Collaborative Decision Making
Collaborative Decision Making
Issue 33 – December 2012Author: Steven Coles (firstname.lastname@example.org)
- Collaborative decision making requires forming a shared understanding of an issue
- Different professionals and service users can have assumptions, values and goals that are in conflict with each other
- Legal, organisational and professional forms of power can inhibit equality in decision making
Implications for practice
- It is important for staff to critically reflect on, and be open about the robustness or otherwise of their professional knowledge, models and practice
- We should place greater emphasis on the experience and knowledge of service users
- We can usefully reflect on and try to modify the operation of power at an interpersonal level
What is decision making and collaboration?We make decisions all the time, often we do this with-out giving it much thought or based on ‘gut instinct’. With more complicated decisions or when there are significant differences of opinion, we might take more time identifying the possible courses of action and then choosing an option. When two or more people collaborate on a decision, they are usually working together towards a shared goal with a mutual interest in achieving this. Decisions resulting from such collaborations will be shaped by the values, assumptions and relative power of those involved. This raises such questions as: does a particular mental health professional and a service user have shared assumptions, values and goals? If not, how far apart are they? Can they be reconciled? How much have we listened to, comprehended and shown we’ve grasped the service user’s perspective? With-out a shared understanding of an issue, it is very difficult to find a mutually agreeable way to resolve a problem.
What are the barriers to collaborative decision making?Reaching a mutual understanding in mental health services can be difficult. Even between mental health professionals, there can very different models and assumptions regarding mental health. Biomedical models tend to dominate mental health services and this can conflict with the fact that the general population tend to favour socially /environmentally focussed explanations2. How does a professional with a firmly held belief in a biological model of ‘delusions beliefs’, collaborate with someone with a firmly held belief that the CIA are trying to poison them? My belief is that we need to find some form of common ground. It is difficult for two people to find common ground, if they hold rigidly to their point of view and do not attempt to listen to and appreciate another’s perspective. Listening and understanding does not necessarily mean agreeing with, but shows an openness and respect to the other. Our professional knowledge, models and skills are important to our roles and identity, however such expert knowledge can be a barrier to collaboration if it narrows our view of a situation and closes down possible options to resolving a problem. All models of mental distress are contested and have weaknesses in terms of their evidence base and logic of their theoretical underpinnings3. Therefore as professionals, I feel we should be open to critically reflecting on the robustness of our own models and practice, whether cognitive, biological, or psychodynamic. Alongside modesty and reflection regards our professional knowledge, I believe we need to give more respect to the knowledge and subjective experience of service users (see also Campbell, 20094). Psychiatrist Joanna Moncrieff5 has also made this point convincingly regarding decision making around the use of psychiatric medication. She argues that we need ask more about, and place greater emphasis on, the positive and negative experience of psychiatric drugs recounted by those taking them.
Importance of Power and RiskCollaborative decision making suggests some form of approximation to equality in power for those involved. However, this is rarely the case in mental health services; tensions and contradictions between care and control are widespread. Coercion is embedded in the legal framework of the Mental Health Act, and the civil liberties of those with a diagnosis of a mental disorder are more at risk than any other group in British society – other than suspected terrorists6. Even the idea that we are working in the interests of the service user is questionable; those entering mental health services often do so at the behest of family members or people in the neighbourhood. Professionals have there own interests and anxieties, which may conflict with the interests of service users. Such anxieties have increased as risk has become ever more prominent in mental health services. Vassilev and Pilgrim (2007)6 note that whilst ‘…social control has always been at the centre of mental disorder and its ‘‘treatment’’, it is the current climate of ‘‘risk’’, the culture of risk assessment, and the politics of anxiety, that have led to more conservative decision making…’ (P. 352).
Aspiring to Collaborative Decision Making?The barriers noted above severely restrict collaborative decision making, however this does not mean we should not aspire to it. I believe power is a crucial consideration in decision making. Social, legal and organisational power influences decision making and even professionals striving for collaboration will feel restricted by such power. However power also operates within the nuances of a face to face interaction, I believe we can try to make some positive changes in this area. It is useful for us to reflect on questions such as: How accessible is the language of the professional? How much space and respect is given to the service user’s perspective? How much support has been given to a service user before a meeting, so that they can express their views in the best possible manner? Who has set the agenda to a meeting? How transparent and open are we regarding weaknesses in our professional knowledge, such as the scientific weakness of diagnosis? How comfortable does the physical environment make the client feel? Does the service user have an advocate? Has the service user been directed to groups who share their concerns? Furthermore, the minor details of body language and tone of voice can either invite and open up conversations, or close down and restrict.
Final CommentWithin the current structures of mental health services and legal framework of the Mental Health Act, full collaborative decision making is more illusory than actual, however, this should not stop us from aspiring for a greater voice for people within mental health services.
- Nottingham Healthcare NHS Trust (2012). Positive about delivering CQC standards. Nottingham: Nottinghamshire Healthcare NHS Trust
- Read, J., Haslam, N, Sayce, L. & Davies, E. (2006). Prejudice and schizophrenia: a review of the ‘mental illness is an illness like any other’ approach. Acta Psychiatrica Scandinavica, 114, 303–318.
- Read, J., Mosher, L. & Bentall, R. (Eds.) (2004). Models of Madness. Hove: Brunner – Routledge.
- Campbell, P. (2009). The Service User/Survivor Movement. In J. Reynolds, R. Muston, T. Heller, J. Leach, M. McCormick, J. Wallcraft & M. Walsh (Eds.). Mental Health Still Matters. Basingstoke: Palgrave.
- Moncrieff, J. (2008). The myth of the chemical cure. Hampshire: Palgrave Macmillan.
- Vassilev, I. & Pilgrim, D. (2007). Risk, trust and the myth of mental health services. Journal of Mental Health, 16, 347 – 357.
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