Protected: Chapter 6: Presenting Solutions

What We Know About Presenting Solutions

The patient who leaves a consultation without understanding what is wrong, what can be done, and what to do next has not been helped — regardless of how accurate the diagnosis was. Presenting solutions well is a clinical skill, and the evidence for how to do it comes largely from general practice, where decades of research on doctor-patient communication have produced a robust evidence base.

MAAS contributed to this body of work. The instrument emerged from observing what skilled physicians actually do when they talk with patients — not what textbooks prescribe, but what happens in practice when a consultation goes well. The structure of presenting solutions in MAAS reflects what was found to work: sequencing information so patients can receive it, checking whether they understood, involving them in decisions, and following up to ensure the plan survives contact with real life.^1,2

In mental health, almost no comparable research on presenting solutions exists. What we have instead is a clinical tradition that recognized early what the subsequent literature has confirmed — that presenting solutions to a patient with a mental health condition requires something beyond good communication technique. We draw on the GP evidence as our foundation, and this chapter builds on it.

The key findings, briefly:^3–9

Every item in this chapter is shaped by cultural context. How a diagnosis is received, how a formulation is understood, what treatment the patient will accept, who makes the decision, and what implementation looks like — all of these are culturally mediated. A patient from a culture where mental illness is understood as spiritual affliction hears “you have a dissociative disorder” differently from one raised in a biomedical framework. A patient from a collectivist culture may expect the family to decide, not the individual. A patient whose community stigmatizes psychiatric treatment may need the plan to survive scrutiny from people who do not believe in what you are offering. Presenting solutions that ignore cultural context are solutions that will not be followed.

These findings apply to all clinical communication. What follows is what changes when the condition is mental, when the relationship itself becomes part of treatment, and when the words you use to name the condition carry consequences that go far beyond the consultation room.

Opening

Dr. Martinez has completed the clinical examination — three scales, nearly an hour of careful attention. She now has a picture: depersonalization as a dissociative response to childhood trauma, reactivated six months ago by a chance encounter. Mrs. Noor’s flat affect, collapsed intentional arc, and fragmented sleep make sense together. Her isolation within her marriage, her children as anchors, her passive suicidal ideation moderated by connection — all of this forms a coherent formulation. Now comes the part that will determine whether this understanding translates into actual help.

“I’d like to talk about what I think is happening,” Dr. Martinez says, “and then I want to hear what you think. After that, we can look at what might help.”

Everything before this chapter was assessment — understanding what the patient experiences, what alterations are present, and what context surrounds them. This chapter is where understanding becomes action.

The GP evidence on presenting solutions applies here. But in mental health, something more fundamental changes. Presenting solutions requires not just explaining but understanding — not just Erklären but Verstehen. Karl Jaspers identified this as the phenomenological backbone of psychiatric method: Verstehen grasps meaningful connections from within the patient’s experience; Erklären explains through mechanisms, biology, categories.¹⁰ Both are needed; the order matters. The patient must feel understood before they can receive explanation. A treatment plan built on explanation alone — however technically correct — will not land.

MAAS adopted this distinction as a clinical organizing principle from its earliest work and structured it into the instrument from 1981: formulation before prescription, understanding before explanation.¹¹ The validation confirmed the two-dimensional model: process skills predict satisfaction (Verstehen), content skills predict diagnostic accuracy (Erklären).^1,2 The presenting solutions phase is where these two dimensions converge.

There is a further reason why presenting solutions changes in mental health. In general practice, a diagnosis is a clinical tool — useful, practical, usually neutral. In mental health, a diagnosis touches identity. It carries stigma. It can validate a patient who finally has a name for what they have been experiencing, or it can follow them for decades in ways that affect employment, relationships, and self-understanding. The words we use — and how we use them — matter in a way that “you have bronchitis” never will. This is not a side issue; it runs through every section of this chapter.

Scale 6 has 17 items where the GP scale has 13. The four additional items reflect what is genuinely different: safety planning (6.5), self-management readiness (6.6), social context of treatment decisions (6.12), and exploring disagreement (6.13). These exist because the relationship, the context, and the patient’s own understanding of their condition play a larger role when the condition is mental.

The sections follow the natural sequence of a treatment discussion: understanding before explaining, explaining before proposing, proposing before deciding, deciding before implementing. In practice, these phases overlap — a concern raised during shared decision-making may loop back to formulation, and safety planning weaves through several items. But the sequence ensures nothing is missed.

Section I: From Diagnosis to Formulation (6.1-6.2)

A patient who hears “you have bronchitis” receives useful information. A patient who hears “you have borderline personality disorder” receives something that may follow them for decades — in employment, insurance, relationships, and in how they understand themselves. The same act of naming carries a fundamentally different weight when the condition is mental. Some patients find the diagnosis profoundly relieving; others find it frightening or reductive. The patient needs more than a label — they need to understand why this is happening to them.

The cultural dimensions of this moment are profound. A psychiatric diagnosis carries different weight in a community where mental illness means divine punishment than in one where it means a treatable brain condition. In many cultures, the diagnosis belongs not just to the patient but to the family — and the family’s response shapes whether treatment is pursued or abandoned. A formulation must be intelligible within the patient’s cultural framework: the patient whose explanatory model involves spiritual causation, ancestral influence, or social transgression needs a formulation that respects this understanding while integrating clinical knowledge. The goal is not to replace the patient’s model but to build a shared narrative that both clinician and patient can work with.

This is why diagnosis alone is not enough. Item 6.1 names the condition — the Erklären. Item 6.2 builds the formulation — the Verstehen. The patient who receives a label without a story remains alone with it. The patient who receives a formulation that connects the diagnosis to their life has the beginning of understanding.

6.1 Explains diagnosis

The physician explains the diagnosis or problem-definition in terms the patient can understand. When no clear diagnosis is possible, the physician describes the problem as understood so far, including important conditions that have been ruled out.

