Bias
Declarative
Organized by language
Visual Images
Organized within Episodes and Narratives
Conscious Organization of Experience
Construction of Narrative Self
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Relationships Matter
June 20, 2013
The Neurobiological Process of
Attachment (cont.)
IMPLICIT Memory System
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Early Development
Highly Functional at Birth
Subcortical/Amygdala Bias
Non-declarative
Emotional
Visceral/Sensory-Motor
Context Free
Procedural Learning
Behavior Patterns
The Neurobiological Process of
Attachment (cont.)
•
Benjamin Kearney, Ph.D.
Attachment system-- the inborn,
evolutionarily prescribed system that
organizes motivational, emotional, and
memory processes with respect to
significant caregivers.
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Relationships Matter
June 20, 2013
The Neurobiological Process of
Attachment (cont.)
•
Emotion-- The primary ingredient or
currency within the relationship between
self and attached objects. It is the
fundamental process that links arousal
with the appraisal of value or meaning.
The Neurobiological Process of
Attachment (cont.)
Representations
• Representations are mental process which
serve as the building blocks that permit
experiences to be linked to internal and
interpersonal worlds.
• The organization of these representations form a
network of interpretation and expectation as the
self relates to the external world.
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Relationships Matter
June 20, 2013
Top down/Bottom up processing
Divisions
• Neocortex
• Limbic System
• Diencephalon
• Brain stem
Functions
Cognitive: Abstract
thought, Concrete thought,
Affiliation
Emotional: attachment,
Sexual behavior, emotional
reactivity,
Motor: Motor regulation,
Arousal, appetite/satiety,
sleep
State: Blood pressure, heart
rate, body temperature
Bottom up processes
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Excitatory
Unrestrained
Reactive
Impulsive
Example: think of the crying six week old
baby who won’t eat, and can’t sleep
• These are necessary to assure survival—
this is all that the brain has time to mature
in utero
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Relationships Matter
June 20, 2013
Brain Structure
• The approach system is largely controlled by the
ventral striatum, avoidance system by the
amygdala and lastly, the regulatory system by
the prefrontal cortex.
• two key regions implicated in cognitive and
motivational behavior
– prefrontal cortex, known to be important for cognitive
control
– the striatum critical in detecting and learning about
novel and rewarding cues in the environment
• play a role in levels of excitement and positive affect when
receiving rewards, as well as the propensity for sensationseeking and risk-taking
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Relationships Matter
June 20, 2013
Brain Structure
Prefrontal Cortex:
• Holds the representation of goals and the means
to achieve them
• Requires the affective evaluation of short-term
goals vs. long-term goal: gratification delay
• Left side-approach related, appetite (more than
food) related---responsive to reward
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Relationships Matter
June 20, 2013
Brain Structure
Prefrontal Cortex (cont.):
• Right side-behavioral inhibition and
withdrawal---responsive to punishment
• Right prefrontal regions play a role in
negative affect
• Right posterior regions play a role in
arousal and anxiety
Brain Structure (cont.)
Hippocampus: (involved in left-right/top-down
processes)
• Involved in episodic, declarative, contextual
learning and memory (significantly word based
memory)
– If damaged, the information remains in the working
memory for a few seconds and then disappears—only
applies to facts and events, not new skills or
procedures
– Intelligence not impacted—memories themselves are
in the cortex, this just controls the process
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Relationships Matter
June 20, 2013
Brain Structure (cont.)
Hippocampus (cont.):
• Regulation of hormone secretion
• Significant role in evolutionary prescribed
freezing/shock responses
• Provides contextual learning and decoding
of behavioral information when presented
below level of conscious processing
Brain Structure (cont.)
Hippocampus (cont.):
• Late development—even through adolescence
– Very sensitive to development disruption
– Delayed functional availability
• Very impacted by glucocorticoids released by
stress
– Dendritic degeneration, decreased functioning and
cell death
– Impacted by TRAUMA--PTSD
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Relationships Matter
June 20, 2013
Brain Structure (cont.)
