Decision-Making Part 2: Tools
Part 2 In a 3-Part Series
In last week’s blog, I shared about decision-making and how it's not what we think it is. We tend to think it's very logical, analytical, and reasoned, when in fact it's a very emotion-based process.
Check out Decision-Making: Faking You Out Big Time! to learn about the parts of the brain — almost all involved with emotion — that we use in the decision-making process, t the power of implicit memory (the deep, old memories that we're not even necessarily conscious of) in the decisions we make, and why decision-making skills should be taught to people starting at a young age.
What's a Decision-Making Model?
Decision-making models are tools that are helpful to people faced with making an important choice. The ones I share here are useful in the context of healthcare, and especially in the context of birth in the healthcare setting.
There are several decision-making models used by both patients and providers.
Use Your BRAIN
The BRAIN model is an acronym representing questions patients or clients can ask when a procedure or treatment is recommended.
B Benefits of the procedure or treatment
R Risks of the procedure or treatment
A Alternatives to the procedure or treatment
I Intuition
N Nothing, or Not Now
You've probably heard about the importance of weighing the benefits and risks of many things in life. It’s important to remember that all procedures or interventions have a potential benefit and a potential risk. In healthcare, we're weighing the benefits against the risks in the context of the medical condition.
100% Risk-Free!
There's no intervention that is risk-free. Even breathing air can come with a risk if there's pollution in the air. Yet, certainly, stopping breathing would carry a bigger risk. So we need to look at alternatives.
What are the alternatives to what’s being recommended? There could be one thing, three things…15 things! And for each one, you have to go through the benefits and risks.
If you’re paying attention, you’re probably starting to realize that this isn't just a simple five-question process. It can be lengthy if it involves a lot of alternatives.
'I' Is For Intuition
The letter ‘I’ in the BRAIN acronym stands for intuition. Intuition is a different kind of information that we can access. But it's not highly valued. In fact, it’s often not considered at all in healthcare situations.
Intuition hasn't been researched, it’s hard to measure, and there's very little data on the efficacy of intuition. But in my opinion, it's extremely important.
During pregnancy, people's intuition is heightened; in labor, it’s even more acute.
So we can ask a client: What does your intuition, your gut, your sixth sense, say about this intervention?
We can help them get into a state where they can access their intuition, instead of being influenced by their thoughts or by the voices of others.
When people are supported in this way, they often have a strong sense if this is something they want to do now or not.
Not Now!
Which leads us to ‘N.’ What if we do Nothing, or Not Now? This is just another alternative, but it's an important one.
What would happen if we didn't do this thing at all? Or if we waited an hour, a day, a month?
Answering the 5 questions is how the BRAIN model gathers information for decision-making.
But something is missing: the context.
It's All About the Context
What is the medical situation that's occurring, and how important, urgent, or dangerous is that situation? If the situation is dangerous or urgent, the risks may not seem as bad. But if the situation is normal — something that happens to everyone or is just a symptom of the process — then the risks are not worth it.
Without knowing the situation’s severity, you can't accurately weigh the benefits and risks.
Consider this: If someone is sitting in their living room writing up their birth plan and they are choosing the intervention they want or don’t want, ALL the risks don’t seem worth it because nothing dangerous is happening in their living room. It’s impossible to say what you might want or not want later in labor.
That’s why it’s so important to have a model like this one to use in labor when someone might need to be making decisions in the moment.
SHAREing is Caring
The next model I want to tell you about is a model that care providers use to develop a collaborative decision-making relationship with a patient. It’s called the SHARE model.
S Seek the patient’s participation
H Help them explore the options
A Assess the patient’s values and preferences
R Reach a decision
E Evaluate the decision
In this process, the care provider is inviting their patient to join them in decision-making. It’s not only the care provider’s expertise, or the patient’s preferences, that are being considered.
Any good decision-making model looks at options; that is the core of informed consent. The care provider can explain what they are recommending, provide alternatives to their recommendation, and describe how each option works along with their benefits and risks.
The next step is finding out what is important to the patient. What are their values and preferences when it comes to their healthcare? These might include religious or spiritual practices, mental/emotional preferences, and personal values.
From here, together they can reach a decision on the course of action. Then, the care provider can evaluate the decision to make sure it is relevant to the situation and assess its effectiveness over time.
There you have it! Two common tools used to help in making a decision.
By the Numbers
But now I want to dive a little bit deeper. I want to look at some of the factors that influence what decisions are made.
One of them has to do with research information, data, and how numbers are presented. Remember, we are conditioned to try to make rational, logical decisions. We tend to pay attention to the numbers.
But the numbers can be manipulated to try to influence people.
If someone is told they have a 5 in 100 chance of a complication, they probably think that number is pretty low. They’d have to try hard to imagine 100 people in a room and pick out the 5 that have the complication.
But if someone is told they have a 1 in 20 chance of developing a complication… ooh! They can imagine 20 people in a room and see the 1 unlucky person.
Five in one hundred or one in twenty are the same odds. But unless someone is quick at math, they are likely to hear those numbers differently and that can influence their decision.
Another way data is manipulated is when someone is told, “You are twice as likely to have this complication if you do A versus B.” For example, if intervention A has a complication that happens to 1 out of 1,000 people and intervention B has a complication that happens to 2 out of 1,000 people, intervention B is twice as likely to cause a complication. That is true.
But the real risk is .1% vs .2%. We’re talking very small numbers here. If someone is very risk-averse, those numbers might mean a lot to them. But to the average person, 1 to 2 out of 1,000 people are very small odds.