Psychiatric diagnoses sit on a stigma hierarchy: schizophrenia carries more stigma than bipolar disorder, which carries more than depression.^12,13 But even “depression” is not neutral. Some patients find diagnosis profoundly relieving — finally, a name for what they have been experiencing. Others find it frightening, reductive, or shameful. The word can be a tool or a verdict; the clinical task is knowing which, for this patient, and framing accordingly.

Frame the diagnosis as a description that helps guide treatment, not a defining identity: “This is a way of understanding what you’re going through so we can find the right help — it doesn’t define who you are.”

When diagnosis is uncertain — and in mental health it often is — say so honestly. Patients tolerate uncertainty better than discovering later that certainty was faked: “I’m not yet certain what’s causing this, but I can tell you what it isn’t, and what we’ll do to understand it better.”

6.2 Explains causes

The physician explains what caused the problem and what keeps it going. In mental health, this means building a formulation — not a diagnosis repeated in more words, but an integrated story that connects this patient’s vulnerability, triggers, and maintaining factors.

A formulation answers four questions: Why this person? Why now? Why is it persisting? What protects them? The patient should recognize themselves in your formulation¹⁴. If they don’t, it is not yet shared.

The biopsychosocial model is easy to invoke and hard to do well. The risk is three separate lists: biological (low serotonin), psychological (negative cognitions), social (isolation). Thomas Fuchs proposes something more useful: these levels are not three columns but mutually constituting processes.^15,16 The patient’s relational withdrawal diminishes social affordances, which dysregulates neuroendocrine function, which further constrains lived possibilities — one ecology, not three domains. A good formulation is an integrated narrative, not a tripartite checklist.

Connect the explanation to the patient’s own account. Avoid implying blame — maintaining factors like avoidance or substance use are understandable responses, not moral failures.

Framework Box: Verstehen und Erklären in Practice

The distinction describes what happens when a formulation lands versus when it doesn’t. The patient who hears “you have dissociative disorder” receives a label. The patient who hears “your mind found a way to protect you from something overwhelming, and it’s still doing it” receives recognition. Both are needed; the order matters.

The Verstehen/Erklären distinction has been part of MAAS from the beginning, introduced in the 1981 discussion paper on basic psychomedical care and built into the instrument from the same year.¹¹ Causes (6.2) follows diagnosis (6.1) because the label needs grounding in the patient’s story. The 1987 construct validity study of the MAAS-Mental Health confirmed that this sequence works: clinicians who structured presenting solutions around understanding before explanation achieved better diagnostic accuracy and higher patient satisfaction.^1,2 Formulation is not delivered but negotiated — it emerges through dialogue in which the clinician’s framework and the patient’s experience meet and refine each other. When a patient says “so I’m not going crazy,” that is the moment Verstehen has landed.

Sanneke de Haan’s enactivist perspective adds a further layer: psychiatric disorders are disorders of sense-making.¹⁷ A formulation that connects symptoms to life history is an act of restored sense-making — it reintegrates experience that the condition had fragmented. This is therapeutic in itself, before any treatment begins.

Mrs. Noor

Dr. Martinez does not begin with a label. She begins with recognition: “What you’ve described — the feeling that the world looks right but doesn’t feel real, that your body moves but doesn’t feel like yours — that has a name. It’s called depersonalization. It’s something your mind does to protect you when something is too much to process.”

Mrs. Noor looks up. “It’s a real thing?”

“It’s a real thing. And it makes sense in the context of what you’ve been through.”

She builds the formulation: “From what you’ve told me, several things came together. You experienced something very difficult as a child — something you never had help processing. Your mind found a way to cope: it turned down the volume. That worked for years. Then six months ago, you ran into someone connected to what happened. That brought everything closer to the surface, and your mind responded the way it knows how — by creating more distance. The depersonalization got worse.”

She pauses. “And then there are the things that keep it going: not sleeping well, carrying everything alone, not having anyone who knows what happened. The isolation doesn’t cause the depersonalization, but it means there’s nothing to interrupt the cycle.”

Mrs. Noor is quiet for a moment. “So I’m not going crazy.”

“No. Your mind found a way to protect you, and it’s still doing it even though you’re safe now. That’s the part we can work on.”

Notice what Dr. Martinez did: not “you have X” but “here is what I understand about why you experience what you experience.” The diagnosis names; the formulation explains; the patient recognizes. In that recognition — “so I’m not going crazy” — Verstehen has landed.

Section II: Prognosis and Expectations (6.3-6.4)

A patient starting treatment for depression needs to know that improvement takes weeks, not days. A patient entering trauma therapy needs to know that things may feel worse before they feel better. A patient with a personality disorder needs to understand that change happens over years, not months. Without honest timelines, patients measure their recovery against expectations nobody corrected — and interpret normal progress as failure.

6.3 Explains prognosis

The physician explains what to expect — the likely course with and without treatment, including expected timeline, what improvement looks like, and when to seek help if things don’t go as expected.

Most patients arrive carrying one of two fears: that their condition is permanent, or that if treatment doesn’t work quickly, nothing will help. The honest framing varies by condition. Most people with depression recover fully, but improvement takes weeks and setbacks are normal. For chronic conditions — recurrent depression, personality difficulties, enduring psychotic illness — the framing is a good life with the condition, not a life after it.

Safety netting in mental health has specific content. Tell the patient what should prompt earlier contact: worsening of symptoms, emergence of suicidal thoughts, side effects of medication. Be specific: “If you start having thoughts of harming yourself, or if things feel significantly worse rather than better, please contact us immediately — don’t wait for your next appointment.”

6.4 Explores expectations

The physician asks what the patient hopes for and expects from treatment. After receiving information, the patient now needs space to respond — not to confirm understanding, but to say what they actually want. This is the pivot between information-giving and shared decision-making.

