American Journal of Psychiatric Rehabilitation, 17: 348–364, 2014

Copyright # Taylor & Francis Group, LLC

ISSN: 1548-7768 print=1548-7776 online
DOI: 10.1080/15487768.2014.903877

Veterans’ Views of a Shared

Decision-Making Process: A
Qualitative Substudy of REORDER
Deborah Gioia
University of Maryland, Baltimore, School of Social
Work, Baltimore, Maryland, USA

Sophia Autrey and Amy L. Drapalski

VA Capitol Network Mental Illness Research Education
and Clinical Center (MIRECC), Baltimore, Maryland, USA

Shirley Glynn and Amy N. Cohen

Greater Los Angeles VA Healthcare Center, Department
of Psychiatry and Biobehavioral Sciences, Semel
Institute, University of California, Los Angeles (UCLA),
Los Angeles, California, USA

Lisa B. Dixon
VA Capitol Network Mental Illness Research Education
and Clinical Center (MIRECC), New York State
Psychiatric Institute, Columbia University, New York,
New York, USA

The Recovery-Oriented Decisions for Relatives’ Support (REORDER) inter-

vention is an innovative, manualized protocol utilizing shared decision-making
principles with military veterans who have serious mental illnesses to promote
recovery and encourage consideration of family involvement in care. This

Address correspondence to Deborah Gioia, PhD, University of Maryland, Baltimore,

School of Social Work, 525 W. Redwood St., Baltimore, MD 21201, USA. E-mail:
dgioia@ssw.umaryland.edu

348
 Veterans’ Views of a Shared Decision-Making Process 349

treatment study by Dixon et al. (2014) compared REORDER to enhanced treat-

ment as usual in a randomized design. This qualitative sub-study sought to
understand the nuances of the decision-making process of including family
members through in-depth interviews with veterans who were randomized
to REORDER. The qualitative themes support the willingness of the inter-
viewed veterans who have previously not included family members to situate
themselves at the center of their care and deliberate through facilitated conver-
sation, the pros and cons of involving family. REORDER brings a fresh perspec-
tive to adapting recovery principles into family-based interventions.

Keywords: Shared decision-making; Social support; Veterans

INTRODUCTION

Shared decision-making (SDM) is a clinical model that helps to

bridge empirical evidence about a mental health treatment or medi-
cation choice for consumers, with the unique concerns, values, and
life context of the individual client (NIMH, 2010; Deegan & Drake,
2006). It has been utilized with persons with serious mental illness
being treated in the public mental health system (Woltmann &
Whitley, 2010; Drake. Deegan, & Rapp, 2010), and it sometimes
includes the use of online decision support tools (Andrews, Drake,
Haslett, & Munusamy, 2010). According to Drake & Deegan (2009),
SDM is viewed as ‘‘an ethical imperative’’ to offer consumers
opportunities to weigh information and express preferences in
the range of treatment options, although specific questions about
how to operationalize the SDM process for different population
groups remain (Mahone et al, 2011; Edwards & Elwyn, 2006).
SDM is a transactional model that involves weighing trade-offs
among options in collaboration with a skilled facilitator to arrive
at an informed decision (O’Connor et al., 2007).
Despite emerging notions about clients’ inclusion in decision
making around pertinent issues in their mental health recovery as
optimal, consumer preferences are not routinely solicited, nor do
individual consumers have adequate opportunities to engage in
decision making with a skilled facilitator (SAMHSA, 2013; National
Research Council, 2001).The basic intent of using an SDM model is
that, through client-provider partnerships, shared expertise can
facilitate more durable client-centered goals, and evidence from
the literature suggests that SDM can directly improve client out-
comes, including engagement in treatment (Kreyenbuhl, Nossel,
& Dixon, 2009).
350 D. Gioia et al.

