In Reply: Many thanks to Drs. Corrigan and Larson for their thoughtful letter. They raise the important issue of the interface between self-determination and shared decision making. Is shared decision making a step backward in the long struggle for autonomy, choice, and self-determination for people with psychiatric diagnoses, or does it represent a step forward? We appreciate the opportunity to extend this discussion.
We view shared decision making as a critically important step forward in the struggle to make choice an option for autonomous adults who are faced with tough treatment decisions in behavioral health. Shared decision making emphasizes the process, rather than the decision itself. To make decisions that are well informed, consistent with one's values, and in one's own best interests, people need information, unbiased decision aids, support, and opportunities to ask questions and consider alternatives. An infrastructure must be created that makes this process efficient and realistic in typical clinic settings. It should include decision support centers located in the clinic, Web-based multimedia decision aids, and decision support specialists, particularly people in recovery (1). Such an infrastructure helps to ensure that the practice of shared decision making is firmly embedded as standard operating procedure within the clinic. The need for a formal infrastructure is further underscored by research that shows that physicians, therapists, case managers, nurses, employment counselors, and other mental health practitioners do not reliably convey accurate, up-to-date, evidenced-based information and do not always include clients in the process of making decisions (2). Thus we do not agree with the statement that "joint decision making is a relatively easy enterprise." In the absence of an infrastructure to support shared decision making, joint decision making happens at the discretion of the provider, who may or may not convey accurate information. Shared decision making promotes choice because it removes the practitioner as the arbiter of information and allows individuals to explore information in a self-directed fashion.
Shared decision making recognizes and honors the autonomy of both the practitioner and the person with a diagnosis. In this model, there is a dynamic tension between the two parties. The practitioner is a gatekeeper with the legal power to give or deny access to treatment. On the other hand, the individual can exercise personal autonomy by refusing or consenting to treatment. For instance, a physician can recommend ECT, but a client can refuse it. Conversely, a client with a substance abuse history can request a benzodiazepine, but the physician can refuse that request. Shared decision making is a platform that invites and empowers both autonomous parties to form an alliance, exchange information, and find common ground regarding what, if any, treatment might help and what desirable treatment outcomes might be. Of course, watchful waiting, or postponing treatment in favor of monitoring events over time, has always been an integral component of shared decision making.
Finally, shared decision making is not indicated in situations when decisional capacity is clearly compromised according to the law. Examples include PCP intoxication, advanced Alzheimer's disease, and delirium. In such situations the spirit of self-determination and shared decision making can be honored through the use of psychiatric advance directives.
A cartoon published in 2003 in the British Medical Journal shows a group of physicians hovering about a bed-ridden patient. The attending physician pronounces to the patient, "When we want your opinion, we'll give it to you." Shared decision making heralds the end of the monologue and the beginning of the dialogue.
Deegan PE, Rapp C, Holter M, et al: A program to support shared decision making in an outpatient psychiatric medication clinic. Psychiatric Services 59:603–605, 2008
Adams JR, Drake RE, Wolford GL: Shared decision-making preferences of people with severe mental illness. Psychiatric Services 58:1219–1221, 2007