[Solved] Models of shared decision

Assignment Prompt & Instructions

**files (3)**

– ## Modelsofshareddecision.docx

– ## Zisman-Ilanietal2021SDM.pdf

– Dundas20211.pdf

**## Modelsofshareddecision.docx**

**Please follow APA format, add citations and references from the articles. Document will be verified for plagiarism and AI use. Thank you!**

Topic
**Models of shared decision-making in mental healthcare**

Please read the articles. Please note topics relevant to clinical decision making, including assessment, formulation, diagnosis, and treatment. Take those interesting points and expand form two relevant articles
**from your library journals.** The articles you choose must contribute something new to our understanding of the topic. I frown on rehashes of commonly known or repetitive topics.

You do not need a cover page for discussion. Please include at least two original references from the literature that are not solely from the articles that I provided. Your discussion should be about
**250 words**.  Provide two responses to your peers of about 100 words with at least one original article. You may not use the previous two articles from the original discussion post.
**Please do not submit as attachments**. These posts should be
**innovative, creative, exploratory, thought provoking, and relevant.** Students who include content from the literature with correct references and citations typically earn the highest grades. I am strict about APA. Consult the APA Manual. Do not guess and do not rely on copy and paste, as often it is incorrect APA.

**## Zisman-Ilanietal2021SDM.pdf**

Shared Risk Taking: Shared Decision Making in Serious
Mental Illness
Yaara Zisman-Ilani, M.A., Ph.D., Paul H. Lysaker, Ph.D., Ilanit Hasson-Ohayon, M.A., Ph.D.

Shared decision making (SDM) is an interpersonal health
communicationmodel that is underutilized with people with
serious mental illness. Although research has emphasized
the role of patient capacity–, clinician-, and system-related
barriers in SDM underutilization, the risk taking that affects
SDM with people with mental illness is less often discussed.
ThisOpen Forumpresents a reconceptualization of SDMas a

process of shared risk taking that often occurs during dif-
ferent phases of illness management and recovery. The
concepts of intersubjectivity, meaning making, and meta-
cognition are offered to inform clinical interventions needed
to address risk in SDM.

Psychiatric Services 2021; 72:461–463; doi: 10.1176/appi.ps.202000156

Shared decision making (SDM) aims to facilitate patient-
centered care and treatment adherence by promoting joint
treatment decision making between patients with chronic
conditions and clinicians (1). In mental health care, SDM has
been recommended for people with serious mental illness,
given that self-determination, choice, and autonomy are core
aspects of recovery-oriented care (2, 3).

Despite the proliferating development of SDM interven-
tions (2), SDM implementation for patients with serious
mental illness has been relatively less successful than for
other groups. This disparity has been attributed to a variety
of barriers (4), including clinicians’ paternalistic approach
to care of patients with serious mental illness and stigma-
related beliefs that SDM is inappropriate for such patients.
Unlike other chronic nonpsychiatric conditions, the char-
acteristics of serious mental illness may pose a major barrier
to SDM implementation. For example, psychotic symptoms
and cognitive deficits associated with schizophrenia can
affect decision-making capacity and serve as barriers to
SDM, whereas an elevated blood-glucose level associated
with diabetes does not stop patients from being involved in
SDM. Another potential barrier to SDM among patients
with serious mental illness is negative internalized self-
stigma, a common experience that leads patients to un-
derestimate their own competency for decision making and
autonomy (5, 6).

A greater barrier, though, may be clinicians’ fear of lia-
bility and legal exposure. Clinicians may resist SDM with
patients with serious mental illness because they fear being
held liable for any potentially negative outcome that might
result fromSDM, such as symptom exacerbation, hospitalization,

or death. Burnout, patient load, and limited appointment
time also contribute to clinicians’ reluctance to engage in
SDM (4).

Although promising, research and implementation of
SDM in mental health care have overlooked the fact that
SDM is sometimes at odds with clinicians’ training to miti-
gate the risk of harm and with organizational policies that
are inherently risk averse. To promote the implementation
and usage of SDM with people with serious mental illness,
clinicians must acknowledge and directly confront issues of
risk, which are inherent in psychiatry and which hinder
SDM with individuals who have serious mental illness. In
this Open Forum, we offer a new conceptualization, shared
risk taking, as a unique way to view SDM with people with
serious mental illness. We argue that risks are an inevitable
part of the SDM process and are not related only to the
decision at hand and that joint reflection by the clinician and
patient should be used to address SDM-related risks.