Recovery-oriented decision-making for relatives’ support

(REORDER) is an innovative, manualized, brief program that
includes an initial SDM process designed to promote recovery
and help the consumer systematically consider family (family is
used generically and includes any veteran-designated, social-
support person) involvement in REORDER (Dixon et al., 2014).
There are two phases in REORDER: (1) The individual consumer
phase consists of up to three 50-minute sessions led by a trained
REORDER clinician wherein considering the role of family in care
is the main focus; and (2) The family phase consists of up to three
50-minute sessions with the REORDER clinician, consumer, and
family member and focuses on education, support, and strategies
to promote the consumer’s recovery goals (Dixon et al., 2014).
Participation in our randomized controlled trial of REORDER
required only willingness to discuss family involvement; consent
to family involvement was not required (Dixon et al., 2014). The
REORDER clinician discusses family involvement in care guided
by attention to the consumer’s goals and how the consumer views
the potential benefits or drawbacks to such involvement. If the con-
sumer wishes, he or she invites the family member to meet with the
REORDER clinician: the relative then makes a parallel decision
about whether the involvement is desirable and practical from his
or her perspective.
This completed, randomized treatment study (Dixon et al., 2014;
Cohen et al., 2013) comparing REORDER with enhanced treatment
as usual is the basis for this qualitative study. We asked some veter-
ans who were randomized to the REORDER intervention, specific
questions about their involvement with the REORDER clinician
and the SDM process. REORDER recruitment criteria targeted
veterans who had initial low rates of family involvement in their
mental health care, as demonstrated by family members who had
not been enrolled in a family psychoeducational group nor had
monthly contact with the veteran’s clinician during the 6 months
before recruitment. Dixon et al. (2014) had significant study
findings in three key areas: (1) more than half the Veterans in the
REORDER condition were able to successfully invite family mem-
bers to attend at least one family session, which demonstrated
increased family engagement and family contacts with the
REORDER clinicians; (2) veterans assigned to the REORDER con-
dition self-reported improved outcomes related to recovery,
especially the ability to ask for help when needed, compared with
 Veterans’ Views of a Shared Decision-Making Process 351

enhanced treatment as usual; and (3) a decrease in self-reported

psychiatric symptoms, specifically paranoid ideation. This qualitat-
ive study sought to contextualize these findings from the main
study in a smaller sample of veterans who successfully invited fam-
ily to the intervention through use of interview methods that allow
the veterans to reflect on their engagement in REORDER and the
changes they experienced as a result of participation.

METHODS

Recruitment
After veterans and their family members finished the full REORDER
study, including a 6-month follow-up, they were referred for an
additional qualitative interview if they had completed at least one
family session. The qualitative study was framed to the veteran
as an opportunity for him or her to provide feedback about the
REORDER intervention to neutral interviewers who had not been
involved in the main study. The aim of this qualitative research
was to be descriptive and exploratory around key components of
the study processes.
Even though the randomized trial included participants from VA
Greater Los Angeles as well, only Greater Baltimore-area veterans
were included as possible referrals for the qualitative study because
of the physical location of the qualitative interviewers. The inter-
views took place from 2009 to 2011. Out of the 111 veterans in the
main study who were randomized to the REORDER intervention,
a total of 56 from two Baltimore area VA facilities (Baltimore and
Perry Point) had relatives who participated in the family sessions.
These individuals were informed at consent that they may be
contacted for a one-time qualitative interview. Delays in starting the
qualitative study resulted in the decision not to contact veterans with
family sessions completed in the first year of the main study, because
more than a year had elapsed since completion of the 6-month
follow-up, and recall of their participation might be an issue.
Twenty-four veterans were contacted by the team to set up an
in-person interview—one refused, one did not show up, and two
were referred but had very poor recall over the phone screening
about their study participation, so were excluded. Twenty qualita-
tive interviews were completed at the VA and those 20 interviews
were transcribed and analyzed. These veterans appeared to have
352 D. Gioia et al.

