A grounded construction of shared decision making for psychiatric medication management: findings from a community mental health team

Decisions concerning psychiatric medication are complex and often involve a protracted process of trial and error. The serious and enduring nature of side effects associated with psychiatric medication demands that medical and experiential expertise is shared in a way that is supportive of the longer term recovery journey. Historically poor concordance rates point to a lack of trust and difficulties in sharing decisions constructively. This Ph.D explores views and experiences of shared decision making for psychiatric medication management amongst mental health service users and practitioners. The study was conducted in a community mental health service, in the UK. A participatory methodology was employed, within a social constructionist paradigm. Service users and a carer were involved in all phases of the research process. Thirty qualitative interviews were undertaken with different stakeholders: psychiatrists, community psychiatric nurses, and service users. A thematic analysis was employed. In addition, an applied conversation analysis was undertaken on four recorded outpatient medication related meetings. Enablers of and barriers to shared decision making were found at three levels of analysis: the interaction, the relationship, and the system. Many divergent discourses were apparent across these levels, both within and between the different stakeholder groups. A typology of involvement is proposed and discussed, from fractured passivity through to active self- management. The barriers to collaborative practice identified in these findings, and the structural factors at work in the mental health system in particular, were seen to explain the gap between policy ideals and current practice. Strong therapeutic relationships were found to be a vital enabler, comprising of: a formation of trust, practitioners knowing and believing in service users’ potential, and ‘walking the journey together’. Shared decision making in this study is found to be a dynamic process over time, involving two (or more) participants in a complex interplay. The thesis emphasizes the interaction between structure and agency in shared decision making in psychiatric medication management and highlights how power is enacted in the context of shared decisions in a community setting. Original theoretical, methodological and practical contributions to knowledge are presented and discussed.