Inherent Risks in Serious Mental Illness Management
and Recovery

Across many psychiatric settings, different levels of risk and
standards of risk management are used to mitigate harm
and minimize negative health outcomes while prioritizing
management of some risks over others. In psychiatry, re-
ducing risks to safety is the highest priority, because it is a
key part of one aspect of clinicians’ professional training and
responsibility and is the common institutional policy among
mental health services. Perceived risks to safety affect both
clinicians and patients, but differently. For clinicians, safety

Psychiatric Services 72:4, April 2021 ps.psychiatryonline.org 461

OPEN FORUM

[http://ps.psychiatryonline.org](http://ps.psychiatryonline.org/)

[https://psychiatryonline.org/servlet/linkout?type=rightslink&url=startPage%3D461%26pageCount%3D3%26copyright%3D%26author%3DYaara%2BZisman-Ilani%252C%2BPaul%2BH.%2BLysaker%252C%2BIlanit%2BHasson-Ohayon%26orderBeanReset%3Dtrue%26imprint%3DAmerican%2BPsychiatric%2BPublishing%26volumeNum%3D72%26issueNum%3D4%26contentID%3D10.1176%252Fappi.ps.202000156%26title%3DShared%2BRisk%2BTaking%253A%2BShared%2BDecision%2BMaking%2Bin%2BSerious%2BMental%2BIllness%26numPages%3D3%26pa%3D%26issn%3D1075-2730%26publisherName%3Dnone%26publication%3Dps%26rpt%3Dn%26endPage%3D463%26publicationDate%3D04%252F01%252F2021](https://psychiatryonline.org/servlet/linkout?type=rightslink&url=startPage%3D461%26pageCount%3D3%26copyright%3D%26author%3DYaara%2BZisman-Ilani%252C%2BPaul%2BH.%2BLysaker%252C%2BIlanit%2BHasson-Ohayon%26orderBeanReset%3Dtrue%26imprint%3DAmerican%2BPsychiatric%2BPublishing%26volumeNum%3D72%26issueNum%3D4%26contentID%3D10.1176%252Fappi.ps.202000156%26title%3DShared%2BRisk%2BTaking%253A%2BShared%2BDecision%2BMaking%2Bin%2BSerious%2BMental%2BIllness%26numPages%3D3%26pa%3D%26issn%3D1075-2730%26publisherName%3Dnone%26publication%3Dps%26rpt%3Dn%26endPage%3D463%26publicationDate%3D04%252F01%252F2021)

risks, such as relapse, present high potential for legal lia-
bility, particularly if the risk is accompanied by symptoms
potentially related to harm, such as suicidality or homi-
cidality. For patients, these risks may take the form of re-
duced quality of life, which might stem from symptom
exacerbation, hospitalization, or the psychological or po-
tentially permanent physical side effects of treatment (7).

Yet the path to recovery from serious mental illness re-
quires more than minimizing safety-related risks. Recovery-
oriented care involves a broad array of risks inherent in all
domains of patients’ lives, such as employment, education,
and relationships. For a patient, a decision to stop working
poses economic and mental health risks, whereas returning
to work after a psychiatric hospitalization may be associated
with high risks of humiliation or failure, which pose other
sets of emotional and psychological risks. Nevertheless,
recovery-related decisions do not usually pose significant
risks for either clinician or patient, and SDM can be en-
couraged. Therefore, there is a greater chance of success-
fully implementing and using SDM in recovery-related
decisions, such as those concerning employment or educa-
tion, and a lower chance of using SDM in health-related
decisions, such as tapering medications, that involve safety
risks for both patients and clinicians.

Shared Risk Taking

With the understanding that risk is both unavoidable and a
core element of any decision (8), the challenges of SDM for
persons with serious mental illness become apparent. How
should clinicians and patients make decisions with poten-
tially negative outcomes or when a patient’s decision-making
capacity is unclear? These dilemmas point to the reality that
in some situations and for some decisions, joint decision
making with people with serious mental illness will likely
involve decisions about risk and thus might be better char-
acterized as shared risk taking.