What a patient wishes for and what they expect often differ. A patient may wish for complete recovery while expecting nothing will help. Both have factual and emotional dimensions that need exploration. In mental health, expectations are shaped by stigma, previous treatment experiences (often negative), family attitudes, and cultural beliefs about mental illness. A patient referred under family pressure may have expectations shaped entirely by others: “What are YOU hoping for — not what your family wants or your GP expects?”

Patients often overestimate treatment benefits and underestimate demands. Some expect medication to fix everything; others expect nothing will help. Neither can be argued away — both must be explored.

Mrs. Noor

“Depersonalization that’s connected to trauma has a good prognosis,” Dr. Martinez says. “Most people improve significantly with the right treatment. But I want to be honest: it takes time. The therapy I’d recommend involves gradually processing what happened, and that can be hard. Some people feel worse before they feel better.”

“How long?”

“Typically several months. And the fact that you’ve been managing for years — working, raising your children — suggests resilience that will support recovery.”

She pauses. “Before we talk about options, I want to know what you’re hoping for.”

Mrs. Noor thinks. “I want to feel real again. I want to hold my children and actually feel it. I want —” she stops. “I want to stop being afraid all the time.”

“And what do you expect will happen?”

A long pause. “I don’t know. Part of me thinks maybe talking about it will make it worse.”

“That’s a real concern. Some people do find that therapy stirs things up before it settles them down. That’s why we plan for that — it’s not a sign things are going wrong.”

Mrs. Noor’s fear that therapy will make things worse is common in trauma patients. It needs to be named and planned for, not discovered mid-treatment. Exploring expectations is not a courtesy — it surfaces concerns that change the treatment plan entirely.

Morning Meeting

“The patient said she understood, but her eyes looked vacant.” A patient can repeat the formulation back perfectly and still not connect to it. Items 6.1-6.4 succeed not when the patient can recite the diagnosis, but when they show signs of recognition — the moment when a clinical explanation meets lived experience. If the patient’s eyes look vacant, the explanation may be accurate but disconnected from what the patient actually cares about. Return to 6.4: what are they hoping for?

Section III: Safety Planning (6.5)

A patient who has disclosed suicidal thoughts during the assessment needs to leave the consultation with something concrete to protect them — not reassurance, not a referral, but a plan they helped build and believe in. This item does not exist in the GP scale. It sits here because it is the most time-sensitive element when risk is present: identifying suicidal ideation in Scale 5.14 and then moving on to treatment options without addressing safety leaves the patient unprotected in the hours that matter most.

6.5 Develops safety plan when indicated

Prescriptive. When risk is identified — whether through Scale 5.14 or emerging during the treatment discussion — the physician collaborates with the patient to create a personalized, written safety plan. This is the most evidence-based intervention for suicide prevention in outpatient settings, reducing suicidal behavior by approximately 43%.^18,19

A safety plan is not a crisis card. It is not a list of phone numbers handed over at the door. It is a structured conversation that produces a personalized document the patient keeps — on paper, on their phone, wherever they will actually reach for it at 2 AM. The six components are built collaboratively:

1. Warning signs: “What are the early signals for you that things are getting dangerous?”
2. Internal coping: “What has helped you get through difficult moments before?”
3. Social contacts for distraction: “Who could you call or visit when you need to get out of your own head?”
4. Social contacts for help: “Who would you contact if you needed someone to talk to about how you’re feeling?”
5. Professional contacts: Crisis line, emergency services, clinician contact.
6. Making the environment safer: “When people are in crisis, having access to certain things can make a bad moment worse. Is there anything we should think about removing or securing?”

The conversation about means restriction is often skipped because clinicians find it intrusive. Patients almost always experience it as caring. Ask directly. The time between suicidal impulse and action can be very short; reducing access to lethal means during that window saves lives.

Framework Box: What Safety Plans Do and Don’t Do

Safety plans interrupt the pathway from suicidal thought to suicidal action. A meta-analysis confirms they reduce suicidal behavior but not suicidal ideation¹⁹ — preventing thoughts is the work of treatment. The goal is to keep the patient alive while treatment works.

The IMV model maps the pathway from defeat and entrapment through ideation to action^20,21. The safety plan translates what this model reveals about the volitional phase into a practical intervention: warning signs correspond to escalation signals, coping strategies interrupt the pathway, social contacts provide external regulation, means restriction removes opportunity during the critical window.

What makes a safety plan effective is personalization. The patient’s own warning signs, their own coping strategies, their own people. A generic list of crisis numbers is better than nothing but far less effective than a plan built from the patient’s actual life. Review and update the plan at every follow-up.

Mrs. Noor

“You mentioned that sometimes you wish the suffering would just end,” Dr. Martinez says. “I take that seriously, and I want to make sure you’re safe between now and when we meet again. Can we make a plan together?”

Mrs. Noor nods.

“What are the warning signs for you — the moments when those thoughts get louder?”

“Late at night. When the children are asleep and the house is quiet and I can’t sleep. That’s when it’s worst.”

“And what has helped you get through those moments?”

“I go to their rooms. I watch them sleep. I remind myself they need me.”

They build the plan together: her children as anchors, a colleague she trusts enough to call, the crisis line number saved in her phone, agreement to remove the stockpiled painkillers from the bathroom cabinet. Dr. Martinez writes it out and gives Mrs. Noor a copy.

“This is ours,” she says. “We’ll review it every time we meet.”

No hedging on safety. Build the plan. Write it down. Review it at every contact.

Section IV: Treatment Options and the Patient’s Role (6.6-6.10)

Most patients arriving for mental health treatment have already been told what they need — by their GP, their family, or the internet. What they have not been given is a genuine map of possibilities. For most common conditions, both medication and psychological therapy have evidence. Different therapies suit different people. Lifestyle changes have measurable effects. Watchful waiting is sometimes appropriate. “No active treatment” is a legitimate option. The patient deserves to see the full landscape before choosing a path.