Amygdala: (involved in down-up/right-left
processes
• Influences the prefrontal and orbital frontal
cortex through direct output relays
• Directly linked to the hypothalamus with
extensive interconnections
• Influences drive related behavior and the
subjective feelings accompanying these
activities
Brain Structure (cont.)
Amygdala (cont.):
• Any somatic experience that is triggered by the
hypothalamus can be elicited by triggering the
Amygdala, but it is more “natural”---building up
slowly and then gradually decaying
• Directs attention to affectively important stimuli—
attention response appears to determining
whether a fear response should follow
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Relationships Matter
June 20, 2013
Brain Structure (cont.)
Amygdala (cont.):
• Calls for further processing of stimuli that have
major importance to individual
– Novel
– Surprising
– Ambiguous
• Therefore determines the emotional weight of
memory importance and then facilitates long
term memory storage with the hippocampus
Brain Structure (cont.)
• The amygdala sends impulses to the
hypothalamus for important activation of
the Sympathetic Nervous System
– Helps express fear by innervating the facial
nerves
– Activates the release of dopamine,
norepinephrine and epinephrine through out
the brain.
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Relationships Matter
June 20, 2013
Brain Structure (cont.)
Amygdala
• release stress hormone for fight/ flight
• 3 micro second alert to the
Hypothalamus– preconscious
• Then to the Hippocampus for categorizing
• then to the Cingulate Gyrus – and to the
prefrontal cortex for conscious elaboration
Amygdaloid Memory Networks
• At low levels of arousal, amygdala activation
supports hippocampal learning by boosting the
biochemical aspects of neural plasticity,
• At higher levels of arousal, the amygdala
stimulates HPA activation, which interrupts
hippocampal learning while supporting fearbased amygdala learning
• during states of high arousal, hippocampal and
amygdala networks become dissociated,
resulting in a disconnection between visceralemotional (amygdala) and declarative-conscious
(hippocampal) processing
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Relationships Matter
June 20, 2013
Neurotransmitters and
Neuromodulators
• Neurotransmitters are synthesized in the
neuron
– A mechanism in the neurons or the
synaptic cleft acts to remove or
deactivate the neurotransmitter
• Neuromodulators regulate the effects of
the neurotransmitters on receptor neurons
– hormones, testosterone, estrogen,
cortisol, and other steroids, amino acids
Neurotransmitters
•
Glutamate: The main excitatory transmitter,
whose task is to initiate neuronal firing,
involved in all brain functions, including
learning
•
GABA: most abundant inhibitory
transmitter in the brain, and it functions
as widely as glutamate.
glutamate and GABA—Responsible for
overall brain inhibition and excitation
•
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Relationships Matter
June 20, 2013
Neurotransmitters
Norepinephrine: mediates the alerting, arousal,
and efficiency of information processing
These control holistic aspects of the brain
functioning rather than discrete behavioral
processes.
• NE--controls higher brain activity…
• NE system sends inputs to the cortex,
hypothalamus, cerebellum, lower brain stem,
and spinal cord – exerting global control over
brain activity.
Neurotransmitters
Dopamine
• a key neurotransmitter in motor activity and
reward reinforcement
• Too much dopamine can result in mood
changes, increased motor behavior, and
disturbed frontal lobe functioning, which, in turn,
can cause depression, memory, impairment,
and apathy
• DA systems restrict their outputs to the limbic
system and frontal cortex
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Relationships Matter
June 20, 2013
Neurotransmitters
Norepinephrine
• key component of the emergency system of the
brain
• especially relevant for understanding stress and
trauma
• High levels result in anxiety, vigilance,
symptoms of panic, and a fight-flight response
• serves to enhance memory for stressful and
traumatic events.
Benjamin Kearney, Ph.D.
