Why Psychiatry Fails to Implement Shared Decision-Making

Shared Decision-Making in healthcare has grown in popularity but long-held beliefs in psychiatry create barriers to implementation.

Samantha Lilly
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A new study, published in the Journal of Psychiatric and Mental Health Nursing, finds that shared decision-making (SDM), a popular practice throughout medicine, is not routinely practiced in psychological and psychiatric settings. Shared decision-making refers to a process through which patients are given enough information concerning their treatment to help dictate and decide its course. However, despite SDM’s known benefits, such as increased autonomy, empowerment, and trust between practitioner and patient, the barriers to application in psychiatry appear insurmountable.

“The concept of SDM has gradually spread to the field of psychiatric care. But to date, there is little agreement on the transferability of the originally medicine-oriented concept of SDM to psychiatry, especially when it comes to a decision in inpatient psychiatric settings,” the researchers, led by Caroline Gurtner from Bern University in Switzerland, explain.
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The trusting relationship between practitioner and patient in mental healthcare is integral to the recovery and improvement of psychological distress. The study sought to determine whether shared decision-making practices have been integrated into psychology and psychiatry literature since SDM’s rise to popularity in the late ’90s. The authors, Caroline Gurtner of the University of Bern, alongside her Dutch and Austrian colleagues, found that the concept of SDM has not evolved in the literature due to preexisting notions of psychiatric patients’ decision-making capacity.

Utilizing an integrative review methodology, useful for defining complex concepts by integrating and reviewing empirical and theoretical work, the authors searched multiple online databases, e.g., PubMed and PsycINFO, with specific MeSH terms and keywords related to shared decision-making. In addition to the electronic search, experts in the field were also contacted to ensure a comprehensive analysis.

A total of 754 articles were found. But 698 were excluded from the review due to their focus on the cognitive and or biomedical aspects of human decision-making rather than the collaborative process and act of decision making. The remaining 56 articles were evaluated for suitability. Only 14 met the inclusion criteria.

Out of the 14 articles, 10 were empirical studies, meaning that 5 were qualitative, 4 were quantitative, and 1 was mixed methods. In addition, 4 articles that ranged from conceptual to theoretical to methodological were included in the analysis.

The analysis revealed that there is no universal conceptual understanding of SDM in the psychological and psychiatric literature. However, key themes concerning barriers to the implementation of SDM emerged.

There are significant barriers to creating and implementing shared decision-making practices in the psychiatric sphere. In particular, health professionals’ role during the process of SDM is integral to its success—necessitating that changes to the socialization of mental healthcare professionals are required to begin building trustful relationships between both patient and practitioner. This must address the belief in psychiatric care that patients do not have adequate capacity for decision-making.

The study’s findings should be interpreted in the context of its limitations. In particular, the study’s literature collection was only conducted in English and German; this limitation is significant as practices similar to shared decision-making in mental healthcare are common in the Global South.

Further research is needed to examine how mental healthcare practitioners in Europe, Canada, and the US can implement shared decision-making in both psychiatry and psychology.

 

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Gurtner, C., Schols, J. M., Lohrmann, C., Halfens, R., & Hahn, S. (2020). Conceptual understanding and applicability of shared decision-making in psychiatric care–An integrative review. Journal of Psychiatric and Mental Health Nursing. (Link)

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Samantha Lilly
Samantha Lilly brings their background in philosophy, bioethics, and social justice to their work as a critical suicidologist, with the belief that suicidology, at its best, is social justice work. Before beginning a Ph.D. in Health in Social Science at the University of Edinburgh, Sam was awarded a Thomas J. Watson Fellowship. Their project, “Understanding Suicidality Across Cultures,” gave them the privilege of working alongside ethicists, scholars, and rights advocates in the Benelux countries, Lithuania, Argentina, Aotearoa, and Indonesia. Sam’s current research is dedicated to bringing feminist and decolonial methodologies to suicide prevention.

10 COMMENTS

  1. Sorry, but that image of the man in a white coat, with a stethoscope, a pen and an observation pad, given that it pertains to psychiatry is a putrid image.