Before presenting options, however, one question shapes everything that follows: what role is this patient ready to take in their own recovery?

6.6 Explores self-management

The physician explores how much responsibility the patient is prepared to take for their own treatment and recovery. Recovery is not something done to patients but with them — and that requires understanding where the patient is.

Self-management readiness is not a personality trait. It is a clinical variable that changes with the condition and its treatment. A severely depressed patient may be unable to do anything beyond showing up; that same patient, three months later, may be actively managing sleep, exercise, and social contact. Treatment must match where the patient is, not where the clinician wishes they were.

Explore without judgment: “Some people want to focus mainly on medication right now. Others want to work actively on changing patterns. Where are you?” When motivation appears low, consider whether this is a symptom: “It sounds like part of you wants things to change but another part isn’t sure you have the energy. That’s very common in depression — the condition takes away the very energy you’d need to fight it.”

6.7 Proposes solutions

The physician presents treatment options for the patient to consider, establishing that choices exist. Most patients can hold three options; more requires structure. Present the main approaches first, then discuss combinations and sequencing: “We could start with therapy, medication, or both. There are also things you can do yourself that have real evidence behind them. Let me explain each, and then we can see what fits.”

Some patients arrive having been told what they need. Restore agency: “That’s one option, and it may well be a good one. But there are others. Let’s look at them together.” Avoid presenting medication as the only “real” treatment or therapy as the “soft option.” Both are legitimate.

6.8 Explains appropriateness

The physician explains why proposed treatments fit this patient’s specific situation — not just the diagnosis, but the whole picture: circumstances, preferences, practical life. This is where the formulation becomes practically useful.

Generic recommendations undermine trust. “Antidepressants work for depression” is less convincing than “Given that your depersonalization is connected to unprocessed trauma, a therapy that specifically targets trauma memories would address the root of the problem rather than just the symptoms.” The patient needs to understand why this treatment is recommended for them.

6.9 Discusses pros and cons

The physician presents balanced information about benefits and risks. This includes side effects patients care about — weight gain, sexual dysfunction, emotional blunting — not just medically “serious” effects. Use absolute numbers: “About 1 in 10 people experience nausea in the first week — it usually passes. Serious side effects are rare, maybe 1 in 100.”

For therapy, discuss emotional demands honestly: “Trauma-focused therapy involves gradually engaging with painful memories. Some people find the first sessions very difficult. That’s expected — it doesn’t mean the therapy isn’t working.” Be honest about what we don’t know: “We can’t predict exactly how you’ll respond. We may need to adjust as we go.”

6.10 Shares resources

The physician directs the patient to reliable information sources. In mental health, the internet contains both excellent resources and dangerous misinformation. Direct patients to specific sources rather than suggesting they search: “These organizations have good, reliable information. I’d avoid general internet searches — there’s a lot of misleading content out there.”

Consider peer support — some patients benefit from connecting with others who have similar experiences. Check digital access and literacy; written materials or a brief summary in your own hand may be more useful than a website.

Framework Box: The Therapeutic Relationship in Presenting Solutions

A large meta-analysis across 295 studies and over 30,000 patients found a consistent relationship between therapeutic alliance and outcome (r = .278) — and this extends beyond psychotherapy to all mental health encounters.^22,23 How you present treatment is not a communication technique layered on top of clinical content — it is a therapeutic intervention in its own right.

The MAAS validation anticipated this finding: process skills predicted satisfaction, content skills predicted diagnostic accuracy.^1,2 Presenting solutions is where both converge. The formulation is content; the relationship in which it is delivered is process; both predict outcome.

A note of prudence: shared decision-making in mental health has a weak evidence base — the first umbrella review confirms that SDM research in mental health remains exploratory, with little experimental replication and no validated measures developed with patients.^24,25 The principles are sound and patients want involvement. But the research has not caught up with the aspiration. What we can say with confidence is that graduated autonomy — matching the level of guidance to the patient’s current capacity — respects both the evidence for alliance and the reality that capacity fluctuates.

Mrs. Noor

“When we look at treatment options,” Dr. Martinez says, “some will ask a lot of you. Therapy means talking about painful things. I want to know: is this something you feel ready for, or would you rather start with something less demanding and build from there?”

“I’ve been carrying this for twenty years,” Mrs. Noor says. “I’m tired of carrying it. But I’m also scared of what happens when I put it down.”

“That’s honest, and it’s important. We don’t have to do everything at once.”

Dr. Martinez presents the options: trauma-focused therapy as the treatment with the strongest evidence for what Mrs. Noor is experiencing; medication as a possible adjunct that can create a foundation without addressing the root cause; the option to start with one and add the other.

“Given that your depersonalization is connected to unprocessed trauma,” she says, “a therapy that specifically targets trauma memories would address the root rather than the symptoms. Medication can help with the low mood and sleep in the meantime. But this is your decision.”

Section V: Shared Decision-Making (6.11-6.14)

The patient has heard the formulation, understood the options, and considered the trade-offs. Now comes the question that determines whether the treatment plan will actually be followed: does the patient believe in it? A plan the patient agreed to is not the same as a plan the patient chose. These four items are where the treatment plan becomes the patient’s plan — or fails to.

Shared decision-making assumes a model of individual autonomy that is culturally specific. In collectivist cultures, treatment decisions may involve the family, the community, or a religious authority — and this is not a failure of patient autonomy but a different model of decision-making. Some patients expect the doctor to decide (“you are the expert”); others expect to consult their family before committing; others need the treatment to be acceptable to their religious community. Explore what decision-making looks like for this patient rather than assuming one model. The goal is a decision the patient can live with, in the world they actually live in.

