A new systematic review of 140 studies finds that when people with mental health conditions are supported to take part in decisions about their care, outcomes often improve. At the same time, without safeguards, “shared decision-making” can also mask coercion.
The review, led by Cathy J. Francis at RMIT University in Australia, examined how shared and supported decision-making interventions affect people who use mental health services. Published in Health Expectations, the study synthesizes research from 2008 to 2023, the period following the United Nations Convention on the Rights of Persons with Disabilities (CRPD), which established the right of all people to participate in decisions about their own treatment.
The authors found that such interventions can reduce suicidal thoughts, strengthen recovery, and limit involuntary hospitalization. But they also warn that when poorly implemented or co-opted by professionals, these practices may conceal new forms of pressure and control.
“Our review indicates some important outcomes for people with mental ill health. Specifically, there is favourable evidence for these types of interventions in reducing, more so than treatment‐as‐usual, suicidal ideation and drivers, and some symptom measures. Also, for improving some important aspects of recovery that people with mental illness appear to particularly value, including: knowledge, empowerment and independence/control.”
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Do people really need evidence to convince them that violating or revoking someone’s bodily autonomy causes them intense harm? Those people would be evil, really, and should not be in positions of power.
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It says a lot that NOT “sharing” decision-making with clients appears to be the standard they are trying to alter. How can this be considered anything but destructive? The CLIENT is the one who should get to choose to “share” his/her decision making with the doctor, not the other way around! How do psychiatrists have the right to ignore the wishes and intent of their patients? Would this be acceptable in any other field? How is this consistent with “healing” as they claim to be engaged in?
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Steve, Supported decision making is an alternative to guardianship, so guardianship is the standard they are trying to alter. But this article conflates shared and supported decision making in a way that I find really confusing. They seem to be using the terms interchangeably? I’m not sure what they’re actually talking about here.
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It’s odd to me that this study combines both shared and supported decision making since those are completely different things.
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I do agree with Dr. Lopez-Aybar’s main point though. We need comprehensive SDM legislation that’s enforceable, with safeguards, not just lip service. Currently 23 states have this. You can look at supporteddecisions.org to see if your state is one of them.
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It seems kind of painful to realize that doctors actually imagine NOT “sharing” decision making with their clients! They think they can decide FOR their clients? Quite arrogant!
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Or if they don’t judge the patient competent, they might turn to the patient’s support person instead of honoring the rights of the patient to be fully involved and decide for themselves. I’m sure it happens in non-medical settings too. The model makes the most sense to me when I think of someone with a profound disability who may have real trouble communicating and understanding their options, but with the help of a trusted supporter, like a close friend or family member, they can do it. Professionals need to understand the role of the supporter and follow the SDM agreement.
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*I should have said, if the doctor doesn’t judge that the patient has capacity. Capacity is the correct word there, not competence. Competence is determined by courts. Decision-making capacity is determined by clinicians and is necessary for informed consent.
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