Shared decision making in mental health care settings: Perspective, purpose and practice

Rates of chronic illness are growing rapidly, as are health care costs. These phenomena and the burdens that they present demand not only biomedical and care‐delivery advancements but also innovations in patient engagement, defined as the process of “engaging patients and their caregivers in effective self‐care, behavior change, and chronic disease management; and [addressing] the need to better align treatment choices with patients’ well‐informed preferences and values through shared decision making”1. In his review on shared decision making (SDM) in mental health care, M. Slade2 provides an excellent examination of existing research on the topic and offers innovative recommendations – such as involving social marketing and the hospitality industry – to move the field forward. While I agree with what Slade has written about SDM tools, I would like to go one step back in this commentary, (re)examining theoretical perspectives on SDM and proposing a fidelity framework to support the practice of SDM at the service level. Without the commitment of practitioners and the transformation of the entire workplace3, SDM is rhetoric, not a reality.

Examining the theoretical perspective that underpins SDM is not purposeless. It helps us better understand the essence and values behind the practices. The closure of asylums and psychiatric institutions across the globe beginning in the 1970s, along with the introduction of community care, brought about a paradigm shift in mental health care, moving the field from one that was traditional and professionally‐led to one that is service‐centered and in which patients participate (patient‐led care remains rare in practice). The authors of a seminal work explain that “at present, there are broadly three strands to the project of critical psychiatry: the development of a critique of the influence of the pharmaceutical industry on the theory and practice of psychiatry, the establishment of a medical discourse about mental suffering that is sensitive to the issue of meaning, and the promotion of a partnership with the emerging user/survivor movement”4. In other words, the traditional medical paradigm has been challenged, and an alternative discourse has been offered, one that acknowledges the existence of both professional knowledge and lived‐experience knowledge that lay the often forgotten foundation for SDM.

The sociological analysis of medical versus lived‐experience knowledge dates back to the early 1970s, with Freidson's landmark publication5. Knowledge is created by people working individually or interdependently, and it is often bounded by what society believes to be legitimate3, 6. Knowledge is “never a neutral or objective phenomenon but a matter of positionality, that is, of the place from which one speaks, to whom and for what purpose”7. Knowledge construction (e.g., recovery‐oriented use of medication, illness management strategies) and communication – the essence of SDM – are human activities and therefore subject to human vices and virtues. There is a difference in power between professional and service user in an SDM session, and that difference is only exaggerated by time pressure and by the meaning and suffering associated with a mental health condition.

Combining professional and lived‐experience knowledge in the search for personal recovery is not always a straightforward process. The two forms of knowledge sometimes work in a complementary manner, but at other times their interaction causes more tension and raises questions. It is of paramount importance that health knowledge construction moves from a process that is hierarchical to one that is horizontal, or defined by consensus3, 8. Such a shift would allow all parties, if willing, to participate in the construction of knowledge that forms the basis for decision‐making in the search for personal recovery from mental illness. The proposed fidelity framework consists of the following elements9, 10:

External environment. Health care services would deliver systematic and specific programs to promote social inclusion and equality and to reduce the stigma and discrimination associated with mental illness (e.g., targeting people recovering from psychosis whose employment is at risk). These programs would form a solid base from which to implement SDM.

Leadership commitment. Organizations would adopt a recovery approach in their overarching philosophies and put that concept into practice (e.g., interactions with service users would be directed toward nurturing the service user's autonomy and choices). The position adopted in SDM is that both professional and lived‐experience knowledge are valid and that knowledge is most powerful when professional and service user collaborate on terms of mutual understanding, respect and equality. There should be clear publicity in the form of brochures, posters and web resources about using SDM as a tool to support service users in achieving their recovery goals. Senior personnel of a given organization would join forces with everyday practitioners to ensure that SDM be implemented in a multidisciplinary manner across different clinical services (from acute inpatient facilities to community‐based services) throughout the entire organization. Similarly, the practice of SDM would be incorporated into the day‐to‐day operation of organizations. Finally, a hallmark of leadership commitment to SDM would be the employment of people with personal experiences of mental illness in positions of senior management, in committees monitoring SDM execution, and as peer support specialists to assist SDM programs.

Implementation of SDM. Organizations would establish SDM implementation teams to provide for the ongoing and regular supervision of practitioners. The five essential steps of SDM stipulated in the SHARE approach form part of the proposed fidelity framework9. These steps are: a) to seek the participation of service users in the SDM process; b) to help service users explore and compare intervention options based on their recovery goals; c) to assess service users’ values and preferences; d) to reach decisions jointly with service users; and e) to evaluate the outcomes of SDM. Services would provide physical settings that assist service users in participating in the SDM process, with features such as SDM corners and gadgets (e.g., tablets, laptops). Moreover, senior management would invest in building up reference resources (e.g., evaluation instruments, SDM aids) and evaluating SDM implementation.

The current body of literature on SDM has three major limitations. First, although the outcome measures used by the majority of trial studies are fairly comprehensive in terms of covering clinical status, service satisfaction and intervention adherence, no studies have assessed the innovation and creativity of service users in problem solving, service users’ decision making, or service users’ insight into and understanding about their conditions. Second, we should not undermine the increasingly sophisticated capability of smartphones in the era of Web 3.011. It provides new options and groundbreaking social media interfaces that could support the application of SDM. Third, there is a void in the existing literature on the application of SDM in non‐Western, non‐Nordic jurisdictions.

SDM is largely a psycholinguistic process. The use of words, metaphors and non‐verbal communication; the art of involving families and caregivers in the intervention process; and the level of service users’ participation in mental health services more broadly are crucial factors that need to be considered when it comes to delivering SDM in mental health care.

Samson Tse
Department of Social Work and Social Administration, University of Hong Kong, Hong Kong