Two of these items — 6.12 (social context) and 6.13 (disagreement) — do not exist in the GP scale. They exist here because the patient’s treatment decision happens within a social world — family attitudes, cultural beliefs, relational pressures — and because the patient’s own understanding of their condition may differ fundamentally from the clinician’s. Both need to be surfaced before a decision can be genuinely shared.

6.11 Asks opinion

The physician explicitly asks what the patient thinks about the proposed treatment. The patient needs genuine space to respond: “I’ve given you a lot of information. What’s your reaction?” And then wait. Some patients need time. Some need permission: “Some people feel relieved at this point, others feel overwhelmed or skeptical. There’s no wrong answer.”

Watch for passive compliance — the patient who nods and agrees but whose affect suggests otherwise. Name it gently: “You’re nodding, but I want to make sure you actually agree rather than just going along.” Patients who are used to not being heard, or who feel pressured, are especially likely to comply without agreeing.

6.12 Explores social context

The physician asks how the patient’s social world will affect treatment. A patient does not make treatment decisions in isolation. Family attitudes toward mental health care vary enormously — supportive, skeptical, ashamed, controlling — and these attitudes directly affect whether the patient starts treatment, continues it, and recovers.

This item connects directly to Scale 5 findings. If the relational assessment revealed a partner who is present but emotionally distant (5.1), or cultural attitudes that stigmatize mental illness (5.9), these now inform the treatment discussion. Ask without assuming: “How do you think your husband will react to you seeing a therapist?” Offer family involvement when appropriate, always with the patient’s consent. For some patients, family is the problem — proceed carefully.

A decision that makes clinical sense but ignores the patient’s relational reality will often fail — not because the patient was “non-compliant,” but because we did not ask about the world the treatment had to survive in.

6.13 Explores disagreement

The physician explicitly checks whether the patient sees things differently — the problem, its causes, or the proposed solution. Many patients hold back disagreement out of deference to the clinician’s authority. This is the item most clinicians skip and most patients need.

Patients may understand their problems through frameworks very different from psychiatric ones: spiritual explanations, life circumstances that don’t fit diagnostic categories, cultural understandings of distress. These are not obstacles to treatment; they are data. Disagreement is not failure — it is information. When disagreement exists, clarify exactly where: “It sounds like you accept the depression diagnosis but you’re not convinced about medication. Is that right?”

Sometimes the patient is right. A patient who attributes their depression to an intolerable work situation may not need medication; they may need help changing their situation. When the patient’s experiential vocabulary is overwritten by clinical language, shared understanding breaks down.

6.14 Supports decision

The physician explicitly asks the patient to choose among the options discussed. For patients who have felt powerless — over their symptoms, their treatment history, sometimes their lives — making an explicit choice is itself therapeutic. Frame the choice clearly: “So our options are therapy, medication, or starting with self-help and seeing how that goes. Which feels right to you?”

Accept decisions to defer — not every decision must be made today. When patients struggle to decide, explore what makes the decision difficult rather than deciding for them. For patients whose decision-making is impaired by their condition, offer more guidance while preserving choice: “If I were in your situation, I might start with… but this is your decision.”

Framework Box: Ambivalence, Capacity, and the Condition That Impairs Its Own Treatment

Three principles organize shared decision-making in mental health:

Ambivalence is normative. Motivational interviewing assumes ambivalence, not unmotivation. Decisional conflict in mental health is amplified by stigma, identity concerns, and side effects. A compliance-oriented approach fails; exploration succeeds. Item 6.13 structures the space for ambivalence.

Capacity may be impaired. The functional test asks: can the patient understand, retain, use and weigh, and communicate a decision? A substantial proportion of psychiatric inpatients lack capacity for their primary treatment decision, with schizophrenia and bipolar mania showing the highest rates.²⁶ Insight (4.23) and judgment (4.24) from the psychiatric examination directly inform the approach. Graduated autonomy matches guidance to current capacity — more when impaired, full partnership when intact, stepping back as recovery progresses.²⁴

The condition may impair the decision about treating the condition. Depression takes away motivation to engage. Anxiety catastrophizes risks. Psychosis may distort understanding. This does not mean shared decision-making should be abandoned — it means it must be adapted. Even patients with severely impaired capacity usually have preferences. Ask. Listen. Document.

Mrs. Noor

“What are you thinking?” Dr. Martinez asks.

Mrs. Noor is quiet. Then: “The therapy — I think I need to do it. But I’m scared. And I don’t know what to tell my husband.”

“Those are two separate things. Let’s take them one at a time. The fear — that’s normal. People who work through trauma almost always say the anticipation was worse than the actual process. And you don’t have to go into everything right away.”

“And my husband?”

“What do you want him to know?”

“He knows something is wrong. He just doesn’t know what. I want him to understand but I can’t — I’m not ready to tell him about what happened.”

“You don’t have to tell him everything. You can say you’re getting help for something you’ve been struggling with, and that the doctor said it’s treatable. Would it help if I spoke to him?”

“Maybe. Not yet. But maybe later.”

“The offer stands whenever you’re ready. Now — it sounds like you’d like to start with the therapy referral, and hold off on medication for now?”

“Yes. I want to try the therapy first.”

Morning Meeting

“She agreed to everything, but I’m not sure she actually wanted any of it.” When patients agree passively, the treatment plan belongs to the clinician, not the patient — and plans that don’t belong to patients tend not to be followed. Items 6.11-6.14 are designed to prevent this: asking opinion surfaces doubts, exploring social context reveals barriers, surfacing disagreement identifies hidden objections, and supporting a decision creates a moment of genuine agency. If you leave uncertain whether the patient actually chose what was agreed, you have not yet completed these items.