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Relationships Matter
June 20, 2013
Neurotransmitters
• serotonin systems--mediates central state
function
– All motivated and active emotional behaviors,
including feeding, drinking, sex, aggression, play, and
practically every other activity (except sleep)
– acts on certain receptors, emotional behaviors such
as anxiety increase, but when other receptors are
involved, emotionality is reduced
– operates on a vast number of receptors with
apparently very different functional properties.
• serotonin release can also controlled by local presynaptic
mechanism which determines which effect it will have
Neurotransmitters
• Cholinergic systems--have the ability to
control much of the brain’s activity
• appear to be executive systems for broad
psycho behavioral functions
– waking and attention
– important for sustaining higher information
processing
– facilitate information processing
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Relationships Matter
June 20, 2013
Neurotransmitters/
Neuromodulators
neuropeptides
– endorphins, enkephalins, oxytocin, vasopressin, and
neuropeptide-Y.
•
work together with neuromodulators to regulate pain,
pleasure, and reward systems
• Endogenous endorphins (endorphins produced by the
body) serve as an analgesic in states of physical pain.
• They are also involved with dissociation and self-abusive
behaviors.
Neurotransmitters/
Neuromodulators
Glucocorticoids/Cortisol
• At normal levels and over short periods,
cortisol enhances memory, mobilizes
energy, and helps to restore homeostasis
after stressful situations
• Glucocorticoids stimulate gluconeogenesis
– the breakdown of lipids and proteins to make
energy available for emergencies
– to fight or flee needs energy.
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Relationships Matter
June 20, 2013
Secure Attachment
Opiates
Dopamine
Stress Hormones, Regulators, &
Transmitters
Ambivalent Attachment
Opiates
Dopamine
Stress Hormones, Regulators, &
Transmitters
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Relationships Matter
June 20, 2013
Avoidant Attachment
Opiates
Dopamine
Stress Hormones, Regulators, &
Transmitters
Link between Neurotransmitters
and Affect—across mammals
• emotional instinctual behavior generating
systems are the fundamental substrates of
emotional feelings
• instinctual emotional behaviors indicate the
experience of certain basic affective sensations
– angry behaviors reflect angry feelings
– fearful behaviors reflect certain anxieties
– separation distress systems may help create
sadness.
• all basic emotions in the brain have dedicated
evolutionarily derived, circuits for the mediation
of certain core psycho-behavioral states
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Relationships Matter
June 20, 2013
SEEKING System:DA
• Animals ‘love’ to self activate – to self-stimulateit becomes addictive
• a basic, positively motivated action system that
helps mediate our desires, our foraging and
positive expectancies
– Not simply reinforcement
– Impacted cognitively, but driven sensorially through
affective arousal
– Food, water, safety, and sexual which produce goaldirected behavior.
– Cognitive processes attempt to mediate awareness
and appraisal
FEAR System—NE, E
• An energetic state of uptight trepidation-a
restrained shaking
– At a low level of stimulation produces a freeze
response
– At a high level of stimulation it produces an urge to
flee
• Affect is linked cognitively through learning
• Some fears are cross cultural—indicating
evolutionary prescription
– Rat and cats
– Primates and looming objects
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Relationships Matter
June 20, 2013
LUST System—test, oxy,opi
• sexual courtship and orientations are strongly
built into all mammals.
– Only humans can exercise extensive cognitive choice
• male and female sexual systems are laid down
early in gestating
• not brought fully into action until puberty
– maturing gonadal hormone secretions begin to spawn
male and female sexual desires.
• there is abundant plasticity to allow learning and
culture to promote a complexity
RAGE Systems—test, NE, Glut
• protects life-sustaining resources
• can be evoked by any of the variety of
situations where there is stiff competition
for resources
• triggered when other systems are overrun
• be aroused by restraint and frustration,
and fear
• When we do not get what we think we
really need to survive
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Relationships Matter
June 20, 2013
CARE System:oxi,opi,x-tst
• encourages parents, especially mothers,
obsessively and pleasurably to care for their
offspring
• The more devoted the care the stronger psychobehavioural resilience and competitiveness of
the next generation
– during pregnancy: peripheral oestrogen,
progesterone, prolactin and brain oxytocin figure
heavily
– exposure to young also sensitizes the CARE giving
circuitry.