good recall about participating in REORDER, and 19 of the 20 had

two or three family sessions (by phone or in-person) to discuss.
To understand veteran’s interview responses regarding shared
decision making inherent in REORDER, several details of the
REORDER process need to be emphasized. Once the veteran was
enrolled, the task of the REORDER facilitator was to situate the
veteran at the center of their care, accentuate the value of asserting
a preference, and empower them to deliberate through conversation,
the pros and cons of the decision to involve someone in the brief
family education available to them—all part of SDM. Although
veterans could invite multiple individuals, the majority invited
one person. If they decided against including family or there was
no family member available, REORDER was complete at the end
of the individual phase. If a decision was made to invite family,
the veterans were the ones who did the inviting. Ultimately, this
complex decision rested with the veterans’ weighing knowledge
of their family’s circumstances, whether they wanted their family
more involved in their mental health care and whether they were
willing to take the risk to invite them.
The qualitative study was approved by the University of
Maryland Internal Review Board and the VA Maryland Health
Care System Research and Development Office.

Sample Demographics
Eighteen of the participants in the qualitative study were male, 11
were Black, and on average participants were in their early 50 s
(52.9  6.8). Ten of the veterans were diagnosed with bipolar
disorder, six with schizophrenia, and the remaining four with
schizoaffective or depression with psychotic features. As part of
the inclusion criteria for the study, all participants had some degree
of contact with their families, but their families were having little or
no contact with the treatment team. Fourteen were unmarried and
16 had children. Most of the veterans (19 out of 20) were not
gainfully employed.

Interview Procedures
A single, semistructured qualitative interview was completed at the
VA with the veterans. The interview, which lasted approximately
 Veterans’ Views of a Shared Decision-Making Process 353

60 minutes, was further described to the veteran during their con-

sent process as an opportunity to provide independent feedback
about their involvement in REORDER and the decision to include
family. Veteran interview guides were developed to capture the
following phases of REORDER: (1) individual sessions with
REORDER clinician including the shared decision-making skills
around family engagement, (2) inviting family member(s), (3) con-
tent and reflections on family sessions, (4) observed communication
change with family or health professionals noticed by the veteran as
a result of involvement, and (5) overall reflections about REORDER.
The interview guide can be obtained from study author D.G. who,
along with S.A., conducted all the interviews in person at the
Baltimore or Perry Point VA medical centers. Veterans received a
$25 voucher for the interview.

Data Analysis Procedures

All interviews were audio-recorded and transcribed in order to be
imported into NVivo 9 (2010), a qualitative, data-analysis software
program. Listening to the original recording and checking the
transcription for accuracy was a primary task during initial data
analysis. Impressionistic memos were completed immediately after
the interviews and were used in data-analysis discussions. The
interview guide served as the de facto template for data analysis
mainly because the interview was structured to provide detail
about particular components of the intervention.
De-identified transcripts were numbered for retrieval and coded
by both interviewers. Verbatim quotes were placed in a grid that
mirrored the interview guide where emerging themes from par-
ticipant responses could be viewed, compared, contrasted, and dis-
cussed. By using a grid as a visual tool, novel comments and
themes that did not easily fit with the rest of the data could be seen
by the researchers.
Template analysis is an organizing style that assists the resear-
cher in sorting data by similar text segments and coding the data
to develop patterns and themes around the structure of the inter-
view guide questions. Miles, Huberman, & Saldana (2013) provide
guidance for coding text by developing practical codes that are
directly related to the research questions, while remaining open
to the serendipitous finding in a participant response that is not
directly linked to the interview questions. Due to the small sample
354 D. Gioia et al.

size, codes were not counted, as can sometimes be the case in

template analysis in order to reflect code density. Rather, the coding
process was interpretive and based mainly on examining similar
content and language across the developing themes. This meant
that there was an emergent nature to the analysis—repeated
readings of the transcript and efforts to understand the essence of
the responses—rather than applying a derived code from the guide
to all the responses.
The narrative data in this study are displayed in the findings
section by inserting direct quotes from the veterans in their entirety,
or in fragments, into each theme. Labeling of categories is the
researchers’ construction and best representation of the responses.
The researchers acknowledge their bias in the interpretation of the
veteran’s feedback to the interview guide questions which they
developed, and they have arranged the themes broadly knowing that
some specific veteran’s sentiments may have been lost in the process
and others have been prioritized because of their salience to the query.