Section VI: Implementation (6.15-6.17)

The patient has understood, chosen, and committed. But understanding and choosing are not enough — the patient who leaves without knowing concretely what to do next, when to come back, and who to call if things go wrong has not been helped. These three items turn the decision into action — and this is where the gap between what clinicians think they communicated and what patients actually take home becomes visible.

6.15 Explains implementation

The physician provides clear, practical instructions for carrying out the agreed plan. But before giving instructions, consider the patient’s actual life. Can they afford the medication? Can they get to the therapy appointment? Does their work schedule allow it? These are not afterthoughts — they are the realities uncovered in Scale 5 (income, transport, housing stability, access barriers) against which every treatment plan must be tested. A perfect plan that the patient cannot follow is not a plan.

Psychiatric medications have specific challenges the patient needs to understand: delayed onset (SSRIs take 2-4 weeks — the patient needs to know improvement is not immediate), early side effects that resolve, dosage titration, and interactions. For therapy referrals, explain the process and realistic timeline — waiting lists exist. Write things down: patients forget most of what physicians say, and cognitive symptoms make this worse.

6.16 Checks understanding

The physician verifies understanding through teach-back — not “Do you understand?” (which always yields “yes”) but asking the patient to explain in their own words: “I’ve given you a lot of information. Just so I know I’ve been clear — what’s your understanding of what we’re doing and why?”

Frame it as checking your own communication, not testing the patient. In mental health, cognitive symptoms — concentration difficulties in depression, distractibility in anxiety, memory problems in psychosis — are the rule, not the exception. When understanding is incomplete, simplify rather than repeat the same explanation louder. Written summaries are not optional.

6.17 Arranges follow-up

The physician arranges specific follow-up, ensuring continuity. For the patient, the first weeks after a mental health consultation are often the most vulnerable — high-risk for both dropout and deterioration. For new medications, schedule review within two weeks. For therapy referrals with waiting lists, maintain contact: “Let’s check in monthly while you’re waiting.” Match follow-up intensity to risk — higher-risk patients need closer monitoring.

Follow-up is also a message. It communicates that the clinician takes the problem seriously and that the patient is not being abandoned. For patients with histories of broken trust and disrupted relationships — which is many mental health patients — reliable follow-through is itself therapeutic. Psychiatric adherence runs at 42-58%⁷, and insight and alliance predict adherence more than information quality. Continuity is clinical, not administrative.

Mrs. Noor

“Let me make sure we’re on the same page,” Dr. Martinez says. “Can you tell me what you understand about what we’re planning?”

“I’m going to be referred to someone who specializes in trauma therapy. That will take a few weeks to arrange. I have the safety plan” — she holds up the paper — “for when things feel bad at night. And I’m coming back to see you in two weeks.”

“That’s exactly right. And if anything feels worse before then — particularly the thoughts about wanting the suffering to end — you call me or the crisis number. You don’t wait.”

“I won’t wait.”

Dr. Martinez writes a brief summary on a card: the diagnosis, the plan, the follow-up date, her direct number, the crisis line. She hands it to Mrs. Noor.

“One more thing,” she says. “What you told me today took enormous courage. Most people carry things like this alone for years. You came here and you spoke. That’s the hardest part.”

Section VII: When the Condition Shapes the Consultation

A patient with bronchitis can attend to information about antibiotics. A patient with a fracture can weigh options for pain management. The illness and the consultation about the illness occupy separate domains. In mental health, this separation breaks down. The condition interacts with the consultation about treating it — and this interaction is the rule, not the exception.

What follows is not a checklist but a guide to clinical reasoning: for each major condition group, what you may encounter in the presenting solutions phase, and what you can do about it.

Depression. You explain treatment options and the patient stares at the wall. She says, “I don’t know. Whatever you think.” This is not laziness or disinterest — it is the disease. Depression takes away the energy to engage with options, the motivation to imagine a different future, and the capacity to make decisions. Decisional paralysis is a symptom. What helps: simplify choices to two rather than four. Offer gentle guidance: “If I were in your situation, I might start with…” Keep the session shorter and the follow-up closer. Do not interpret passivity as consent.

ADHD. You are ten minutes into explaining the treatment plan and the patient has lost track of what you said three minutes ago. They nod, but when you ask them to summarize, they struggle. Chunking becomes essential; written backup is non-negotiable. But there is another dimension: many adults diagnosed with ADHD in their thirties or forties have spent years believing they were lazy, undisciplined, or personally flawed. For them, the diagnosis itself can be profoundly validating — a reframing of an entire life. The moment of naming matters enormously: “This isn’t about willpower. Your brain processes things differently, and now that we know that, we can work with it rather than against it.” Give them the written summary before they leave, not as an afterthought.

Anxiety. You mention a 1-in-100 risk of a serious side effect and the patient fixates on it for the rest of the consultation. Risk communication requires particular care — relative risk framing can trigger panic. Use absolute numbers, name the most common experience first, and acknowledge the fear directly: “I can see this is worrying. Let me tell you what most people actually experience.” Some patients avoid treatment itself out of fear — the therapy that requires confronting anxiety provokes the very anxiety it is meant to treat. Name this paradox; it helps.

Autism. Open-ended questions like “How do you feel about that?” may produce confusion or silence. The patient may need concrete, explicit, unambiguous communication: “I see three options. Would you like me to explain each one?” Implied meaning and social nuance may not land. Give information in writing. Allow processing time. Strong preferences about treatment modality should be respected as informed choice, not pathologized as rigidity.

Personality disorder. You present the treatment plan and the patient reacts with intensity: “You’re the only one who understands me” or, next session, “You don’t care about me at all.” The treatment discussion may trigger relational patterns — idealization, devaluation, intense reactions to perceived rejection. What helps: consistency and reliability. Do exactly what you say you will do. Ruptures in the alliance are not failures but opportunities to model a different kind of relationship: one where disagreement does not mean abandonment.

