Psychiatric Rehabilitation Journal 2015, Vol. 38, No. 3, 242–248

In the public domain http://dx.doi.org/10.1037/prj0000114

Consumer Satisfaction With Psychiatric Services: The Role of Shared Decision Making and the Therapeutic Relationship Elizabeth A. Klingaman

Deborah R. Medoff

VA Capitol Health Care Network, Baltimore, Maryland and University of Maryland School of Medicine

University of Maryland School of Medicine and VA Capitol Health Care Network, Baltimore, Maryland

Stephanie G. Park

Clayton H. Brown

University of Maryland

VA Capitol Health Care Network, Baltimore, Maryland and University of Maryland School of Medicine

Lijuan Fang

Lisa B. Dixon

University of Maryland School of Medicine

New York State Psychiatric Institute, New York, New York, and Columbia University

Samantha M. Hack

Stephanie L. Tapscott

VA Capitol Health Care Network, Baltimore, Maryland and University of Maryland School of Medicine

Emory University

Mary Brighid Walsh

Julie A. Kreyenbuhl

VA Capitol Health Care Network, Baltimore, Maryland

VA Capitol Health Care Network, Baltimore, Maryland and University of Maryland School of Medicine

Objective: Although dissatisfaction is a primary reason for disengagement from outpatient psychiatric care among consumers with serious mental illnesses, little is known about predictors of their satisfaction with medication management visits. The primary purpose of this study was to explore how dimensions of consumer preferences for shared decision making (i.e., preferences for obtaining knowledge about one’s mental illness, being offered and asked one’s opinion about treatment options, and involvement in treatment decisions) and the therapeutic relationship (i.e., positive collaboration and type of clinician input) were related to visit satisfaction. Methods: Participants were 228 Veterans with serious mental illnesses who completed a 19-item self-report questionnaire assessing satisfaction with visits to prescribers (524 assessments) immediately after visits. In this correlational design, a 3-level mixed model with the restricted maximum likelihood estimation procedure was used to examine shared decision-making preferences and therapeutic alliance as predictors of visit satisfaction. Results: Preferences for involvement in treatment decisions was the unique component of shared decision making associated with satisfaction, such that the more consumers desired involvement, the less satisfied they were. Positive

This article was published Online First February 9, 2015. Elizabeth A. Klingaman, PhD, Mental Illness Research, Education, and Clinical Center (MIRECC), VA Capitol Health Care Network (VISN 5), Baltimore, Maryland and Department of Psychiatry, University of Maryland School of Medicine; Deborah R. Medoff, PhD, Department of Psychiatry, University of Maryland School of Medicine and MIRECC, VA Capitol Health Care Network (VISN 5); Stephanie G. Park, PhD, Department of Psychology, University of Maryland; Clayton H. Brown, PhD, MIRECC, VA Capitol Health Care Network (VISN 5), and Department of Epidemiology and Public Health, University of Maryland School of Medicine; Lijuan Fang, MS, Department of Psychiatry, University of Maryland School of Medicine; Lisa B. Dixon, MD, MPH, New York State Psychiatric Institute, New York, New York, and Department of Psychiatry, Columbia University; Samantha M. Hack, PhD, MIRECC, VA Capitol Health Care Network (VISN 5), and Department of Psychiatry, University of Maryland School of Medicine; Stephanie L. Tapscott, MS, MSW, Department of Health Policy and Management, Emory University; Mary Brighid Walsh, MS, MIRECC, VA Capitol Health Care Network (VISN 5); Julie A. Kreyenbuhl, PhD, PharmD, MIRECC, VA

