Shared Decision Making in Mental Health

Written by: Marie Chesaniuk, PhD

What is shared decision making?

Shared decision making refers to a collaborative process of choosing tests and treatments in healthcare based in part on provider expertise and available information on the risks and benefits of a given treatment for a client as well as the client’s personal values, preferences, and expertise on their own subjective health and daily life. Shared decision making originated as a new model of doctor-patient interaction in medicine following a number of lawsuits establishing that, “Every human being of adult years and sound mind has a right to determine what shall be done with his own body…” (as quoted in King & Moulton, 2006). Following on the heels of Carl Rogers’ person-centered treatment approaches, the term was first used in 1972 by Robert Veatch when he proposed a then-new model of ethical medicine involving more patient participation in medical decisions. 

Shared decision making has since become markedly more widely known since milestones such as the 1982 President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, the Patient Self-Determination Act of 1990, the Health Insurance Portability and Accountability Act of 1996, and remains relevant to this day as healthcare providers and clients alike navigate unprecedented availability and volumes of health information, misinformation, and disinformation and shifting attitudes toward the relationship between patient and provider.

Does shared decision making actually improve treatment process or outcomes?

The short answer is yes, but the outcomes are mixed and the effect sizes are small to medium.

The long answer is that it depends on a lot of different factors and what specific outcomes and process variables you are looking at. In their review and meta analysis of shared decision making outcomes across a variety of health conditions, including mental health conditions, Shay & Lafata (2014) broke a variety of outcomes down into the following three categories: affective-cognitive, behavioral, and health. The found the most positive effects of shared decision making on affective-cognitive outcomes like patient satisfaction and decisional conflict. They found fewer positive effects for behavioral (e.g., treatment adherence) and the least positive effects for health outcomes (e.g., reduction in symptom severity.) This was a pattern seen across a number of other reviews and meta analyses.

Similarly, Stovell and colleagues (2016) found small beneficial effects of increased shared decision-making on treatment-related empowerment. Naparaka and colleagues (2024) found that shared decision making was associated with more patient satisfaction, although patient satisfaction results were mixed across different reviews and meta analyses. 

As far as treatment related variables, Stovell and colleagues (2016) found that among clients with schizophrenia, shared decision making had a trend toward reduced involuntary treatment over the following 15-18 months. Windle and colleagues (2019) meta analyzed 29 randomized clinical trials for participants with a mental health diagnosis and found that those participants who received their preferred psychosocial mental health treatment had lower treatment dropout rates and a medium effect on better therapeutic alliance, although they found no effect of shared decision making on clinical outcomes in this analysis.

One possible explanation for the mixed effects was larger effects for patient satisfaction in digital or electronic interventions versus in-person interventions and length of intervention (there were stronger effects for people who received >3 months of intervention) (Naparaka et al., 2024). It may also depend on who you ask. Shay & Lafata (2014) found that 52% of outcomes assessed with patient-reported SDM were significant and positive, compared with 21% with observer-rated and 0% with clinician-reported shared decision making. There is a lack of research available to fully explain why results are so mixed.

What are the barriers to shared decision making in mental healthcare? And how do I manage them?

Guidry-Grimes (2020) identifies the following common barriers to shared decision making in mental healthcare: 1) a patient’s lack of decision-making capacity, 2) a patient’s poor insight, 3) a health care professional’s therapeutic pessimism or personal dislike, and 4) a patient’s or health care professional’s conflicting recovery orientations or goals of care. Depending on level of severity, intellectual disability, age of minority, the nature of some psychiatric diagnoses (e.g., psychotic episodes, hopelessness, rigidity) and the provider themself, clinicians may face one or more of these barriers to implementing shared decision making. 

Managing these barriers often means striking a balance between the ethical guidelines of beneficence and nonmaleficence for client-oriented barriers. Clinicians may seek the input of a client’s medical power of attorney holder, caregivers, and those involved in their life or care who have a good sense of what the client wants for themself, what approaches seem most effective in achieving their goals, and what treatments are feasible given their lifestyle and available supports and resources. Psychoeducation about what symptoms may contribute to feelings of hopelessness, negative bias, or avoidance behaviors and people pleasing (among other) may help mitigate insight-related challenges. 

Managing clinician-oriented barriers may require consultation/supervision, addressing burnout, clinician education in treatment modalities and psychological conditions relevant to their clients, self-awareness of personal preferences and limitations, taking responsibility for repair and effective communication of goals and expectations with clients, and/or referring out to an appropriate provider or resource if necessary. With respect to referring out, it is important to note that this is not a sign of failure on the part of a clinician but can instead be a part of that clinician helping a client along their healing journey. I found my own therapist when another provider realized she was a poor fit for me and provided me with a referral, and I could not be more grateful!

What would that look like in practice?

In practice, shared decision making in mental healthcare might involve some elements we are familiar with from the Rogerian person centered approach and motivational interviewing. Roughly following the SHARE Approach for shared decision making, a mental health provider would Seek their client’s participation, or elicit in motivational interviewing terms. Next, they would Help the client learn what their treatment options are and compare against options. This would be a good time for helpful infographics, videos, and psychoeducation that would be considered a decision aid in this process. Then, they would Assess for client values and preferences and Reach a decision together about how to proceed. This is often how we collaboratively set therapy goals. Finally, a clinician would Evaluate the client’s decision by tracking progress in treatment and seeking feedback from the client regarding their sense of progress.

Why would I implement shared decision making?

Because we can’t do anything without informed consent. Because we know the importance of self-determination and therapeutic alliance. Because so many of us value empowering clients, making shared decision a value-based activity for so many clinicians.

In sum, we in mental healthcare are in a position to bring person centered care full circle to its psychotherapeutic origins, but with the benefit of 50 years of advancements in knowledge and treatment.

Sources

Guidry-Grimes, L. (2020). Overcoming obstacles to shared mental health decision making. AMA journal of ethics, 22(5), 446-451.

King, J. S., & Moulton, B. W. (2006). Rethinking informed consent: the case for shared medical decision-making. American journal of law & medicine, 32(4), 429-501.

Narapaka, P. K., Kaduburu, S., Obulapuram, R., Singh, M., & Murti, K. (2024). A systematic literature review and meta-analysis of randomized control trials on the influence of shared decision-making as intervention on patients’ satisfaction among mental healthcare. Journal of Public Health, 1-15.

Shay, L. A., & Lafata, J. E. (2015). Where is the evidence? A systematic review of shared decision making and patient outcomes. Medical decision making, 35(1), 114-131.

Stovell, D., Morrison, A. P., Panayiotou, M., & Hutton, P. (2016). Shared treatment decision-making and empowerment related outcomes in psychosis: systematic review and meta-analysis. The British Journal of Psychiatry, 209(1), 23-28.Windle, E., Tee, H., Sabitova, A., Jovanovic, N., Priebe, S., & Carr, C. (2020). Association of patient treatment preference with dropout and clinical outcomes in adult psychosocial mental health interventions: a systematic review and meta-analysis. JAMA psychiatry, 77(3), 294-302.