We introduce shared risk taking as a new perspective that
aims to emphasize the often-overlooked risks associated
with SDM with patients with serious mental illness that
might inhibit SDM usage, implementation, and effective-
ness. For example, clinicians might involve patients in
choosing between different medications but will not present
the option of abstaining from medication (9). Patients, for
their part, might conceal certain information relevant to
SDM from their clinician—for example, that they have tapered
or stopped taking their medications—to avoid the risk of
losing disability stipends or other benefits or of being seeing
negatively by the psychiatrist (10). We offer shared risk
taking as a way to attend to, via processes of intersubjectivity
and metacognition, unspoken risks that the SDM literature
does not explicitly discuss or offer ways of addressing.

In shared risk taking, the clinician and patient should
jointly reflect on the inherent risks of any decision and
discuss issues related to the patient’s and clinician’s stig-
matizing or paternalistic beliefs regarding their inability to

participate in decision making. The clinician and patient
should explicitly conduct a risk assessment of the decision,
its safety implications, and the patient’s capacity to be in-
volved in the decision making. A shared-risk-taking ap-
proach is valuable not only in psychiatry and mental health
settings but also in populations of individuals with de-
velopmental disorders, Alzheimer’s disease, or drug abuse
and even with children, whose capacity for decision making
is questioned and who are often exposed to stigmatizing and
paternalistic beliefs.

The recognition of risks in SDM with patients who have
serious mental illness calls for a deeper exploration of at
least two aspects of the SDM process that have been rela-
tively unrecognized. First, SDM focuses more on presenting
medical options and discussing their risks and benefits than
on sharing emotions pertaining to risk taking. We believe
that the success of SDM relies on a set of fundamentally
intersubjective patient-clinician processes that involve a
shared experience of anxiety, worry, and fear when certain
decisions are made (11). Patients’ and clinicians’ expression
of both worries and hopes during SDM can serve as a
foundation for joint reflection and can lead to a better
decision-making process, an informed decision, and a greater
commitment and motivation to attain a positive outcome.
Of note, appointment lengths and professional attitudes
in some setting are less likely to leave room for sharing
thoughts and feelings than in other settings. Nevertheless,
we recommend that clinicians at least attempt to share
thoughts and feelings related to risk taking when making
decisions.

The second aspect of SDM that may have been previously
unrecognized involves considering the process of meaning
making and the metacognitive abilities that enable it (12, 13).
Certainly, any decision to take a risk must involve meanings
assigned to the behavior in question. For example, deciding
whether a risk isworth takingwhen considering discontinuing
a medication, seeking a romantic relationship, or applying
for a new job must be a function of how meaningful a
medication, a relationship, or a new job could be to the de-
cision maker (8, 14). Often, SDM does not invite broader
explorations of meaning, and SDM principles do not ade-
quately translate into existing SDM tools. Thus, to improve
SDM in mental health care, clinicians must acknowledge that
through joint reflection, risks are given meaning in the context
of the patient’s unique life—that is, they are interpreted as
more than simply generic medical risks.

Conclusions

There is a gap between recommendations to disseminate and
implement SDM in mental health care and the limited use
of SDM in practice. We suggest a new conceptualization,
shared risk taking, to explain this gap and to facilitate the
implementation of SDM and adherence to its principles,
when applicable. This is not simply a matter of semantics:
reframing SDM as shared risk taking poses important

462 ps.psychiatryonline.org Psychiatric Services 72:4, April 2021

SHARED DECISION MAKING IN SERIOUS MENTAL ILLNESS

[http://ps.psychiatryonline.org](http://ps.psychiatryonline.org/)