FINDINGS

The following themes were derived directly from the template

analysis of the questions in the interview guide with the procedures
described above.

Shared Decision-Making
The narrative results indicated that a main dialectic for the veteran
and the REORDER clinician seemed to be exploring the tension
between including family as a benefit to them and weighing the
burden of including family.

Benefit
There were several benefits reported. Most of the veterans expressed
that it was a ‘‘plus’’ to have the person closest to them know the
warning signs of relapse and that they were pleased that the VA was
moving in this direction of including family. One veteran expressed
that family involvement is the ‘‘key to understanding’’ one’s mental
health conditions, but had previously felt that involving family was
‘‘only for physical health care’’ and had not considered involvement
in his mental health care prior to the intervention.
 Veterans’ Views of a Shared Decision-Making Process 355

Another stated that when he invited his family member and she
agreed, ‘‘it showed she cared and the meetings basically let me
know how she was feeling about things.’’ Involving family was
seen as a means to ‘‘rebuild one’s life’’ with these connections
and provide some social support insurance that one not ‘‘go into
the psych ward again.’’
When the person chosen was a spouse or partner, there was an
expressed tone of gratitude and mutuality. ‘‘I had more of an
understanding [when my spouse was involved] of my mental
health, and my medication, and the effectiveness of both,’’ declared
one married veteran.
A veteran who loved the idea of the study when he first heard
about it, said he got involved, ‘‘because I think it’s important for
family members to be involved in it [mental health care]. Otherwise
they will just feel more alienated, you know, because understanding
is the key to knowing.’’

Burden
Some veterans expressed worry that inviting family members
might place a burden on them. There was deliberation about which
family member would be suitable and ‘‘strong enough’’ to invite to
the sessions.
One veteran deliberated this idea of emotional ‘‘strength’’ of
their relatives and then invited them with the support of the
SDM process and found that ‘‘it went better than expected.’’

The only person I could think of was my mother in [a city far from the
Veteran’s home] but she was already overextended with my brother and
sister who are disabled. But I called her and, to my surprise, she said
yes. But my main concern was that she would be overwhelmed. The big
thing was . . . I didn’t want to burden anyone and part of me wondered
if anyone would want to be bothered. I don’t usually like to talk about
[the illness]. . . . Actually, I try not to talk about it.

Identity
Older, male veterans, in particular, wanted to see themselves as
the provider rather than someone to worry about. One male stated,
‘‘Veterans are trained to take care of problems, and deal with prob-
lems, and overcome problems, and suppress, don’t worry about
356 D. Gioia et al.

problems . . . ’’ And another veteran stated, ‘‘It’s harder for men, we

have that cave-man image.’’ And another,

I’m 53 years old and when I came up, men didn’t talk about certain things.
My father’s the type of person where if you cried, you showed weakness. If
you even talk about certain things you weren’t supposed to, it really
showed that you was weak.

Vulnerability
Even with the assistance of the REORDER clinician, one veteran
said he did hold some things back during sessions because he
did not want to present these things in front of family members.
Another stated how he held things back: ‘‘I didn’t want anyone
in my family knowing about my business, feeling sorry for me,
worrying about me, driving me crazy about it.’’
In response to a question about whether a male veteran brought
up all the things he wanted to in the family sessions, he stated that
he didn’t because ‘‘I don’t want to start a whole lot of stuff’’ in his
family wherein it was typical not to communicate very much except
on holidays.

