Implementing shared decision making in routine mental health care

Abstract

Shared decision making (SDM) in mental health care involves clinicians and patients working together to make decisions. The key elements of SDM have been identified, decision support tools have been developed, and SDM has been recommended in mental health at policy level. Yet implementation remains limited. Two justifications are typically advanced in support of SDM. The clinical justification is that SDM leads to improved outcome, yet the available empirical evidence base is inconclusive. The ethical justification is that SDM is a right, but clinicians need to balance the biomedical ethical principles of autonomy and justice with beneficence and non‐maleficence. It is argued that SDM is “polyvalent”, a sociological concept which describes an idea commanding superficial but not deep agreement between disparate stakeholders. Implementing SDM in routine mental health services is as much a cultural as a technical problem. Three challenges are identified: creating widespread access to high‐quality decision support tools; integrating SDM with other recovery‐supporting interventions; and responding to cultural changes as patients develop the normal expectations of citizenship. Two approaches which may inform responses in the mental health system to these cultural changes – social marketing and the hospitality industry – are identified.

Psychiatric service staff perceptions of implementing a shared decision-making tool: a process evaluation study

“…The process evaluation, however, revealed additional “hidden” attitudes among staff that may contribute knowledge regarding the challenge of implementing recovery-oriented services such as SDM. Staff, who were very vocal in supporting user participation, nonetheless expressed concerns during the role play, that exposing users to various alternatives might lead to unnecessary stress, and would therefore instead decide which alternatives were most appropriate “for them.” This result, which was elicited in the concrete application of the DST, further supports the idea there is a complex interaction between attitudes and practice that demands further exploration (Joseph-Williams et al, 2017; Slade, 2017). …”

“…Although SDM is mentioned in key policy documents in Sweden and internationally, there are no incentives built into organisational structures and it is not promoted systematically at national, regional, or organisational levels (Stovell et al, 2016). A need to foster cultural change among managers, clinicians and users may be seen as well as a prerequisite for structural change, and this is described in the area of user involvement as a considerable challenge (Slade, 2017). The results of the study reinforce the need for a focus on the connection between culture and structure.…”

“…Sanctioned local facilitators would reflect a readiness for change and development, a commitment on the part of the local organization to dedicating resources, a support to the adaptation of interventions to the actual local conditions, and a resource for both technical support (in this case related to DST) and to the attitude change that the intervention may entail (in this case a developing view of participation and capacity among staff). Facilitators with their own “lived experience” of mental health problems and service use might also be seen as a particularly important factor in facilitating the attitude changes the intervention requires so that this change might be seen as connected to other recovery-oriented interventions (Ramon et al, 2017; Slade, 2017). Managing the facilitator role requires however, training and continuous support, a need that clearly was underestimated by the research team.…”

“…Despite these potential benefits, research on SDM and its implementation in practice in psychiatric care is still at a formative stage (Morant, Kaminskiy, & Ramon, 2015; Stovell et al, 2016). Attempts to describe and measure the benefits of SDM in psychiatric care have often been compromised by poor implementation (Morant et al, 2015; Ramon et al, 2017; Slade, 2017; Stovell et al, 2016). In the field of somatic care, SDM has been described as a process of supportive collaboration between users and staff, drawing on user’s preferences and values, and the best available evidence to discuss multiple options and reach a consensus in care (Duncan, Best, & Hagen, 2010; O’Connor et al, 2007).…”

“…Decision tools, adapted to the needs of users, have the potential to restructure how people with mental illness and staff work together to arrive at shared decisions about the next steps in treatment or support (Deegan & Drake, 2006; National Board of Health and Welfare, 2011). As yet, such tools remain a rarity in the field of psychiatry (Slade, 2017). However, initial studies of existing decision support tools designed for psychiatry show promise for increasing user engagement, satisfaction, knowledge and reductions in decisional conflicts (LeBlanc et al, 2015).…”