Capitol Health Care Network (VISN 5), and Department of Psychiatry, University of Maryland School of Medicine. Stephanie G. Park, PhD, is now at the MIRECC, VA Capitol Health Care Network (VISN 5), and Department of Psychiatry, University of Maryland School of Medicine. This research was supported by a U.S. Department of Veterans Affairs Health Services Research and Development Merit Award (IIR-07-256) and the Department of Veterans Affairs Office of Academic Affiliations Advanced Fellowship Program in Mental Illness Research and Treatment. It is the result of work supported with resources and the use of facilities at the VISN 5 MIRECC. Special thanks to Melanie Bennett for her contributions to this manuscript. This reflects the authors’ personal views and in no way represents the official view of the Department of Veterans Affairs of the U.S. Government. Correspondence concerning this article should be addressed to Elizabeth A. Klingaman, PhD, VA Maryland Health Care System, Baltimore VA Medical Center, 10 North Greene Street (Annex Suite 720), Baltimore, MD 21201. E-mail: [email protected] 242

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collaboration and prescriber input were associated with greater visit satisfaction. Conclusions and Implications for Practice: When consumers with serious mental illnesses express preferences to be involved in shared decision making, it may not be sufficient to only provide information and treatment options; prescribers should attend to consumers’ interest in involvement in actual treatment decisions. Assessment and tailoring of treatment approaches to consumer preferences for shared decision making should occur within the context of a strong therapeutic relationship. Keywords: satisfaction, shared decision making, therapeutic relationship, Veterans, serious mental illness Supplemental materials: http://dx.doi.org/10.1037/prj0000114.supp

Consumer-driven advocacy movements and national policy recommendations have led mental health care service systems to move toward a patient-centered model of service provision over the last decade. Consumers and their families have promoted a recovery model of care that emphasizes empowerment, hope, self-direction, personal responsibility, and mutual respect (Bellack, 2006). Meanwhile, the Surgeon General (Department of Health and Human Services, 1999) and the Institute of Medicine (2001) have stressed the need for mental health care agencies to prioritize rehabilitation and consumer rights. To deliver care to consumers with serious mental illnesses within a recovery model, providers and systems must actively elicit and act upon consumers’ preferences and self-identified needs. Consumer satisfaction has become an increasingly important metric by which health-care systems evaluate their success in delivering patient-centered care (Manary, Boulding, Staelin, & Glickman, 2013). One common definition of consumer satisfaction is a consumer’s evaluation of how well his or her “personal and emotional, as well as physical needs” are met (p. 45, Press, 2002). Health-care systems can meet these needs through improved continuity/convenience of care, access, and availability of services as well as through improved consumer-provider interactions when treatments are provided (Ware & Snyder, 1975). Research using qualitative interviews, survey data, and analyses of consumer-provider speech on a microlevel has identified factors that consumers value regarding satisfaction with interactions with providers (Roter, Hall, & Katz, 1987; Ruggeri et al., 2007; Urden, 2002). These can be grouped under two general headings: satisfaction with task orientation (e.g., the provider’s technical skills, competence, and/or expertise) and satisfaction with socioemotional support (e.g., courtesy, respect, and/or interpersonal skills; Bertakis, Roter, & Putnam, 1991; Cruz et al., 2011). Mental health care service satisfaction is related to better engagement in treatment and more positive recovery outcomes among consumers with serious mental illnesses (Lanfredi et al., 2014). Conversely, although satisfaction is linked to good outcomes, dissatisfaction is related to decreased rates of engagement in mental health care and more frequent dropout among those with serious mental illnesses (Kreyenbuhl, Nossel, & Dixon, 2009; Ruggeri et al., 2007). Rossi and colleagues (2002) found that outpatient mental health consumers who were less satisfied with provider skill and behaviors (i.e., “task orientation”) had 2.5 times the odds of dropping out after 3 months compared with those more satisfied. Finding ways to make mental health treatment visits positive and useful for consumers with serious mental illnesses is imperative. Chue (2006) reviewed 15 years of literature to identify 29 articles that examined predictors of patient satisfaction and treatment outcomes among consumers with schizophrenia. The review

