Shared decision-making between people with experience of psychosis and mental health professionals: A discourse analysis.

Ideas about shared decision making (SDM) began to emerge in the 1970s as a challenge to the tradition of paternalism in healthcare. Theoretical models have focused on delineating this process and identifying discrete stages including exploration of service-user preferences, deliberation in relation to possible interventions and an emphasis on interactional, two-way communication processes that prioritise collaboration. There are particular challenges in terms of enacting the principles of shared decision-making with those with more complex mental health needs including experience of psychosis. Types of experience (unusual beliefs, intrusions, suspiciousness, changes to cognitive processes) along with issues of capacity, consent and the legal framework of the Mental Health Act (MHA; 1983) make it more challenging to implement these principles, even though they are laid out in best practice guidelines, and consistently correlate with positive outcomes for service-users.
This study focused on the construction of SDM in routine clinical practice by video-recording consultations involving decisions between service-users with experience of psychosis and mental health staff in a community setting. This was with a view to moving beyond exploration of the experience of SDM to look at the enactment of these ideas in practice. Three separate clinical meetings were recorded, which captured seven decisions related to different aspects of care and treatment. The final sample comprised 3 service-users, 1 carer and 5 professionals. Participants then watched the recording with the researcher, and reflective interviews were conducted to facilitate exploration of their experience in the meeting. The study proceeded from a social constructionist perspective, drawing from the principles of Discourse Analysis, more specifically Discursive Psychology. Analysis focused on constructions of psychosis, key features of participant talk and discursive and rhetorical features in order to examine impact on SDM.
The findings highlighted different ways of sharing opinions, directing or redirecting the dialogue, expressing agreement or disagreement and the challenge for staff in terms of promoting choice whilst also fulfilling legal and clinical responsibility. The findings also pointed to some important differences between physical and mental health SDM, and supported previous findings indicating that dominant discourses of psychosis impact collaboration at the micro-level of interactions between speakers in individual meetings. Based on these findings, I offer some reflections on implications for clinical practice, including consideration of idiosyncratic and decision-specific approaches to SDM with this population that account for the nuanced experience of psychosis. I also make some suggestions for directions for future research, including repeating the study in acute inpatient settings.