CARE System
• males and females have such large
differences in CARE brain and body
systems
• males require more emotional education to
become fully nurturant, engaged
caretakers
• hormonally promoted sensitization of
CARE circuitry encourages all mammals
to respond supportively to their newborn
babies…
Benjamin Kearney, Ph.D.
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Relationships Matter
June 20, 2013
PANIC System:ne, e,glut,p, oxi-opi
• the feeling of social loss is that which
yields separation distress calls (crying) in
all mammalian species
– Children: cry out for care, have feelings of
sudden aloneness and distress
– Adults: sadness and grief
• drives us to create relationships of support
• panic attacks are activated because this
affective system is triggered
PLAY System: low opi, glut, -DA
• All mammals play!
• navigate social possibilities in joyous ways
• experience expectant process which
brings young animals the knowledge of
what is permitted within the community
– Teaches the impact of behavior
– Develops empathy
– Teaches behavioral limits
– Socializes youth
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Relationships Matter
June 20, 2013
Attachment
• These seven domains drive attachment
• Parental awareness of these affective
processes drive “mindfulness and
empathy”
Moral Emotions
• Moral Emotions—emotions that set the
rules for companionship and collaboration,
permit the translation of culture, language
and meaning
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Relationships Matter
June 20, 2013
Moral Emotional State
• Openness
– people being intertwined,
– open to others and to our own experiences,
– being real, connected, safe
• Mindfulness
– quiet reflection, an inner senses of security
– open yet present in the here and now—permitting
emotional integration
– being in the mind of another and having the mind of
another
Moral Emotional State
• Awareness
– of that which is healthy and which is
unhealthy,
– a sense more of coherence that just cohesive
(Siegel),
– cohesive permits the understanding of
behavior and emotion, but coherence permits
a purposefulness,
– an explanation, a reason,
– the loss of rigidity (not just shame for
shame’s sake)
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Relationships Matter
June 20, 2013
Moral Emotional State
• Emotional regulation
– The recognition or experience that one can
“feel” emotions and not have them
overwhelming,
– the experience of emotion itself does not
trigger relational anxiety,
– the capacity to tolerate shame and still be
“good enough”
Moral Emotional State
• Empathy
– the capacity to move out of having the mind of
another into having the mind of the emotional
experience of another,
– having the knowledge of how another feels
and permitting this knowledge to be
expressed verbally or non-verbally.
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Relationships Matter
June 20, 2013
Transformational Emotions
• The sense that the basic architect has been
remodeled—a deep structural change, not just
moving the furniture from room to room (Dan
Siegel),
• Diana Fosha—Emotions…when regulated and
processes to completion, can bring about
healing and lasting transformations.
• Capacity for transformation is fundamental to our
nature, a motivational force within us
Transformational Emotional
State
• Hope
– the capacity to believe in the alternative,
– to believe in the “possibly different”
– the placebo effect
• Altruism
– the willingness to give or share resources with others
at the expense of the giver,
– using one’s strengths and capacities for the greater
good Martin Seligman (positive psychology)
– seeking happiness through a meaningful life
Benjamin Kearney, Ph.D.
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Relationships Matter
June 20, 2013
Transformational Emotional
State
• Sympathy
– the capacity to move from empathy into action
(compassion),
– the willingness to be overwhelmed with emotion
beyond words and still be “OK”,
• Truth (Joy)
– experience is intense and deeply felt,
– knowing becomes gentle knowledge,
– capacity to reflect on one’s self, one’s world and one’s
experience
Transformational Emotional
State
• Narrative (Contentment)
– the capacity to move truth into words,
– to build a “story of experience and existence
with purpose, understanding, and comfort with
emotional expression,”
– a gentle wisdom
– an openness to the sacred is present
Benjamin Kearney, Ph.D.