found that numerous factors influence consumer satisfaction with outpatient mental health care, including medication side effect management, social support, life satisfaction, depression, and collaboration in treatment planning with mental health providers. More recent research shows that mental health consumers identify having a positive relationship with psychiatric providers as a highly valued element of successful health care (Shattell, Starr, & Thomas, 2007). Indeed, ratings of the therapeutic relationship strongly correlate with treatment satisfaction among consumers with serious mental illnesses (Roche, Madigan, Lyne, Feeney, & O’Donoghue, 2014). Shared decision making has also emerged as an important predictor of mental health treatment satisfaction among consumers with serious mental illnesses. Shared decision making is a process of collaboration between consumers and providers in which each person shares information, expertise, and preferences to develop a jointly agreed-upon treatment plan (Adams & Drake, 2006). Several studies found that a lack of shared decision making, particularly the lack of collaboration around sharing information and discussing options for treatment during visits to psychiatrists, is associated with lower treatment satisfaction (Chue, 2006). Recent research (Park, et al., 2014) highlights the importance of understanding consumer preferences for shared decision making during medication management visits, finding that consumers with serious mental illnesses vary in their preferences for shared decision making and preferences differ across various elements of shared decision making. That study used Levinson, Kao, Kuby, and Thisted’s (2005) model of preferences for shared decision making, which identifies three elements of consumer preferences: obtaining knowledge, being provided with and asked one’s opinion about treatment options, and making final treatment decisions. Because satisfaction is influenced by the degree to which consumers’ expectations are met (Urden, 2002), consumer preferences for shared decision making may be important predictors of satisfaction in conjunction with the shared decision making that actually occurs during treatment visits. Literature is lacking an in-depth exploration of how dimensions of the therapeutic relationship and preferences for shared decision making may jointly predict satisfaction with task orientation and socioemotional support within prescriber visits. Furthermore, ratings of satisfaction often take place long after the treatment visits in question, thus introducing potential recall bias (Manary et al., 2013). The purpose of the current study was to address these gaps by measuring consumer visit satisfaction immediately after visits with prescribers to investigate how the therapeutic relationship and preferences for shared decision making were related to satisfaction associated with each visit. We used a visit satisfaction measure that

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reflects satisfaction with task orientation and socioemotional support within the consumer-provider interaction. We hypothesized that both (a) preferences for all aspects of shared decision making and (b) therapeutic relationship quality would be associated with consumer satisfaction with prescriber visits.

Method Sample Data were drawn from a randomized controlled trial (RCT) examining a computerized intervention to assist Veterans with serious mental illnesses in receiving monitoring for the metabolic side effects of second-generation antipsychotic (SGA) medications. Control and intervention participants were included in this study. Participants (n ⫽ 239) were recruited from two VA outpatient mental health clinics in the U.S. Mid-Atlantic region. All were 18 –70 years of age; diagnosed with serious mental illnesses (schizophrenia, schizoaffective disorder, psychosis disorder not otherwise specified, bipolar disorder, major depressive disorder [MDD], or posttraumatic stress disorder [PTSD]); currently prescribed at least one SGA medication; and connected to care (had at least two outpatient visits with a prescribing psychiatrist/nurse practitioner [NP] in the past year). All participants provided informed consent. The local institutional review board approved the study.