Psychosis. The patient’s explanatory model may differ fundamentally from yours. He may believe the voices are real, that the medication is a plot, that nothing is wrong. Items 4.23 (insight) and 4.24 (judgment) from the psychiatric examination directly inform how much guidance to offer and when capacity assessment becomes formally relevant. Family involvement is often essential. Even with impaired insight, most patients have preferences about treatment — depot versus oral medication, which side effects matter most, whether hospitalization is acceptable. Ask.

Substance use. The patient knows alcohol is destroying her liver. She has heard this before. She is still drinking. This is not ignorance and it is not denial — the substance is her current coping strategy, the thing that makes life bearable at 7 PM. Ambivalence is the central clinical reality. She is weighing the costs of giving up something that currently works against the promise of something that might work later. Motivational interviewing principles apply most directly here: explore the ambivalence, don’t argue against it.

Framework Box: Chronicity, Identity, and What “Presenting Solutions” Means

Many mental health conditions are not episodes to be treated but patterns to be lived with. Depression that recurs becomes something the patient “has” rather than “got.” ADHD at 40 reframes a lifetime. Personality difficulties are not diseases to cure but patterns to understand and gradually modify. Enduring psychotic illness requires coming to terms with a changed relationship to the world.

This changes what presenting solutions means. In acute medicine, it means “here is how we fix this.” In chronic mental health, it often means “here is how we live with this well.” The formulation is not just a clinical exercise — it becomes part of how the patient understands themselves. And it may need revisiting as the patient’s relationship to their condition evolves.

Thomas Fuchs’s concept of circular causality applies: the condition shapes the patient’s world, which shapes the condition.^15,16 Treatment is not a linear intervention on a passive system. It enters a circular process and must work with it.

The same depression that paralyzes decision-making in one patient motivates urgent help-seeking in another. The same anxiety that catastrophizes risks in one patient drives thorough engagement with treatment information in another. The guidance is not “do X for condition Y” but: consider how this condition may interact with this conversation, and adapt accordingly.

Integration: From Assessment to Action

What the patient told you during the assessment — their experience, their symptoms, their context — is what makes the treatment plan personal rather than generic. Every item in Scale 6 draws on what came before: the formulation on the patient’s story, the treatment choice on the diagnosis, the safety plan on the risk assessment, the implementation on the social realities. The table below traces this through Mrs. Noor’s case:

When presenting solutions feels mechanical, it usually means the assessment was too superficial to generate a formulation that truly belongs to this patient.

What Can Go Wrong

The formulation that doesn’t land. The patient looks blank. They heard the words but didn’t recognize themselves in them. The formulation may be accurate but disconnected from what the patient actually cares about. Return to their words — the words they used in the exploration and history-taking phases. Start from their experience and build outward. A formulation the patient doesn’t recognize is not yet shared.

The safety plan that lives in a drawer. At 2 AM, when the patient is at their lowest, a form they didn’t help create will not be reached for. The patient should tell you what to write: their warning signs, their coping strategies, their people. A safety plan works because the patient sees their own life in it. If you cannot remember what makes a particular patient’s plan specific to them, it was probably filled in by you rather than built with them.

The options that aren’t options. “I think we should start an SSRI” is not shared decision-making; it is a directive with a polite tone. Presenting one option and calling it a choice undermines trust. Options must be genuine — including the option of no active treatment. The patient should feel that saying no to any particular option is acceptable.

The decision made by the wrong person. The clinician who decides and the patient who complies. The family member who phones to say the patient was never going to take the pills. The husband who was never asked how he felt about his wife seeing a therapist. These trace back to a decision that was made about the patient rather than with them — and to Scale 5 context that was not brought into the treatment discussion.

The follow-up that doesn’t happen. “Come back if you need to” sounds like an open door but feels like a closed one. The patient who is deteriorating may not recognize it. The patient who is struggling may feel they are “bothering” the clinician. The patient who has been forgotten before will not reach out again. Arrange the follow-up. Book the appointment. Write it on the card. Being remembered is itself therapeutic.

Reflection Prompts

1. When you explain a diagnosis, do you start with the label or with the patient’s experience? What happens when you reverse your usual order?
2. Think about a patient who “agreed to everything” but didn’t follow through. What might you have missed in items 6.11-6.14?
3. When was the last time you adapted your presenting solutions approach because the condition itself was interfering with the conversation?
4. Consider a patient whose explanatory model differed from yours. Did you explore it as data, or try to correct it?
5. How often do you check feasibility against Scale 5 realities — income, transport, access barriers — before finalizing a plan?

Key Points

• The patient must feel understood before they can receive explanation — Verstehen before Erklären
• A formulation the patient recognizes answers: why me, why now, why persisting, what protects me — one story, not three lists
• A psychiatric diagnosis touches identity — how it is framed matters as much as what is said
• A patient at risk needs a safety plan they helped build — reduces suicidal behavior by ~43%
• The patient’s capacity fluctuates — match guidance to where they are, not where you wish they were. Ambivalence is honest response, not resistance
• The patient’s explanatory model is data, not an obstacle — and the condition itself interacts with the consultation about treating it
• For patients who have been forgotten before, reliable follow-up communicates: you matter
• A treatment plan built without adequate assessment belongs to the clinician, not the patient

Closing

Mrs. Noor leaves with five things she did not have when she arrived: a name for what she has been experiencing, a formulation that connects it to her life, a safety plan for the dangerous hours, a decision she made herself, and a follow-up that someone else will initiate.

The consultation took just over an hour. In that time, Dr. Martinez moved through exploration of experience (Scale 3), psychiatric examination (Scale 4), socio-emotional context (Scale 5), and presenting solutions (Scale 6) — the full clinical arc from first encounter to treatment plan. Not everything is resolved. Mrs. Noor has not told her husband. The therapy referral will take weeks. The depersonalization continues. But something has shifted: the problem has been named, understood, and met with a plan. For a patient who has carried this alone for twenty years, that is not a small thing.