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Relationships Matter
June 20, 2013
Story Subplots
Tension/Stres
s
Subplots & Themes
in a Novel
SP1
SP2
SP3
Them
e
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June 20, 2013
Biven, L. & Panksepp, J. (2012). The Archaeology
of the Mind: Neuroevolutionary Origins of Human
Emotions. New York: W.W. Norton & Company,
Inc.
Cozolino, L. (2010). The Neuroscience of
Psychotherapy: Healing the Social Brain (2nd ed.).
New York: W.W. Norton & Company, Inc.
Schore, A. N. (2012). The Science of the Art of
Psychotherapy. New York: W.W. Norton &
Company, Inc.
Siegel, D. (2012). Pocket Guide to Interpersonal
Neurobiology: An Integrative Handbook of the
Mind. New York: W.W. Norton & Company, Inc.
Stahl, S.M. (2013). Stahl’s Essential
Psychopharmacology: Neuroscientific Basis and
Practical Applications. New York: Cambridge
University Press.
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Steve Jewell, M.D.
Marjorie Cook
Alex Cook
Partnerships Amoung Youth, Families and Clinicians
June 20, 2013
PARTNERSHIPS AMONG YOUTH, FAMILIES AND CLINICIANS: SHARED DECISION MAKING FOR MEDICATION MANAGEMENT
Margaret Clark Morgan Foundation Forum
Relationships Matter: Stories of Healing Across a Lifetime
June 20, 2013
Rootstown, OH Presenters:
• Steve Jewell, M.D.
– Child & Adolescent Psychiatrist
– Medical Director of Child Guidance & Family Solutions, Akron, Ohio
• Marjorie Cook
– Parent
• Alex Cook
– Youth
– Youth Move Ohio 1
Partnerships Amoung Youth, Families and Clinicians
June 20, 2013
Agenda:
I. Role Play
 Medication management session with traditional/medical model of decision‐making II. Overview of Shared Decision‐Making (SDM)
III. Personal Reflections on SDM from perspective of:
 Parent
 Youth
 Clinician
IV. Role Play
 Medication management session with SDM
V. Discussion
ROLE PLAY
Medication management session with traditional/medical model of decision‐making 2
Partnerships Amoung Youth, Families and Clinicians
June 20, 2013
CONTEXT OF ROLE PLAY
• Alex is in treatment for severe anxiety & depression
• As part of his care a trial of Zoloft (sertraline) was recently started
• Three weeks ago at the last appointment Dr. Jewell increased the dose of Zoloft from 100 mg to 150 mg/day
• The agenda for today’s session is thus to assess the impact of that dose increase
OVERVIEW OF SHARED DECISION MAKING IN MENTAL HEALTH
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June 20, 2013
SDM & THE RECOVERY MOVEMENT
A number of key national reports emphasize the essential role of families & consumers in achieving positive outcomes…
SDM & THE RECOVERY MOVEMENT
• The report of the President’s New Freedom Commission on Mental Health (2003): – Called for mental health care to be consumer & family driven. 4
Partnerships Amoung Youth, Families and Clinicians
June 20, 2013
SDM & THE RECOVERY MOVEMENT
• SAMHSA’s National Consensus Statement on Mental Health Recovery (2006) – Among the 10 fundamental aspects of mental health care identified in that report were self‐
direction; individualized care; person‐centered care; as well as care that supports empowerment, individual responsibility, and recovery. SDM & THE RECOVERY MOVEMENT
• Two Institute of Medicine (IOM) reports:
– Crossing the Quality Chasm (2001), & Improving the Quality of Health Care for Mental & Substance‐Use Conditions (2006)
– Both emphasized a goal of understanding & honoring consumer preferences, & promoting fully shared decision‐making with providers to develop person‐centered treatment plans
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Partnerships Amoung Youth, Families and Clinicians
June 20, 2013
SDM & THE RECOVERY MOVEMENT
• The Action Plan of the Annapolis Coalition on the Behavioral Health Workforce (2007) – Included as its first goal “Significantly expand the role of individuals in recovery…to participate in, ultimately direct, or accept responsibility for their own care” SDM & THE RECOVERY MOVEMENT
• Recent documents from SAMHSA:
– Consumer‐Driven Care (2006), & Family‐ Driven Care, (2006) – Supported consumers & families in having the primary decision‐making role regarding mental health & related care offered & received. 6
Partnerships Amoung Youth, Families and Clinicians
June 20, 2013
SDM & HEALTHCARE REFORM
• SAMHSA is actively promoting the use of SDM in mental heath services
– July 2007 meeting of experts & stakeholders resulted in report: “SDM in Mental Health Care: Practice, Research, & Future Directions”
– Conclusion: “Shared decision‐making holds substantial promise to advance the goals of many initiatives focused on improving care and promoting recovery for persons with mental illnesses. Because it supports consumers’ self‐determination and their involvement in decisions about their care and aids consumers in identifying and advancing their values and preferences, SDM can also be viewed as a basic human right. In that light, the question is not whether to advance SDM, but how best to do so.”