Measures To assess visit satisfaction, we used a 19-item questionnaire based on an existing, validated measure of patient satisfaction (Bertakis et al., 1991). This measure is designed for use in conjunction with measures assessing patient-provider communication patterns in visit satisfaction research and is frequently used by Roter and colleagues to assess satisfaction with interactions between consumers and their doctors and/or nurses in outpatient care (Cousin, Schmid Mast, Roter, & Hall, 2012; Agha, Schapira, Laud, McNutt, & Roter, 2009; Schmid Mast, Hall, & Roter, 2007). The items are designed to capture patients’ satisfaction with interactions with their providers that occur during a specific visit and represent the domains of task orientation (11 items) and socioemotional support (8 items). Responses are rated on a 5-point scale (1 ⫽ strongly disagree to 5 ⫽ strongly agree), such that higher scores represent greater satisfaction with that visit. Example items representing task orientation and socioemotional support, respectively, are, “My doctor/NP was not as thorough as he or she should have been (reverse scored),” and “My doctor/NP was friendly and warm.” In the current study, responses on the task orientation, socioemotional support, and overall measure demonstrated excellent internal consistency (Cronbach’s ␣s ⫽ .93, .88, and .95, respectively). Psychiatric symptom severity over the past week was measured by the average score of the 24-item, self-report revised Behavior and Symptom Identification Scale (BASIS-24), which has demonstrated adequate validity within samples of people with serious mental illnesses (Eisen, Normand, Belanger, Spiro, & Esch, 2004). Responses are rated on a 5-point scale (0 – 4), with higher scores representing greater symptom severity. Therapeutic relationship quality was assessed by the three subscales of the 12-item, patient-

report Scale to Assess the Therapeutic Relationship (STAR-P; McGuire-Snieckus, McCabe, Catty, Hansson, & Priebe, 2007): positive collaboration, positive clinician input, and nonsupportive clinician input. The STAR-P was developed with input from consumers with serious mental illnesses to tap factors that they value most within mental health care and has demonstrated good validity (McGuire-Snieckus et al., 2007). Responses are rated on a 5-point scale (0 ⫽ never to 4 ⫽ always), with higher scores indicating higher relationship quality. To assess preferences for shared decision making, we used the three-item questionnaire that Levinson and colleagues (2005) developed to assess the three components of patient preferences for engaging in shared decision making in a mental health context: obtaining knowledge (“I prefer to rely on my provider’s knowledge and not try to find out about my mental illness on my own”), being provided with and asked one’s opinion about treatment options (“I prefer that my doctor/NP offers me choices and asks my opinion about treatments for my mental illness”), and making decisions (“I prefer to leave decisions about my mental health care up to my provider”). Responses are rated on a 6-point scale (1 ⫽ strongly agree to 6 ⫽ strongly disagree) such that higher scores indicate greater preference for involvement in that component of shared decision making.

Procedures The intervention (or control condition) was conducted immediately before each visit for up to three visits with the participant’s prescriber. The visits were at least 4 months apart over a 1-year period. Veterans had one to three exposures to the intervention or control condition, depending on their clinically scheduled visits (for frequencies, see Table 1). Because satisfaction was measured immediately after each appointment, this study only includes par-

Table 1 Sample Characteristics Characteristic Age Male Race White Black Multiracial American Indian or Alaskan Native Native Hawaiian or other Pacific Islander Married ⬎12 years education Diagnosis Schizophrenia spectrum Bipolar MDD PTSD BASIS-24a Provider type Psychiatrist NP Number of visits 1 2 3

N (%) or M (SD) 54 (8.3) 213 (89%) 113 (47%) 113 (47%) 9 (4%) 3 (1%) 1 (0.4%) 61 (26%) 134 (56%) 72 (30%) 76 (32%) 63 (26%) 28 (12%) 1.38 ⫾ .72 13 (62%) 8 (38%) 228 (95.4%) 193 (80.8%) 114 (47.4%)

Revised BASIS-24: range ⫽ 0 – 4; higher scores represent greater symptom severity.

a

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ticipants who had at least one visit (n ⫽ 228) and includes satisfaction data from each of the participants’ visits (n ⫽ 524 satisfaction assessments) regardless of intervention condition. Preferences for participating in decision making were also assessed at each visit. Demographics, mental health symptom severity in the last week, and therapeutic relationship with prescriber were only assessed at baseline, which was immediately after consent and not connected to a clinical visit.