What made this possible was not the formulation alone, or the safety plan alone, or the treatment recommendation alone. It was the sequence: understanding before explaining, explaining before proposing, proposing before deciding, deciding before implementing. Each phase built on the one before it. Skip any phase and the ones that follow become weaker.

The process skills that made this conversation possible — the structure, the interpersonal quality, the communication skill — are the subject of Chapter 7.

Cross-References

GP Handbook:

• Chapter 4: Presenting Solutions — the GP foundation for recall, structured communication, SDM, teach-back, risk communication, safety netting, and adherence
• Chapter 6: Flow of the Medical Interview — how presenting solutions fits within the consultation arc

MH Handbook:

• Chapter 3: Scale 3 findings inform the formulation — depersonalization (3.2, 3.4), collapsed intentional arc (3.5), intercorporeality (3.8)
• Chapter 4: Scale 4 findings establish the diagnosis — dissociation (4.20), flat affect (4.6), insight (4.23), judgment (4.24)
• Chapter 5: Scale 5 context shapes the treatment plan — relationships (5.1-5.2), suicidality (5.14), trauma history (5.12-5.13), access barriers (5.11), sleep (5.10)
• Chapter 7: Process skills (Scales A, B, C) that underpin this conversation
• Appendix G: Safety Assessment/IMV — the framework behind item 6.5
• Appendix H: Cultural Formulation — when cultural context shapes how diagnosis is received, treatment is chosen, or decisions are made

References

1. Kraan HF, Crijnen AAM. The Maastricht History-taking and Advice Checklist — studies of instrumental utility. Lundbeck, Amsterdam; 1987.
2. Kraan HF, Crijnen AAM. Construct validity studies with the MAAS-Mental Health. In: Kraan HF, Crijnen AAM (Eds.), The Maastricht History-taking and Advice Checklist — studies of instrumental utility (pp. 331–353). Lundbeck, Amsterdam; 1987.
3. Ley P. Communicating with patients. London: Croom Helm; 1988.
4. Kessels RPC. Patients’ memory for medical information. J R Soc Med. 2003;96(5):219-222.
5. Watson PWB, McKinstry B. A systematic review of interventions to improve recall of medical advice in healthcare consultations. J R Soc Med. 2009;102(6):235-243.
6. Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter. Soc Sci Med. 1997;44(5):681-692.
7. Zolnierek KBH, DiMatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care. 2009;47(8):826-834.
8. Gigerenzer G. Calculated risks: how to know when numbers deceive you. New York: Simon & Schuster; 2002.
9. Jones D, et al. Safety netting in primary care. Br J Gen Pract. 2019;69(678):e70-e79.
10. Jaspers K. Allgemeine Psychopathologie. Berlin: Springer; 1913.
11. Crijnen AAM. What is basic psychomedical health care? A discussion paper. Maastricht; 1981.
12. Corrigan PW, et al. The stigma of mental illness. In: The stigma of disease and disability. Washington: APA; 2014.
13. Thornicroft G, Sunkel C, Alkän A, et al. The Lancet Commission on ending stigma and discrimination in mental health. Lancet. 2022;400(10361):1438–1480.
14. Thrower E, et al. The key components of a clinical psychology formulation: a consensus study. Br J Clin Psychol. 2024;63(1):e12455.
15. Fuchs T. Ecology of the brain: the phenomenology and biology of the embodied mind. Oxford: Oxford University Press; 2018.
16. Fuchs T. Psychiatrie als Beziehungsmedizin: ein ökologisches Paradigma. Stuttgart: Kohlhammer; 2023.
17. De Haan S. Enactive psychiatry. Cambridge: Cambridge University Press; 2020.
18. Stanley B, Brown GK. Safety planning intervention: a brief intervention to mitigate suicide risk. Cogn Behav Pract. 2012;19(2):256-264.
19. Nuij C, van Ballegooijen W, de Beurs D, et al. Safety planning-type interventions for suicide prevention: meta-analysis. Br J Psychiatry. 2021;219(2):419–426.
20. O’Connor RC, Kirtley OJ. The integrated motivational-volitional model of suicidal behaviour. Philos Trans R Soc B. 2018;373(1754):20170268.
21. Kirtley OJ, Rodham K, Crane C. A systematic review of the studies testing the integrated motivational-volitional model of suicidal behaviour. Health Psychol Rev. 2024;18(2).
22. Flückiger C, et al. The alliance in adult psychotherapy: a meta-analytic synthesis. Psychotherapy. 2018;55(4):316-340.
23. Wampold BE, Flückiger C. The alliance in mental health care: conceptualization, evidence and clinical applications. World Psychiatry. 2023;22(1):25–41.
24. Slade M. Implementing shared decision making in routine mental health care. World Psychiatry. 2017;16(2):146-153.
25. Chmielowska M, Zisman-Ilani Y, Saunders R, Pilling S. Trends, challenges, and priorities for shared decision making in mental health: the first umbrella review. Int J Soc Psychiatry. 2023;69(5):1095–1107.
26. Calcedo-Barba A, et al. Decision making capacity for treatment in psychiatric inpatients: a systematic review and meta-analysis. Psychol Med. 2024;54(6):1089–1101.

Contributors

The 17-item structure of Scale 6 (Presenting Solutions) is part of the MAAS Mental Health Interview developed by Crijnen and Kraan (1981-2026). Detailed probes and scoring guidance for each item are available on the website.

Chapter 6 covers Scale 6: Presenting Solutions (17 items). Chapter 7 continues with Process Skills, where the structure, interpersonal quality, and communication skills that underpin the entire consultation are examined.