SDM & HEALTHCARE REFORM
• The Affordable Care Act (ACA) specifically encourages greater use of shared decision making in health care. – Specifically, Section 3506 of the ACA aims to facilitate shared decision making.
• Primarily, it funds an independent entity that would develop consensus‐based standards and certify patient decision aids for use by federal health programs and other interested parties. • In addition, the secretary of health and human services is empowered to fund, through grants or contracts, the development and evaluation of these tools.
– The ACA also authorizes the Center for Medicare and Medicaid Innovation to test shared‐decision making models designed to improve patients’ and caregivers’ understanding of medical decisions and assist them in making informed care decisions.
– However, more than 2 years after enactment of the ACA, little has been done to promote shared decision making.
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Partnerships Amoung Youth, Families and Clinicians
June 20, 2013
DEFINING SDM
• There is no single, agreed‐upon definition
• Similar concepts also lack consistent definitions, including:
– Empowerment/engagement
• Consumer activation by acquiring needed knowledge & skills
– Person‐centered
• Focuses on the actions of the provider
– Self‐directed care or Self‐care management
• Focuses on the actions of the consumer
DEFINING SDM
• SDM can be defined as “an interactive, collaborative process between providers and consumers that is used to make health care decisions, in which at least two individuals work together as partners with mutual expertise (professional and experiential) to exchange information and clarify values in relation to options and thereby arrive at a discrete decision.” (SAMHSA, 2011)
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Partnerships Amoung Youth, Families and Clinicians
June 20, 2013
DEFINING SDM
• Key characteristics of SDM:
– At least two people, acting as partners, are involved. – Both partners take steps in sharing a treatment decision. – The two partners share information about treatment options. – The partners arrive at consensus regarding the preferred treatment options.
DEFINING SDM
• SDM process steps include:
1.
2.
3.
4.
5.
6.
7.
8.
9.
recognition that a decision needs to be made; identification of the partners in the process as equals; statement of options as equal; exchange of information on pros and cons of options; exploration of understanding and expectations; identifying preferences; negotiating options and concordance; sharing the decision; &, arranging follow‐up to evaluate decision‐making outcomes 9
Partnerships Amoung Youth, Families and Clinicians
June 20, 2013
GOALS OF SDM
• The objectives of SDM are improved communication, understanding, and decision‐
making.