    If the man in the image wants to help a human being, he should remove his white coat, put down his pen and paper, get out of his institute completely, not engage in labelling for insurance, instead maybe use his own time to make friends with the person he wants to help, use his money or the money of the person who wants to be helped and then help him.

    MDs should stand against the practice of psychiatric labelling for insurance and welfare payments. Communities must exist in every country where drugs are legalised without prescriptions for people who voluntarily want to take them (which lets them stay out of psychiatry).

  2. This is nothing personal against the author. I mean no ill will towards her and I wish her the best.

    However, these articles are so typical of psychiatry and psychology. A lot of fancy scientistic verbiage thrown in there.

    “SDM: Shared decision-making refers to a process through which patients are given enough information concerning their treatment to help dictate and decide its course. However, despite SDM’s known benefits, such as increased autonomy, empowerment, and trust between practitioner and patient, the barriers to application in psychiatry appear insurmountable.”

    As opposed to what? Not telling them what the help they’re receiving actually is? I thought this was common sense, not some exquisite area of research.

    I’m not singling out this specific article, because there are so many more of them like this on MIA and others. All of it gives the impression of “science”.

    The problem is that journal publications have largely been kept out of the public eye. The kind of “research” that institutes do, particularly in fields like psychiatry and psychology, which affect the public the most, are actually kept in the hands of a few select individuals which basically allows them to lord over us and in some cases simply look down on us because we aren’t as learned as them. But the fact of the matter is that for many of us, resources have been kept out of our hands in a free and equal manner (and not as some patient with a begging bowl stretched towards someone in the role of a shrink or doctor).

    If people here have never heard of Sci-Hub, then you have now. Please use it. I don’t know whether it’s legal to use it in your jurisdictions but it will give us a lot more transparency and we can know what’s actually going on, what “research” they are doing and if that has any value at all. If the link doesn’t work, just google it.

    Sci-Hub

    In the search box, you can type the name (it has to be exact) of any journal paper you want to access. For example, if you want to access the paper “Age Effects on Antidepressant-Induced Manic Conversion” (I think this is a paper Robert Whitaker included in his book Anatomy of an Epidemic), just type the name of the paper (without the quotes) in the search box and it will unlock the entire paper.

    We need these resources. We are being fooled if we do not have access to the very information that is used to govern our lives. It is our lives that are becoming statistics in these papers. It is our lives, our behaviours, our families, our parents, our children, our brothers and sisters who are in these papers. Not the lives of the psychiatrists, psychologists, residents in these professions or nurses (even thought there are papers published pertaining to them, it’s in a very different context).

    • Interesting. What are these perceived “barriers to implementation,” and from whom do they come? It seems to me that almost any patient would be foursquare behind being actually told the truth and being consulted before agreeing to a treatment plan. It seems to me that the only barriers to implementation have to come from the rigidity of authoritarian practitioners who want their patients to blindly follow their dictates and are afraid that telling the actual truth will lead to pesky difficulties like the patients actually discovering that these “professionals” don’t actually know what they’re talking about.

      • Check out the mentioned paper on Sci-Hub (“Conceptual understanding and applicability of shared decision-making in psychiatric care–An integrative review”). Type the name of the paper into it. However, under every page it states “This article is protected by copyright. All rights reserved”. I’m completely out of the jurisdiction of North America and Europe. But, if I posted sections of the paper here, maybe MIA would have a problem.

        I’m very sorry to the authors. This would have been an arduous task for the authors, no doubt. They would have exerted a lot of physical and mental effort in publishing this and seeking out references from prior journal publications and authors. I’m not attacking the authors of this paper specifically. There must be a lot of papers like this.

        I will simply say this: Publications of this sort or even any of this sort of research are of NO USE to almost ANY of us who post here on MIA. Zero. Zilch. Nada. They simply bolster the psychiatric system, giving it the appearance of science and that’s it.

      • We can see why psychiatrists oppose this by giving an example of what telling patients the research would look like.

