actively supports these practices. Organizational leaders can take many different actions to create such a culture. First, organizational managers and leaders can demonstrate behaviors that recognize and support consumer decision making in their interactions with other organizational employees. As noted above, each patient’s right to make treatment decisions and receive support in doing so should be clinicians’ and organizations’ default policy unless there is evidence of a danger to the patient or others, or the patient has been determined to be incompetent to make decisions. Organizations’ formal, written policy documents, such as mission statements and policies and procedures manuals, can explicitly endorse and specify this default policy and other organizational actions to support consumer decision making. If the organization has a consumer bill of rights, it can include content on consumer decision making. The orientation of new providers and ongoing training of existing providers also should include content on the adverse effects of stigma on patients’ self-efficacy and recovery, and reaffirm organizational polices and practices that support patient decision making.

Continuing education of clinicians and other service personnel Because it is not reasonable to expect that all clinicians (especially those newly licensed) will come to their practice settings possessing all of the necessary knowledge and skills, organizations need to provide for their clinicians’ ongoing training (IOM, 2004b) and education (see Chapter 7). Education has been shown to decrease stigma and improve clinicians’ attitudes regarding persons with mental illnesses (Corrigan and Penn, 1999; Farina, 1998). Empirical evidence also indicates that having credible and competent leaders deliver this education is important if some of these messages (e.g., those related to stigma) are to be taken up by learners (Corrigan et al., 2001). The education and training provided should include, for example, content on patient-centered care and decision making, erroneous beliefs about dangerousness, and the clinician’s and the organization’s need to tolerate “bad” choices and achieve the right balance between “beneficence” and autonomy (Murdach, 1996).

Tolerance for “bad” decisions23 The Quality Chasm report (IOM, 2001) notes that among all consumers, there can at times be a tension between the aim of providing patient-centered care and that of providing effective (evidence–based) care. For example, a patient may have received information on and desire to receive a particular type of treatment, but the provider


The discussion in this section incorporates content from the paper “Patient-Centered Care/Self-Directed Care: Legal, Policy and Programmatic Considerations,” prepared for the committee by Susan Stefan of the Center for Public Representation.

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