Content and Delivery of the REORDER Sessions

Communication Challenges
In some cases, the family sessions were held using a conference
phone call to join the family with the REORDER facilitator and
the veteran in a VA office. This occurred primarily when a family
member lived too far away or was too ill to come to the VA. One
veteran expressed a preference for face-to-face meetings because
of his tendency to drift off during phone meetings with family
members. Another veteran was unfazed by the type of delivery
and stated, ‘‘Mom liked phone or in-person. She just loves to talk.’’
Because the first REORDER family session did not include the
veteran, several stated that they wished they had attended because
they were confused about what got communicated.
‘‘And then after that [the REORDER facilitator] had a meeting
with my mom by herself without me being in the room. I don’t
know what her and my mother discussed.’’ And another veteran
responded, ‘‘I don’t know what her and the lady discussed because
they had their own meeting.’’
 Veterans’ Views of a Shared Decision-Making Process 357

Content of REORDER Family Education Sessions

Many of the veterans had received mental illness education over the
course of their connection with the VA and other mental health
agencies in the community, and they did not feel that this inter-
vention provided anything particularly new for them—only new
for the family, who had not been connected to their care. This was
phrased generally as criticism of REORDER, however, as one veteran
stated, ‘‘I already knew what was wrong with me but was happy
that my [family member] wanted to learn more.’’ And another,
‘‘Understanding the illness helps . . . because she sees the signs of
it. . . . I think I’m doing OK, but a person that’s looking from the
outside in can see it.’’
Some veterans expressed that they can always benefit from
reviewing illness education because there are ‘‘always new things
to learn,’’ but some veterans wanted advanced illness information
of a type that is more specific to them and their disorder. ‘‘I already
had this education . . .. I’m thinking this doesn’t really concern me.’’
This was particularly true for veterans who are now older and have
changing health conditions in addition to their mental illness.
One veteran who did not have immediate family chose his
neighbor. He had hoped that inasmuch as this neighbor did not
know him very well that the REORDER clinician might be able to
provide some key elements of the veteran’s mental health history
to the neighbor that he would not be able to do on his own. He
wanted to use the opportunity of the study to open up communi-
cation. He felt that the neighbor learned a little from the brief inter-
vention, but that ‘‘it would be impossible to learn about his entire
lifetime of mental health problems.’’

Relationship With the REORDER Clinician During

the Intervention
Benefit
It was unanimous that the veterans expressed favorable regard for
their REORDER clinician (there were five). They found this person
to be easy to talk to, encouraging, and an important support for
them. The sessions themselves were easy and not pressured, and
in general they wished that there had been more sessions to attend.
‘‘She was good . . .. She made it easy to talk.’’ ‘‘We had somewhere
to turn,’’ stated a married veteran who had included his spouse.
Being involved helped them to get referrals for therapists they
358 D. Gioia et al.

could be comfortable with as a couple. ‘‘Ask and you shall receive,’’

was their statement. ‘‘The people who are trying to decide how to
give the right kind of help need to hear from the people who need
the help,’’ emphasized another veteran.

Barriers or Challenges to Family Involvement

Realism
When asked about challenges to this model of family involvement
and what they might like to see for the future, one veteran replied
by saying, ‘‘Families can only do so much,’’ and, as older adults,
they may not want their families as deeply involved in their mental
health decisions as they might have when they were younger.
Many of these veterans have their own offspring but only one
veteran we interviewed chose a son or daughter for REORDER,
and it may have been because this veteran had suffered a stroke
and the son was assisting him with his physical needs. There was
expressed a possibility of feeling further stigmatized in the family
due to the disclosure and invitation to participate in REORDER.
‘‘We don’t talk about things in my family’’ was a familiar comment.

Self-Protection
Some veterans expressed a specific desire to keep family members
out of mental health decisions, perhaps to limit their involvement
in some way despite weighing the pros and cons of family involve-
ment with the REORDER clinician. Other veterans wanted involve-
ment with someone who knew their situation but did not want to
invite additional pain or disparagement:

I might have invited my biological mother but she wouldn’t have taken it
seriously. My stepmother did come . . .. It would be helpful to get the other
family members involved if they would just understand what the other
person [the veteran] is feeling and don’t put them down . . . or make them
feel sorry for themselves.

Ongoing Family Communication/Behavioral Changes

Talking With Family Members After the Intervention
There were mixed responses on whether communication increased
between veterans and their family members after REORDER. Some
 Veterans’ Views of a Shared Decision-Making Process 359

said that they did not really notice any kind of change in their fam-
ily, while others did notice some differences. One veteran said that
he had started to talk to remaining family members who were not
involved in REORDER and he now ‘‘realizes it is not healthy to
hold things in. It’s like something fell off me—I had a burden on
me and it’s just gone away.’’ Another veteran said that ‘‘it’s not
only the bad things that your family needs to know, but you can
let your family know when you are in a good place in your
recovery.’’