        “The evidence this SSRI helps short term is done by those selling it. These studies have half a dozen pro-drug flaws and yet they find the drug improvement is clinically meaningless. Long term studies find the drugs worsen outcomes but if we take people addicted to the drugs and withdrawal them they suffer. The drug takes 5 years off your life by causing physical illness.”

        The biggest problem with psychiatry is they not only refuse to give informed consent but lie about the benefits and harms to get people on the drugs. I’m not even sure this shared decision making idea can work because psychiatrists will just keep being dishonest. It’s not a decision if the party with power lies and manipulates the vulnerable person.

        • No it can’t work, because it would never happen. It’s just talk, actually meant to make it look as if psychiatry considers different views.
          The reality is, they don’t even think about them and most likely snicker about the various “suggestions”.
          I think it might even benefit them.

        • “changes to the socialization of mental healthcare professionals are required to begin building trustful relationships between both patient and practitioner. This must address the belief in psychiatric care that patients do not have adequate capacity for decision-making.”

          Yes, I had no idea twenty years ago that the majority of so called “mental health” workers thought all their patients, people whom they know absolutely nothing about, believed all who walk into their offices “did not have adequate capacity for decision-making.”

          “Trusting doctors” was what we were all brainwashed into believing, for God’s sake. And all doctors, including the psychiatrists, had promised to “first and foremost do no harm,” and had malpractice insurance, to pay for their malpractice, in the event they made a mistake.

          I’ve never met such insane and ungodly disrespectful people in my entire life, as my lunatic “mental health” workers. For God’s sake, I have both a father and a son who graduated from university Phi Beta Kappa. Who the f-ck are these insane “mental health” lunatics, who assume all who walk into their clinics do “not have adequate capacity for decision-making?”

          And the proof of the “mental health” system’s insane belief system is their belief in “agnosia.” Or in other words, one’s immediate “inability to interpret” their own real life problems, likely due to egregious crimes being committed against them, or their family members.

          Which the psychiatric, psychological, and “mental health” industries, blame on being the result “of brain damage,” caused by their make believe and “invalid” DSM disorders. Brain damage, which psychiatric “treatment” then creates, with their neurotoxic psychiatric drugs.

          And the ADHD drugs and antidepressants can create the “bipolar” symptoms. Plus the antipsychotics / neuroleptics can create both the positive and negative symptoms of “schizophrenia,” via anticholinergic toxidrome and NIDS.

          https://www.alternet.org/2010/04/are_prozac_and_other_psychiatric_drugs_causing_the_astonishing_rise_of_mental_illness_in_america/
          https://en.wikipedia.org/wiki/Toxidrome
          https://en.wikipedia.org/wiki/Neuroleptic-induced_deficit_syndrome

          Egregious crimes, committed against innocent families, like child abuse. And covering up child abuse is the number one actual societal function of both the psychological and psychiatric industries, both historically and today.

          https://www.indybay.org/newsitems/2019/01/23/18820633.php?fbclid=IwAR2-cgZPcEvbz7yFqMuUwneIuaqGleGiOzackY4N2sPeVXolwmEga5iKxdo
          https://www.madinamerica.com/2016/04/heal-for-life/

          And this systemic child abuse covering up business is an illegal business, that both psychology and psychiatry, and all their “mental health” and social worker minion, are in. Because it is all by DSM design.

          https://www.psychologytoday.com/us/blog/your-child-does-not-have-bipolar-disorder/201402/dsm-5-and-child-neglect-and-abuse-1

          “The biggest problem with psychiatry is they not only refuse to give informed consent but lie about the benefits and harms to get people on the drugs.” Yes, I’ve never met bigger pathological liars, than the satanic, systemic child abuse covering up “mental health professionals” I have encountered.

          Although I must confess, at this point that I doubt that “changes to the socialization of mental healthcare professionals … to begin building trustful relationships between both patient and practitioner,” will ever be possible again.

          Especially given the fact that the psychological and psychiatric professions have less than zero desire to get out of the systemic child abuse covering up business, since over 80% of their clients are misdiagnosed child abuse survivors.

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