Data Analysis To analyze all available data, the primary analysis model needed to account for two sources of clustering among observations: (a) repeated measures within individual and (b) multiple patients within provider. Therefore, we used a standard, basic, three-level mixed model (Singer, 1998) with separate random intercepts for patients and for providers to analyze the predictors of each of the two subscales of satisfaction. The repeated measurements of satisfaction (level 1) are nested within patients (level 2), which are nested within providers (level 3). Shared decision-making preferences assessed at each visit and therapeutic alliance (STAR-P) subscales assessed at baseline were the independent variables of interest. Covariates included diagnosis and psychiatric symptoms, race, education, sex, age, marital status, and provider type (psychiatrist vs. NP). Tolerance values (Cheng, Edwards, MaldonadoMolina, Komro, & Muller, 2010) were calculated to assess multicolinearity of predictors and none were below the recommended cutoff of .20 (Rovai, Baker, & Ponton, 2014); thus, it was decided that multicolinearity was not problematic for the current analysis. Intervention condition was not statistically significantly related to satisfaction or any of the independent variables of interest (p ⬎ .05), and when visit number and intervention condition were included in the initial model, they were not significant predictors of visit satisfaction; therefore, they were dropped from the final model. The model was fit using the Mixed Procedure in SAS with the restricted maximum likelihood (REML) estimation procedure.

Results Demographics and clinical characteristics are presented in Table 1. Most participants were middle-aged; male; unmarried; identified their race as either Black or White; and had schizophrenia spectrum disorder, bipolar disorder, or MDD. Participants reported low symptomatology on the BASIS-24. Most were seen by psychiatrists. Most individuals had two out of three possible visits; almost half had all three visits. Means, standard deviations, and correlations between key predictors of visit satisfaction are presented in the online Supplemental Table 1. Participants were generally satisfied with their prescriber visits and average STAR-P scores reflected a moderately strong therapeutic relationship. Responses to the shared decision-making preferences items of obtaining knowledge about one’s mental illness and being involved in treatment decisions were both approximately normally distributed; ranges covered the extent of the scale. Across all assessments, there was an overwhelming positive endorsement for being offered options and asked one’s opinion about mental health treatments; at 93.4% of visits, consumers were in agreement, endorsing responses 1, 2, or 3; and at 75.7% of visits, consumers strongly agreed, endorsing response 1. Because of the lack of variability in

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this component of preferences for shared decision making, it was not included in the model. Correlations between predictors ranged from .01 to .80. The subscales of the satisfaction measure were strongly correlated (see Supplemental Table 1), and results from the multilevel analyses were comparable for each (data not shown). Therefore, the two subscales were combined into an overall measure of consumer satisfaction to eliminate redundancy in the presentation of results. Table 2 depicts results from the multilevel analysis. Regarding the therapeutic relationship, positive clinician input and positive collaboration were both associated with greater visit satisfaction whereas nonsupportive clinician input was not. Regarding shared decision making, greater preference for being involved in the decision-making process was associated with lower visit satisfaction, but preference for relying on oneself versus the prescriber for obtaining knowledge about mental illness was unrelated to satisfaction. The only demographic or clinical characteristic related to visit satisfaction was marital status; married people were more satisfied.

Discussion This study provides important insights into the nature of satisfaction among Veteran consumers with serious mental illnesses. Participants were generally highly satisfied with medication management visits, consistent with research on satisfaction in other domains of medical care (Bertakis, Roter, & Putnam, 1991; Ruggeri, Lasalvia, Salvi, Cristofalo, Bonetto, & Tansella, 2007). Some researchers posit that consumers of medical services may not distinguish between their satisfaction with the task orientation and socioemotional aspects of their care (Avis, Bond, & Arthur, 1995). Indeed, we found that ratings of the task orientation and socioemotional subdomains of satisfaction were strongly correlated, indicating that these two subdomains of satisfaction overlap greatly for consumers with serious mental illnesses. We hypothesized that there would be a significant relationship between all aspects of shared decision-making preferences and visit satisfaction; this hypothesis was partially supported. Results reveal that the multidimensionality of preferences for shared decision making is a key to understanding satisfaction. The components of shared decision making assessed in this study included preferences for obtaining knowledge, being provided with and asked one’s opinion about mental health treatment options, and making decisions in a mental health context. We found that the more consumers preferred to partake in treatment decisions, the less satisfied they were with their visits. This is consistent with prior research among consumers with serious mental illnesses on inpatient units (Hamann et al., 2011) and raises the possibility of a mismatch between the level of involvement preferred by consumers and the degree to which they have these opportunities within visits. In other words, low satisfaction with the task orientation and socioemotional support of prescribers during medication management visits may signal a strong preference to be involved in treatment decisions. Prescribers should note that a high desire to participate in treatment decisions may also be a marker for lower satisfaction with care in not only inpatient settings (Hamann et al., 2011) but (also) in outpatient psychiatry. Likewise, there was a significant bivariate relation between preferences for seeking information about one’s mental illness and