Suggestions for Improvements to Care

Finally, there was a general feeling that REORDER signaled that the
VA is sending a positive message that they want to get families
involved in veterans’ care no matter what their age. In general,
the veterans liked this new direction for themselves, especially the
young veterans who are currently returning from Iraq and Afghani-
stan. They seem to sense that involving families early would be the
right thing to do even if early involvement had not happened for
them. One veteran offers this testimony:

It taught me responsibility for myself and it taught me responsibility for

others and it taught me how to speak my mind and to be focused on any
given situation. It taught me communication because I used to be shy . . ..
I’m starting to get out of it.

Discussion and Areas for Future Study

Understanding first-person accounts of participants in randomized
controlled trials is becoming an important component of many
studies, and whether that understanding is obtained before, during,
or after the study ends varies by study (Lewin, Glenton, & Oxman,
2009). Qualitative research participants often feel privileged to share
these views, speak freely about their experiences, and ultimately feel
like a stronger part of the study processes. According to Stanhope
(2012), ‘‘The bottom line for the success of any intervention in mental
health care services is the commitment that the majority of involved
stakeholders have to its existence.’’ The participatory benefit of shar-
ing feedback about REORDER was evident in the tone and quality of
the shared narratives of the veterans in this substudy.
Shared decision-making is a means to respectfully engage veter-
ans in exploring their preferences, in this case, for including family
360 D. Gioia et al.

members not formerly involved in their care. Cohen et al. (2013)

assessed in the baseline preferences paper that 78% of the veterans
in the main REORDER study desired family involvement in their
care. Veterans in the qualitative study spoke openly about the ben-
efits and challenges of REORDER, and we began to understand
some of the answers to how families can get engaged with the
REORDER clinician, nurturing the desire for and the invitation to
family from the veteran to be involved. Knowledge and use of
the tools of shared decision-making by the veterans seemed to
make a difference in offering clear steps to the deliberation around
including family in their mental health treatment. It utilized ambiv-
alence in a constructive manner and there was no judgment made
toward veterans who decided there was no family to invite. The
support of a trusted REORDER clinician made the asking of family
members by the veterans a more conscious and deliberate act,
which they were able to practice in the individual sessions and
carry out by themselves.
The qualitative findings remind us that we need to consider the
issue of perceived burden on family thoroughly, as this was a fre-
quently described outcome of the deliberation process. Family
strength, which was brought up by at least one veteran, is a unique
and interesting dimension to explore in the REORDER deliberation.
Age, culture, and identity issues should also be taken into account
in the SDM deliberative process. The older male veteran shared
a particular sense of perceived burden in making the request for
family to join the family phase of REORDER that seemed to change
their sense of identity from one who seeks help to one who provides
it. The notion of ‘‘family’’ can be further expanded to include
extended relatives, neighbors, support group members (AA, NA),
dependent children, and perhaps others in congregate living
situations with the veteran. It is possible that the SDM process, when
used by mental health clinicians who have had a longer history
with the veterans than the six sessions that REORDER clinicians
had in this study might provide additional ideas for social
contacts. By continually placing the opportunity to express
preference at the center of the veterans’ care, providing decisional
tools, and empowering them to act on their choices, a more expanded
network of supportive individuals and improved recovery outcomes
may emerge.
Overall, the qualitative findings revealed that there was a high
degree of receptivity for this type of brief manualized intervention
 Veterans’ Views of a Shared Decision-Making Process 361