You can see that how statistics are communicated can influence people's sense of risk or safety. That’s why people must see actual numbers and be given guidance on how to interpret those numbers.
The Groopman Spectrums
And that brings me to the Groopman spectrums. Jerome Groopman is a physician who wrote the book, Your Medical Mind, published in 2011. It explored how medical decisions are made, and was used by a lot of physicians and lay people to understand how to factor in information for decision-making.
Groopman identified different spectrums that people might place themselves on that influence how they make decisions.
One is called the Naturalist-Technologist scale. On this scale, people are asked to consider if they favor natural remedies — herbs, acupuncture, diet, meditation, exercise — to treat medical conditions. Or if they prefer technology — machines, medications, devices — for their medical care.
The next one is the Minimalist-Maximalist scale. Do they want to try all the things available or do they like as little intervention as possible? Do they prefer to rely on the natural course of events or do everything in their power to change the trajectory of their health?
The next scale is the Doubter-Believer. Is the person suspicious of doctors, distrustful of the medical system, dubious that any medications work? Or do they do anything their doctor tells them, believe wholeheartedly in the Western medical system, and trust the ads for pharmaceuticals they see on TV?
And finally, there’s the simple Risk Averse-Risk Tolerant scale. Risk-averse folks are not willing to take chances. The numbers scare them and they want as little risk as possible. Risk-tolerant folks see life as a series of probabilities, and they are more interested in trying things aligned with their values even if they don’t provide the best odds.
But here’s where it gets interesting: The spectrums intersect. Someone could be a naturalist and a maximalist. So they want to do all.the.things as long as they fall in the natural-remedy category. Or they could be a risk-taking minimalist. They only want to try the one thing that appeals to them, even if it’s less likely to work. Or they could be someone who wants lots of technology, but only the kind that comes with low risks.
Oh, but there’s more...
First Birth Story
A few weeks ago I wrote a blog about How We Learn and how families are our first teachers. The deep-seated rules and agreements we made as small children affect the decisions we make as adults.
I like to use the process of The First Birth Story to help clients see this phenomenon at work…
What’s the first memory someone has about birth? It usually happens when they are elementary school age, as old as 10 or as young as 3. They might recall hearing a birth story of a relative, or remember when a sibling was born.
If they lived in a hippie commune and all the babies were born at home, they might say, “When the baby comes, the midwife comes over and everyone brings food and is really happy.” They would form a rule or agreement about birth like, Birth is exciting and a celebration and everyone is there.
If they remember when their little brother was born, and "Mom was really loud, and then she was whisked out the door and gone for 3 days, and Aunt Martha stayed with me but she wasn’t very nice and wouldn’t let me go see mom, and then when mom finally did come home she had this baby with her and everyone paid attention to the baby…" their rule and agreement about birth might be, Birth is scary and people go away somewhere and then you lose love.
Now keep in mind, these rules and agreements come from the mind — and with the language — of a child. Over time, other experiences overlay (but don’t replace) the original rules and agreements. Those new experiences might confirm what the child thought, only now with more adult language. Birth is intense, needs to happen in a closed environment, is an ordeal.
When we help clients understand their First Birth Story, they can see how it may be influencing the decisions they're making as adults.
The Aftermath
What happens after a decision is made and then things don't go as hoped for?
A lot has to do with one's stress-coping and resilience skills.
If someone sees their birth plan slowly evaporating — each thing on the list being removed by the hands of fate — they may try to salvage anything that’s left.
They want to feel like they have some control in all of this, that they are a good person/parent/birther who did something right. If they aren’t able to have the home birth / unmedicated birth / vaginal birth they hoped for, maybe they can at least have their baby on their chest right after birth, or keep their placenta, or play a special song. They are looking for the one thing they can still have.
Then there are the “Oh fuck it!” people.
These are the folks who, when their birth plan starts to derail, throw up their hands and say, “Forget it, do whatever you want.”
They're not just throwing up their hands to their birth plan. They're giving up all their agency and power for the rest of their birth.
This is often a stress response, a way they've learned to protect themselves when things get really hard and they don't know what else to do.
How Doulas Can Help
As you can see, there's a lot to the aftermath. And that's why doulas can be so crucial to positive experiences of birth, even if they don’t go as planned.
Doulas help people process and integrate the experience they had at their birth. They do that by giving clients time to first adjust to new parenthood. Then, after they've had a chance to let some of their thoughts and ideas about their birth percolate, we can explore what that experience was like for them.
We often start by just asking clients to tell us what happened from their perspective. It's important to let them tell their story without interruption. Then we ask:
What was that like for you?
Depending on how they tell their story, we might ask some follow-up questions. For some people, it might be helpful for them to verbalize what they wished happened differently, and we can validate that.
We can ask what they learned about themselves from that experience. If you’re familiar with the Heroic Journey, you know that the hero has to face the unknown and go to the underworld, where hard things happen and they have to do things they didn't want to do. But they learn important lessons which they bring back to the upper world in their new version of self.
Someone might have learned that they're tougher than they thought, or that birth is humbling. or that their partner now recognizes their strength and endurance.
Doulas help bring those learnings to the forefront. And that's how we help them to integrate their experience and make sense of it.
I hope you can use some of the nuggets from these decision-making tools to help your clients, family, or friends if they call and say, “I have this thing that I have to make a decision about and I don't know what to do.”
Join me next week because I'm going to share the process I used with my doula clients when I was preparing them for birth. I'm also going to share some stories of decision-making from the trenches in my career as a doula. Thanks for reading!
