Common sense alone is not enough
Authors: Stefan Priebe
Journal: World Psychiatry (2017)

Slade's paper1 suggests implementing shared decision making (SDM) in mental health care. This sounds desirable. SDM is characterized by collaboration, and who would disagree with a call for more collaboration between psychiatrists and patients? A more detailed look, however, raises at least two major concerns. Firstly, what exactly is SDM? According to Slade, SDM is an intermediate position between two extremes, one in which the clinician decides, having consulted the patient, and one in which the patient decides, having received information from the clinician. SDM is in between those two and involves collaboration. Consulting a patient and providing information, however, also require collaboration, possibly with extensive questions, explanations and clarifications. So, the unique characteristic of what would need to be implemented as SDM becomes unclear. Unless the decision is about coercive treatment, clinicians are not entitled to make decisions that patients do not agree to. Obtaining informed consent to any treatment is a professional duty. Patients must explicitly agree to whatever is being decided in a consultation. Beyond this formal requirement, patients’ agreement is needed anyway for making a treatment happen. Decisions about taking medication or attending a group therapy need to be implemented by the patient, and, if the patient is not happy with the decision, the treatment is unlikely to materialize. Reaching an explicit agreement with patients about any decision is, therefore, a matter of both professional obligation and clinical necessity. No new concept of SDM is needed to reflect this. So, is there anything more specific? The referenced review of conceptual models of SDM identifies several types of clinician behaviour that characterize SDM. They include: explaining the problem and options; discussing benefits and risks, patient preferences and abilities; presenting evidence; making recommendations; clarifying patient's understanding; and making decisions explicit. All this has been part of good clinical practice for decades and may be regarded as common sense. It remains unclear how a basic understanding of good communication benefits from being relabelled as SDM2. Secondly, there is a claim that “patients want SDM”. Patients are not one homogenous block of people who would all want the same thing and all of the time. Patients have different preferences for the communication style of their clinicians. Preferences differ associated with their personality, background and experiences, and may vary even for the same patient depending on the given health problem, the context, the specific content of the consultation, and the mood on the day. Slade cites a patient survey in the UK National Health Service, seemingly suggesting that patients in mental health care in the UK are not involved in treatment decisions although they would like to be3. A closer look at the data shows, however, that the question “Were you involved as much as you wanted to be in agreeing what care you will receive?” was answered with “no” by only 7% of patients. Although it should be a challenge to reduce this figure even further, it is hardly a reason to call for a radical change in the current approach. Furthermore, it should be noted that this survey was conducted in patients with severe mental illness in community mental health care in the UK, who cannot easily go to a different clinician in case they are unhappy with their current one. In other systems and other patient groups, e.g. when patients pay for their services directly or through insurance, SDM is presumably even less of a problem, as patients can simply go to a different psychiatrist, if they do not like the communication style or the treatment suggestions of their psychiatrists. Do these concerns suggest that there is no problem in how clinicians and patients communicate in mental health care? Far from it! On the contrary, I would argue that the communication between patients and clinicians is at the heart of mental health care, and that improving this communication is the single most important and promising route to more effective treatment. For achieving this, however, general and vague terms such as SDM are not very helpful. Research on patient-clinician communication requires precise theories, specified models and detailed analyses. Examples from our own group to illustrate such research on different aspects of patient-clinician communication include: in-depth analyses of the difficulty of psychiatrists to address patients’ concerns about their delusions4, 5; a non-clinical experiment about how psychiatrists should introduce themselves in the first encounter6; and randomized controlled trials on how to improve communication and, through that, treatment outcomes. One trial showed that a new intervention structuring and focusing the routine communication between patients and clinicians in community mental health care (DIALOG+) leads to substantially more favourable clinical and social outcomes7. Another trial demonstrated that clinicians can learn and successfully apply new skills in addressing psychotic symptoms of their patients8. Such research still faces a range of significant conceptual and methodological challenges, and the results are hardly conclusive. Yet, the findings may be seen as encouraging to pursue and advance both rigorous research in patient-clinician communication and teaching of relevant skills. The call for SDM may reflect a wider and fundamental problem of current psychiatry. The last decades have seen the rise of appealing terms that arose in the public arena and with lay audiences, where the absence of a precise definition is often an advantage. Recent examples include SDM, but also recovery and co-production. Such terms are intuitively appealing to various stakeholders, who are free to understand them in any way they like. These terms may have their value in a political debate, but less so in a professional discourse. One might argue that, for psychiatry as a scientific discipline, these terms are even harmful. All scientific progress requires intellectual honesty as the starting point. One needs an unbiased account of what a discipline has already discovered and achieved, but also of what the limitations are. If there has been limited progress in treatment concepts in psychiatry over the last three decades, then this is no disgrace. It has to be considered appropriately, so that as a discipline we can learn from failure and hopefully move on. Terms like recovery, SDM and co-production give the illusion of novelty, of new ideas and new insights, when in fact there have been none. I wish such terms would be recognized as what they are, a combination of common sense, simplification and fashionable jargon, without much new substance that would help mental health care move forward. They resemble the “the emperor's new clothes” in Andersen's tale9. Facing a lack of novelty may be uncomfortable, but it is likely to be a necessary step towards real innovation. Stefan Priebe Unit for Social and Community Psychiatry, WHO Collaborating Centre for Mental Health Services Development, Queen Mary University of London, London, UK