A critical narrative analysis of shared decision-making in acute, inpatient mental health care

Shared decision-making (SDM) is a high priority in healthcare policy and is complementary to the recovery philosophy in mental health care. This agenda has been operationalised within the Values-Based Practice (VBP) framework, which offers a theoretical and practical model to promote democratic interprofessional approaches to decision-making. However, these are limited by a lack of recognition of the implications of power implicit within the mental health system. This study considers issues of power within the context of decision-making and examines to what extent decisions about patients? care on acute in-patient wards are perceived to be shared. Focus groups were conducted with 46 mental health professionals, service users, and carers. The data were analysed using the framework of critical narrative analysis (CNA). The findings of the study suggested each group constructed different identity positions, which placed them as inside or outside of the decision-making process. This reflected their view of themselves as best placed to influence a decision on behalf of the service user. In conclusion, the discourse of VBP and SDM needs to take account of how differentials of power and the positioning of speakers affect the context in which decisions take place.

Affect--or feeling (after Leys)

In recent years the ‘affective turn’ has permeated the arts, humanities, social sciences, and psychology, but like any influential academic movement has not escaped critique. We outline and agree in general terms with the critique by Leys (2011b), which emphasises the influence of the basic emotion paradigm; the dualisms that accompany its deployment; and concerns regarding intentionality and meaning. We then propose an alternate approach to affect and feeling, derived from the philosophies of Whitehead and Langer; demonstrate how this avoids the endorsement of cognitivism to which Leys critique succumbs; illustrate the strengths of this approach with respect to analyses of former U.S. President Reagan; and highlight two strengths of affect theory which are compatible with it. We conclude that our approach closes the intentionality gap that Leys identifies whilst retaining a fruitful emphasis upon the affective realm.