Barriers to shared decision making in mental health care: qualitative study of the Joint Crisis Plan for psychosis.
BACKGROUND
Despite increasing calls for shared decision making (SDM), the precise mechanisms for its attainment are unclear. Sharing decisions in mental health care may be especially complex. Fluctuations in service user capacity and significant power differences are particular barriers.


OBJECTIVE
We trialled a form of facilitated SDM that aimed to generate patients' treatment preferences in advance of a possible relapse. The 'Joint Crisis Plan' (JCP) intervention was trialled in four mental health trusts in England between 2008 and 2011. This qualitative study used grounded theory methods to analyse focus group and interview data to understand how stakeholders perceived the intervention and the barriers to SDM in the form of a JCP.


RESULTS
Fifty service users with psychotic disorders and 45 clinicians participated in focus groups or interviews between February 2010 and November 2011. Results suggested four barriers to clinician engagement in the JCP: (i) ambivalence about care planning; (ii) perceptions that they were 'already doing SDM'; (iii) concerns regarding the clinical 'appropriateness of service users' choices'; and (iv) limited 'availability of service users' choices'. Service users reported barriers to SDM in routine practice, most of which were addressed by the JCP process. Barriers identified by clinicians led to their lack of constructive engagement in the process, undermining the service users' experience.


CONCLUSIONS
Future work requires interventions targeted at the engagement of clinicians addressing their concerns about SDM. Particular strategies include organizational investment in implementation of service users' choices and directly training clinicians in SDM communication processes.
Health Service and Population Research Department, King's College London, Institute of Psychiatry, London, UK.
Simone
S
Farrelly
Health Service and Population Research Department, King's College London, Institute of Psychiatry, London, UK.
Helen
H
Lester
Health Service and Population Research Department, King's College London, Institute of Psychiatry, London, UK.
Diana
D
Rose
Division of Health and Wellbeing, Warwick Medical School, University of Warwick, Warwick, UK.
Max
M
Birchwood
Division of Psychiatry, School of Medicine, University of Manchester, Manchester, UK.
Max
M
Marshall
Centre for Primary care, Institute of Population Health, University of Manchester, Manchester, UK.
Waquas
W
Waheed
Health Service and Population Research Department, King's College London, Institute of Psychiatry, London, UK.
R Claire
RC
Henderson
Health Service and Population Research Department, King's College London, Institute of Psychiatry, London, UK.
George
G
Szmukler
Health Service and Population Research Department, King's College London, Institute of Psychiatry, London, UK.
Graham
G
Thornicroft
D000328:Adult; D003657:Decision Making; D004739:England; D005260:Female; D017144:Focus Groups; D066296:Grounded Theory; D006801:Humans; D008297:Male; D008605:Mental Health Services; D008875:Middle Aged; D010347:Patient Care Planning; D010358:Patient Participation / Q000379:methods; D057240:Patient Preference / Q000523:psychology; D010817:Physician-Patient Relations; D011618:Psychotic Disorders / Q000628:therapy*; D036301:Qualitative Research; D013222:State Medicine
England; care programme approach; psychosis; shared decision making; social context