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Table 2 Multilevel Analysis of Predictors of Visit Satisfaction Mean Ratings of Visit Satisfaction Predictor

␤ (SE)

df

T

Age Male White Currently married Some college or higher education Diagnosis (schizophrenia spectrum as reference) Bipolar MDD PTSD Provider type (psychiatrist vs. NP) BASIS-24a “I prefer to rely on my provider’s knowledge and not try to find out about my mental illness on my own”b “I prefer to leave decisions about my mental health care up to my provider”b STAR-P positive collaborationc STAR-P positive clinician inputd STAR-P nonsupportive clinician inpute

⬍.01 (⬍.01) .06 (.09) ⫺.01 (.05) .18 (.06) .10 (.05)

299 299 299 299 299

⫺0.56 ⫺0.64 ⫺0.14 ⫺3.04ⴱⴱ ⫺1.85

⬍.01 (.07) ⫺.07 (.07) ⫺.14 (.10) .01 (.06) ⫺.03 (.03)

299 299 299 299 299

⫺0.12 ⫺0.97 ⫺1.51 ⫺0.87 ⫺1.17

⬍.01 (.02)

299

⫺0.03

⫺.06 (.02) .15 (.04) .18 (.04) .01 (.03)

299 299 299 299

⫺3.07ⴱⴱ ⫺3.52ⴱⴱⴱ ⫺4.42ⴱⴱⴱ ⫺0.50

Note. Variance components. Unconditional model (not shown): total variance ⫽ .309, provider intercepts ⫽ .000, patient intercepts ⫽ .209, residual ⫽ .100. Final conditional model: total unexplained variance ⫽ .191, provider intercepts ⫽ .004; patient intercepts ⫽ .088; residual ⫽ .099, proportion of total variance explained ⫽ (.309 ⫺ .191)/.309 ⫽ .38, proportion of patient variance explained ⫽ (.209 ⫺ .088)/.209 ⫽ .58. a Revised BASIS-24; higher scores represent greater symptom severity. b Higher scores indicate greater preference for involvement in that component of shared decision making. c STAR-P positive collaboration; higher scores indicate higher perceived rapport, communication of goals, openness, and trust. d STAR-P positive clinician input; higher scores indicate greater perception that providers encourage, regard, support, listen to, and understand the client. e STAR-P nonsupportive clinician input; higher scores indicate less perception that the provider withholds the truth and is authoritarian and impatient. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.

satisfaction. As with preference for involvement in decisions, the more clients preferred to independently seek information, the lower their satisfaction. However, preference for seeking information was not a significant predictor in the regression model when preference for involvement in decisions was included, suggesting that preference for involvement in actual decisions is the unique component of shared decision making that contributes to satisfaction among consumers with serious mental illnesses. In other words, if consumers do express a desire to share in the decisionmaking process, it is not sufficient to only provide them with information; it is necessary to assess and attend to consumers’ interest in involvement in final decisions. We were not able to assess the association between preferences for being provided with treatment options and satisfaction because such preferences were nearly universally preferred in our sample. Therefore, we found partial support for the hypothesis that there would be a significant relationship between all aspects of shared decisionmaking preferences and visit satisfaction. One RCT failed to find a significant effect of increasing shared decision making on satisfaction, but it narrowly defined shared decision making as increasing consumer knowledge about treatment options (Hamann et al., 2006). Our research highlights that consumer preferences for involvement in the treatment decisions themselves are an additional important factor. Results support prior literature on some aspects of the consumerprovider therapeutic relationship as they relate to satisfaction and provide partial support for our hypothesis that relationship quality