[https://psychiatryonline.org/servlet/linkout?type=rightslink&url=startPage%3D461%26pageCount%3D3%26copyright%3D%26author%3DYaara%2BZisman-Ilani%252C%2BPaul%2BH.%2BLysaker%252C%2BIlanit%2BHasson-Ohayon%26orderBeanReset%3Dtrue%26imprint%3DAmerican%2BPsychiatric%2BPublishing%26volumeNum%3D72%26issueNum%3D4%26contentID%3D10.1176%252Fappi.ps.202000156%26title%3DShared%2BRisk%2BTaking%253A%2BShared%2BDecision%2BMaking%2Bin%2BSerious%2BMental%2BIllness%26numPages%3D3%26pa%3D%26issn%3D1075-2730%26publisherName%3Dnone%26publication%3Dps%26rpt%3Dn%26endPage%3D463%26publicationDate%3D04%252F01%252F2021](https://psychiatryonline.org/servlet/linkout?type=rightslink&url=startPage%3D461%26pageCount%3D3%26copyright%3D%26author%3DYaara%2BZisman-Ilani%252C%2BPaul%2BH.%2BLysaker%252C%2BIlanit%2BHasson-Ohayon%26orderBeanReset%3Dtrue%26imprint%3DAmerican%2BPsychiatric%2BPublishing%26volumeNum%3D72%26issueNum%3D4%26contentID%3D10.1176%252Fappi.ps.202000156%26title%3DShared%2BRisk%2BTaking%253A%2BShared%2BDecision%2BMaking%2Bin%2BSerious%2BMental%2BIllness%26numPages%3D3%26pa%3D%26issn%3D1075-2730%26publisherName%3Dnone%26publication%3Dps%26rpt%3Dn%26endPage%3D463%26publicationDate%3D04%252F01%252F2021)

challenges for SDM research and practice. It seems imperative
to explore the different experiences of risk for clinicians and
patients. Althoughoutside the scope of thisOpenForum, future
research should explore the institutional and policy factors that
both hinder and enable patients and clinicians in making
adaptive decisions about risk (15). Although SDM occurs in the
interpersonal-intersubjective patient-clinician interaction, cli-
nicians must manage requirements at both the system and
organizational levels simultaneously, which has also been
shown to inhibit the adoption of SDM, even when clinicians
view the practice favorably. Furthermore, current SDM prac-
tice, which often relies on decision aids and decision support
tools (2), is not designed to capture risk taking in the context of
complex decisions with broader life implications. Future re-
search should focus on adapting SDM tools to encompass the
shared risk of decision making in serious mental illness.
Adopting a shared-risk-taking perspective that takes into ac-
count patient capacity, metacognition, and the existence of
intersubjectivity in the experience of risks can facilitate SDM in
mental health care by targeting a blind spot in SDM practice.

AUTHOR AND ARTICLE INFORMATION

Department of Social and Behavioral Science, College of Public Health,
Temple University, Philadelphia (Zisman-Ilani); Veterans Affairs Medical
Center, and Department of Psychiatry, Indiana University School of
Medicine, Indianapolis (Lysaker); Department of Psychology, Bar-Ilan
University, Ramat-Gan, Israel (Hasson-Ohayon). Send correspondence
to Dr. Zisman-Ilani (yaara@temple.edu).

The authors report no financial relationships with commercial interests.

Received March 10, 2020; revisions received June 14 and July 23, 2020;
accepted August 5, 2020; published online February 9, 2021.

REFERENCES
1. Charles C, Gafni A, Whelan T: Shared decision-making in the

medical encounter: what does it mean? (Or it takes at least two to
tango). Soc Sci Med 1997; 44:681–692

2. Zisman-Ilani Y, Barnett E, Harik J, et al: Expanding the concept of
shared decision making for mental health: a systematic and scoping
review of interventions. Ment Heal Rev J. 2017; 22:191–213

3. Salyers MP, Zisman-Ilani Y: Shared decision-making and
self-directed care; in The Palgrave Handbook of American
Mental Health Policy. Edited by Goldman H, Frank RG, Morrissey
JP. Cham, Switzerland, Springer International Publishing,
2020

4. Hamann J, Heres S: Adapting shared decision making for indi-
viduals with severe mental illness. Psychiatr Serv 2014; 65:1483–
1486

5. Simmons M, Hetrick S, Jorm A: Shared decision-making: benefits,
barriers, and current opportunities for application. Australas Psy-
chiatry 2010; 18:394–397

6. Hamann J, Bühner M, Rüsch N: Self-stigma and consumer par-
ticipation in shared decision making in mental health services.
Psychiatr Serv 2017; 68:783–788

7. Ostrow L, Jessell L, Hurd M, et al: Discontinuing psychiatric
medications: a survey of long-term users. Psychiatr Serv 2017; 68:
1232–1238