• When SDM is used more information about consumer preferences, practices, and values emerge and are taken into consideration. • SDM should result in decisions that are more appropriate for individual consumers, and will lead to increased satisfaction and perhaps better health outcomes. GOALS OF SDM
• The clinician role in SDM is as “consultant” to the consumer/family, helping to provide information, discuss options, & clarify values & preferences
• As such, SDM can decrease the informational and power imbalance between the practitioner and the consumer • SDM ideally provides a supportive encounter in which the partners clarify their values and preferences
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Partnerships Amoung Youth, Families and Clinicians
June 20, 2013
BARRIERS TO SDM
• Some view the mere diagnosis of a psychiatric disorder as a barrier to the ability of the individual to successfully participate in SDM
• Involuntary or coercive treatment
• Service delivery system’s design
• Provider attitudes
• Consumer/family attitudes
• Lack of adequate time for the encounter
SDM & Medication management
• “Using medication is an active process that involves complex decision making and a chance to work through decisional conflicts.” • “It requires a partnership between two experts: the client and the practitioner.”
– “SDM & Medication Management in the Recovery Process”, Deegan et al, Psych Serv, Nov 2006
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Partnerships Amoung Youth, Families and Clinicians
June 20, 2013
SDM & Medication management
• Consumer:
– Expert on his/her current functioning, & his/her unique response to meds (both effects & side effects)
• Prescriber:
– Expert on the effects, side effects, & evidence base for use of the medications
• BOTH sets of expertise are essential to effective decision‐making & conflict resolution!
SDM & Medication management
• “Ideal” prescriber:
– Confident in his/her knowledge of the evidence base re: use of psychotropic medications; AND
– Willing to accept & acknowledge the consumer’s expertise re: • The unique impact (both positive & negative) of meds; & • Their control over the process.
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Partnerships Amoung Youth, Families and Clinicians
June 20, 2013
SDM & Medication management
• “Ideal” consumer:
– Confident in their ability to observe & communicate the effects & side effects of medication; AND
– Willing to accept & acknowledge the prescriber’s knowledge of the evidence base re: use of psychotropic medication.
SDM & Medication management
• Tensions are likely to develop when either:
– The prescriber is overconfident or lacking in confidence about their own knowledge base; &/OR not respectful of the family’s expertise; OR
– The consumer is overconfident or lacking in confidence about their knowledge of themselves; &/OR not respectful of the prescriber’s expertise.
• “Mutual humility” required
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Partnerships Amoung Youth, Families and Clinicians
June 20, 2013
SDM & Medication management
Common decisional conflicts:
Prescriber:
Consumer:
Meds are helping
Meds are controlling
Back to baseline
Not myself
Symptoms are controlled
Feeling ‘drugged’
SDM in child mental health
• Added complexities:
– There are THREE “experts”:
• Provider
• Family
• Youth
– The role of the youth in SDM varies depending on his/her developmental level.
• Dynamic, changing youth role over time, gradually shifting…
– From family making decisions with input from youth
– To youth making decisions with input from family, – Thereby can effectively prepare the youth to be an empowered consumer of behavioral health services as an adult!
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Partnerships Amoung Youth, Families and Clinicians
June 20, 2013
PERSONAL REFLECTIONS ON SDM
Parent perspective
Youth perspective
Provider perspective
ROLE PLAY
Medication management session with SDM
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Partnerships Amoung Youth, Families and Clinicians
June 20, 2013
CONTEXT OF ROLE PLAY
• Alex is in treatment for severe anxiety & depression
• As part of his care a trial of Zoloft (sertraline) was recently started
• Three weeks ago at the last appointment Dr. Jewell increased the dose of Zoloft from 100 mg to 150 mg/day
• The agenda for today’s session is thus to assess the impact of that dose increase
DISCUSSION
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Partnerships Amoung Youth, Families and Clinicians
June 20, 2013
Summary
• SDM is an interaction between two partners with mutual expertise (professional and experiential) • SDM promotes empowerment, person‐centered & self‐directed care
• SDM can improve communication, understanding, and decision‐making
• SDM can decrease the informational and power imbalance between the practitioner and the consumer
Summary
• SDM requires mutual respect & humility • SDM can be especially effective in medication management decision‐making
• SDM in child/adolescent mental health:
– Adds complexity (three experts)
– Requires dynamic response to shifting developmental level of youth (changing youth & family role over time)
– Can effectively prepare the youth to be an empowered consumer of behavioral health services as an adult! 17