would be significantly related to visit satisfaction. Consistent with research on elements of the relationship valued by consumers with serious mental illnesses (McGuire-Snieckus et al., 2007), greater collaboration in communicating about tasks and goals and supportive interactions with prescribers each predicted greater satisfaction with the task orientation and socioemotional support experienced during visits. However, our results reflect the complexity of therapeutic relationships by highlighting an important nuance: Nonsupportive clinician input was unrelated to satisfaction. It may be that items that tapped this construct, such as impatience and sternness, are less relevant for consumers in relationships with medication providers than in other contexts, such as psychotherapy. Instead, the more task-oriented constructs of collaboration and positive clinician input may be more salient in a visit to one’s prescriber. Finally, marital status predicted satisfaction, such that married participants were more satisfied than unmarried participants. This is consistent with trends observed in health-care satisfaction research, which also identifies marital status as a sociodemographic predictor associated with patient satisfaction with medical care (Hall & Dornan, 1990). Of note, this was the only consumer characteristic related to visit satisfaction in the regression model.

Limitations Dimensions of preferences for shared decision making measured in this study do not completely correspond to each domain of

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enacted shared decision making (unmeasured in this study; Adams & Drake, 2006); future research should consider how stated preferences for shared decision making relate to behaviors. Other factors that may contribute to satisfaction among consumers should also be considered in future research, such as comorbidities, financial strain, and participation in psychosocial therapy (Kilbourne et al., 2006; Nordon, Rouillon, Barry, Gasquet, & Falissard, 2012). Prescriber training and encouragement to use shared decision making in daily practice and length of treatment relationship were unmeasured and should be explored in future studies. Preferences for shared decision making and satisfaction were assessed at the same point in time, which precludes causal interpretations. Most consumers were engaged in care and were generally satisfied with visits; therefore, results do not necessarily generalize to consumers who disengaged from care, potentially because of treatment dissatisfaction. Nevertheless, we were able to gain a more in-depth understanding of how preferences for shared decision making are related to satisfaction within a homogenous sample of consumers with serious mental illnesses engaged in treatment. It is unknown how findings generalize to consumers prescribed psychotropic medications other than SGAs. The sample was predominantly older, male Veterans who may be accustomed to hierarchical relationships in the military and possibly with their prescribers. This research can inform future studies that should explore the relationship between these constructs within other populations.

Conclusions Consumers with serious mental illnesses want more than just collaboration and positive input from their prescribers; preference for arriving at a joint agreement about treatment is an additional factor related to visit satisfaction. The impetus to engage in shared decision making within a recovery-oriented model of mental health care is ethical and therapeutic. Although all providers are obligated to distance themselves from the paternalistic care previously provided to people with serious mental illnesses, aligning treatment approaches to the needs of consumers by understanding and respecting their desires to be involved in making the ultimate decisions about their treatment also has potential to optimally enhance satisfaction with psychiatric services. Results also suggest that preferences for shared decision making must be considered in conjunction with the therapeutic relationship. The relationship may serve as an important foundation to cultivating a shared decisionmaking process that is satisfactory and effective in enhancing empowerment and engagement in decisions. Future RCTs could assess whether optimizing shared decision making in the context of high-quality consumer–prescriber relationships increases satisfaction and whether satisfaction in turn increases adherence, engagement, and (ultimately) recovery.

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Received June 30, 2014 Revision received November 18, 2014 Accepted November 18, 2014 䡲