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Involving patients in decisions during psychiatric consultations

  • Claudia Goss (a1), Francesca Moretti (a1), Maria Angela Mazzi (a1), Lidia Del Piccolo (a1), Michela Rimondini (a1) and Christa Zimmermann (a1)...



Patient involvement in the decision-making process is a key element for good clinical practice. Few data are available on patient involvement in psychiatry.


To assess in a psychiatric out-patient context how psychiatrists involve patients in therapeutic decisions and to determine the extent to which patient and psychiatrist characteristics contribute to patient involvement.


Eighty transcripts from audiotaped first out-patient consultations, conducted by 16 psychiatrists, were rated with the OPTION (observing patient involvement) scale. Interrater reliability indices were obtained for 30 randomly selected interviews. Associations between OPTION scores and some clinical and socio-demographic variables were tested using t-test, ANOVA and Pearson's correlation coefficient where appropriate. The distribution of scores for each psychiatrist was assessed by intracluster correlation coefficients.


Interrater reliability and internal consistency of the OPTION scale in the psychiatric setting were satisfactory. The total score and the ratings for the single OPTION items showed a skewed distribution, with a prevalence of scores in the low range of abilities, corresponding to minimal attempts to involve patients or a minimal skill level.


The OPTION scale proves to be a reliable instrument to assess patient involvement in a psychiatric setting. Psychiatrists showed poor patient involvement abilities parallel to previous findings in psychiatry and primary care. They need to be encouraged to share treatment decisions with their patients and to apply patient involvement skills. Further research is needed to establish which patient variables and clinical settings in psychiatry are more amenable to shared decisions, and how participation of psychiatric patients in treatment decisions will affect the outcome.

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Corresponding author

Claudia Goss, Department of Medicine and Public Health, Section of Psychiatry and Clinical Psychology, University of Verona, Policlinico G.B. Rossi Piazzale L.A. Scuro 10, 37134 Verona, Italy. Email:


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Involving patients in decisions during psychiatric consultations

  • Claudia Goss (a1), Francesca Moretti (a1), Maria Angela Mazzi (a1), Lidia Del Piccolo (a1), Michela Rimondini (a1) and Christa Zimmermann (a1)...
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Skills for involving patients in decisions

Josephine M Stanton, Psychiatrist
24 January 2009

In the discussion of their paper on involving patients in decision making Goss et al [1] list the skills required for involvement of patientsin decsion making. Information gathering, relationship building and information giving skills are generally addressed in training of psychiatrists. What are not often identified as important for psychiatrists are skills in bringing forward patient knowledge. By their very nature psychiatric illnesses can impair cognitive functioning. At thepoint of presentation to a psychiatrist patients often feel disempowered and overwhelmed. Both these factors can undermine the ease with which theycan access their ideas and knowledge to contribute to a decision making process.

Motivational Interviewing [2] and Brief Solution Focused Therapy [3] are well known therapeutic approaches, each with a particular focus, whichbring patients’ thoughts and ideas into their conscious awareness as a resource. A number of other approaches, notably cognitive therapy approaches, also bring thoughts into conscious awareness but the focus is towards changing or managing thoughts rather than valuing them as a resource. Johnella Bird [4] has developed a more comprehensive therapeuticapproach which employs careful use of language and reflection to bring forward people’s knowledge, values, resource and agency. Embedded in thisapproach are a range of microskills which can enhance psychiatric consultation. I have worked with a colleague to develop a website outlining how Bird’s ideas can be applied to mental health work. [5] Belowis a brief, one sided example of how some of these ideas can support patient involvement in decision making.

When I suggested you take antipsychotic medication you responded quickly with a firm ‘no’. I would like to understand how you came to that decision. We are both aware that I hold the belief that antipsychotic medication could be helpful for you and you hold a different idea. In wanting to understand the decision you are making I am not seeking to persuade you. If the asking about the decision I am doing is feeling as ifI am trying to persuade you I would like you to let me know. How can I support you to let me know? I am wondering if you would find it easier to use a hand signal than words. Would it help if I asked you, now and again,about the level of comfort you are feeling in the conversation?

1.Goss, C., et al., Involving patients in decisions during psychiatric consultations. British Journal of Psychiatry, 2008. 193: p. 416-421.2.Miller, W.R. and S. Rollnick, Motivational Interviewing: Preparing People for Change. 2nd edition ed. 2002, New York London: Guilford Press.3.O'Connell, Solution Focused Therapy. 1998, New York: Sage.4.Bird, J., Talk that Sings: Therapy in a New Linguistic Key. 2004, Auckland: Edge Press.5.Stanton, J. and T. Windelborn. 2007 2008 [cited].
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