8. Ponte K. A risk too big not to take: a story of recovery. Psychiatr
Serv. 2020; 71:516–517

9. Zisman-Ilani Y, Shern D, Deegan P, et al: Continue, adjust, or stop
antipsychotic medication: developing and user testing an encoun-
ter decision aid for people with first-episode and long-term psy-
chosis. BMC Psychiatry 2018; 18:142

10. Roe D, Goldblatt H, Baloush-Klienman V, et al: Why and how
people decide to stop taking prescribed psychiatric medication:
exploring the subjective process of choice. Psychiatr Rehabil J
2009; 33:38–46

11. Hasson-Ohayon I, Kravetz S, Lysaker PH: The special challenges of
psychotherapy with persons with psychosis: intersubjective meta-
cognitive model of agreement and shared meaning. Clin Psychol
Psychother 2017; 24:428–440.

12. Chan KKS, Mak WWS: Shared decision making in the recovery of
people with schizophrenia: the role of metacognitive capacities in
insight and pragmatic language use. Clin Psychol Rev 2012; 32:
535–544

13. Lysaker PH, Minor KS, Lysaker JT, et al: Metacognitive function
and fragmentation in schizophrenia: relationship to cognition, self-
experience and developing treatments. Schizophr Res Cogn 2019;
19:100142

14. Deegan PE, Drake RE: Shared decision making and medication
management in the recovery process. Psychiatr Serv 2006; 57:1636–
1639

15. Morrison AP, Hutton P, Shiers D, et al: Antipsychotics: is it time to
introduce patient choice? Br J Psychiatry 2012; 201:83–84

Psychiatric Services 72:4, April 2021 ps.psychiatryonline.org 463

ZISMAN-ILANI ET AL.

[mailto:yaara@temple.edu](mailto:yaara@temple.edu)

[http://ps.psychiatryonline.org](http://ps.psychiatryonline.org/)

[https://psychiatryonline.org/servlet/linkout?type=rightslink&url=startPage%3D461%26pageCount%3D3%26copyright%3D%26author%3DYaara%2BZisman-Ilani%252C%2BPaul%2BH.%2BLysaker%252C%2BIlanit%2BHasson-Ohayon%26orderBeanReset%3Dtrue%26imprint%3DAmerican%2BPsychiatric%2BPublishing%26volumeNum%3D72%26issueNum%3D4%26contentID%3D10.1176%252Fappi.ps.202000156%26title%3DShared%2BRisk%2BTaking%253A%2BShared%2BDecision%2BMaking%2Bin%2BSerious%2BMental%2BIllness%26numPages%3D3%26pa%3D%26issn%3D1075-2730%26publisherName%3Dnone%26publication%3Dps%26rpt%3Dn%26endPage%3D463%26publicationDate%3D04%252F01%252F2021](https://psychiatryonline.org/servlet/linkout?type=rightslink&url=startPage%3D461%26pageCount%3D3%26copyright%3D%26author%3DYaara%2BZisman-Ilani%252C%2BPaul%2BH.%2BLysaker%252C%2BIlanit%2BHasson-Ohayon%26orderBeanReset%3Dtrue%26imprint%3DAmerican%2BPsychiatric%2BPublishing%26volumeNum%3D72%26issueNum%3D4%26contentID%3D10.1176%252Fappi.ps.202000156%26title%3DShared%2BRisk%2BTaking%253A%2BShared%2BDecision%2BMaking%2Bin%2BSerious%2BMental%2BIllness%26numPages%3D3%26pa%3D%26issn%3D1075-2730%26publisherName%3Dnone%26publication%3Dps%26rpt%3Dn%26endPage%3D463%26publicationDate%3D04%252F01%252F2021)

**Dundas20211.pdf**

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**Dundas20211.pdf**

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**## Modelsofshareddecision.docx**

**Please follow APA format, add citations and references from the articles. Document will be verified for plagiarism and AI use. Thank you!**

Topic
**Models of shared decision-making in mental healthcare**

Please read the articles. Please note topics relevant to clinical decision making, including assessment, formulation, diagnosis, and treatment. Take those interesting points and expand form two relevant articles
**from your library journals.** The articles you choose must contribute something new to our understanding of the topic. I frown on rehashes of commonly known or repetitive topics.