at the VA, even among older veterans whose families had not been
involved in care prior to the study. REORDER is the first study of
its kind to utilize SDM with veterans in this manner. Veterans
spoke favorably about the intervention and wished that it had been
longer than three family sessions. The flexibility of the REORDER
intervention in offering the education by phone to the family
member who could not attend in person certainly increased the
involvement of families not previously included in care. The coach-
ing and support provided by REORDER clinicians in SDM and
the warm regard the veterans felt for their presence represents an
outstanding asset in engaging the veterans in new behaviors.
It is an understandable reaction not to want to burden others
in this culture, and discussing this general feeling normalizes the
process for adults with psychiatric disorders who express reluctance
to have family members see them as needing additional caretaking.
For the veteran, understanding that social support is critical to
their overall well-being is an important educational component of
REORDER. Understanding that the greater the number of family
members who know what is troubling them, the more these
members can serve in a supportive role—an important factor in
the decision to include them in treatment (Glynn, Cohen, Dixon,
& Niv, 2006).

Limitations
The limitations of the study merit attention and our understanding
is limited only to those with family involvement in REORDER who
agreed to the interview. The 20 veterans in this qualitative study do
not mirror all the experiences of the veterans who participated in
REORDER, and the data are not meant to be generalizable to all
participants. Because we interviewed veterans who had at least
one session with family in REORDER, we missed understanding
the experience of those who did not invite family to phase 2 of
REORDER or those whose families declined once invited. Admit-
tedly, this was a lost opportunity to understand particular needs
and challenges of a group of veterans without family support.
The interviewed sample was a smaller proportion of study part-
icipants than we had wished. Some potential participants refused
and others could not be contacted because of the somewhat transi-
ent nature of the population. Furthermore, because a significant
amount of time had elapsed from the end of the REORDER
362 D. Gioia et al.

intervention to the qualitative study interview due the late start of

the study, we needed to assure ourselves that veterans we inter-
viewed were remarking on the REORDER study components and
not on other aspects of their VA care. For those whom the team
deemed were too long from their original engagement in the study,
no contact was made.
Additionally, a qualitative study limitation was not soliciting
information from each veteran about increased amount of family
contact with providers as a result of engagement with REORDER,
although we did have some self-report. This information was
explored by chart review in the main study, and data is reported
elsewhere (Dixon et al., in press). We also did not ask specifically
about decrease in psychiatric symptoms as a result of participation
in the study, although this was a significant finding in the main
REORDER study.

Implications
Implications of this study for mental health professionals in
utilizing SDM are several. First, persons with serious mental disor-
ders are quite capable of engaging in reflection and deliberation
processes involved in shared decision-making around their health
care, and this aligns strongly with recovery principles. The ability
for anyone, with or without SMI, to appreciate and reflect on
a decision is part of overall mental capacity development, and
it needs to be cultivated through a variety of tasks such as those
involved in SDM (Owen, Freyenhagen, Richardson, & Hotopf,
2009). Second, Glynn et al. (2006) remind us that there have been
many changes in mental health treatment over the past 35 years,
and it is necessary to adopt recovery principles into our family
and other treatments, considering our interventions with the
consumer as the focal point. Third, having social support is crucial
at any age, and assisting in a dialogue about whether a client views
asking for support as the placing of burden on family is one that is
critical for us to explore so that we can attend to these conflicts
within the deliberations. Finally, REORDER is important for
bringing a fresh perspective on whether and how to involve family
in mental health care that has been missing from the literature to
date (Cohen et al, 2013). Further exploration will accompany the
dissemination and use of this manualized treatment as it gains
traction in a variety of mental health services settings.
 Veterans’ Views of a Shared Decision-Making Process 363

ACKNOWLEDGMENTS

Special thanks to the veterans, family members, and REORDER

clinicians who shared their perspectives with the interviewers.
Thanks to Dr. Alicia Lucksted for her careful reading of the manu-
script. Many thanks also to transcriptionists Peter Stern and Kara
Sanders for their attention to transforming the audio interviews into
text.

FUNDING

This work was supported by VA Health Services Research and

Development grant IIR 04-255 to Dr. Dixon and by the Mental
Illness Research, Education and Clinical Center (MIRECC) of the
VA Capitol Network and the MIRECC of the VA Desert Pacific
Healthcare Network. The authors report no competing interests.

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