You do not need a cover page for discussion. Please include at least two original references from the literature that are not solely from the articles that I provided. Your discussion should be about
**250 words**.  Provide two responses to your peers of about 100 words with at least one original article. You may not use the previous two articles from the original discussion post.
**Please do not submit as attachments**. These posts should be
**innovative, creative, exploratory, thought provoking, and relevant.** Students who include content from the literature with correct references and citations typically earn the highest grades. I am strict about APA. Consult the APA Manual. Do not guess and do not rely on copy and paste, as often it is incorrect APA.

**## Zisman-Ilanietal2021SDM.pdf**

Shared Risk Taking: Shared Decision Making in Serious
Mental Illness
Yaara Zisman-Ilani, M.A., Ph.D., Paul H. Lysaker, Ph.D., Ilanit Hasson-Ohayon, M.A., Ph.D.

Shared decision making (SDM) is an interpersonal health
communicationmodel that is underutilized with people with
serious mental illness. Although research has emphasized
the role of patient capacity–, clinician-, and system-related
barriers in SDM underutilization, the risk taking that affects
SDM with people with mental illness is less often discussed.
ThisOpen Forumpresents a reconceptualization of SDMas a

process of shared risk taking that often occurs during dif-
ferent phases of illness management and recovery. The
concepts of intersubjectivity, meaning making, and meta-
cognition are offered to inform clinical interventions needed
to address risk in SDM.

Psychiatric Services 2021; 72:461–463; doi: 10.1176/appi.ps.202000156

Shared decision making (SDM) aims to facilitate patient-
centered care and treatment adherence by promoting joint
treatment decision making between patients with chronic
conditions and clinicians (1). In mental health care, SDM has
been recommended for people with serious mental illness,
given that self-determination, choice, and autonomy are core
aspects of recovery-oriented care (2, 3).

Despite the proliferating development of SDM interven-
tions (2), SDM implementation for patients with serious
mental illness has been relatively less successful than for
other groups. This disparity has been attributed to a variety
of barriers (4), including clinicians’ paternalistic approach
to care of patients with serious mental illness and stigma-
related beliefs that SDM is inappropriate for such patients.
Unlike other chronic nonpsychiatric conditions, the char-
acteristics of serious mental illness may pose a major barrier
to SDM implementation. For example, psychotic symptoms
and cognitive deficits associated with schizophrenia can
affect decision-making capacity and serve as barriers to
SDM, whereas an elevated blood-glucose level associated
with diabetes does not stop patients from being involved in
SDM. Another potential barrier to SDM among patients
with serious mental illness is negative internalized self-
stigma, a common experience that leads patients to un-
derestimate their own competency for decision making and
autonomy (5, 6).

A greater barrier, though, may be clinicians’ fear of lia-
bility and legal exposure. Clinicians may resist SDM with
patients with serious mental illness because they fear being
held liable for any potentially negative outcome that might
result fromSDM, such as symptom exacerbation, hospitalization,

or death. Burnout, patient load, and limited appointment
time also contribute to clinicians’ reluctance to engage in
SDM (4).

Although promising, research and implementation of
SDM in mental health care have overlooked the fact that
SDM is sometimes at odds with clinicians’ training to miti-
gate the risk of harm and with organizational policies that
are inherently risk averse. To promote the implementation
and usage of SDM with people with serious mental illness,
clinicians must acknowledge and directly confront issues of
risk, which are inherent in psychiatry and which hinder
SDM with individuals who have serious mental illness. In
this Open Forum, we offer a new conceptualization, shared
risk taking, as a unique way to view SDM with people with
serious mental illness. We argue that risks are an inevitable
part of the SDM process and are not related only to the
decision at hand and that joint reflection by the clinician and
patient should be used to address SDM-related risks.

Inherent Risks in Serious Mental Illness Management
and Recovery

Across many psychiatric settings, different levels of risk and
standards of risk management are used to mitigate harm
and minimize negative health outcomes while prioritizing
management of some risks over others. In psychiatry, re-
ducing risks to safety is the highest priority, because it is a
key part of one aspect of clinicians’ professional training and
responsibility and is the common institutional policy among
mental health services. Perceived risks to safety affect both
clinicians and patients, but differently. For clinicians, safety

Psychiatric Services 72:4, April 2021 ps.psychiatryonline.org 461

OPEN FORUM

[http://ps.psychiatryonline.org](http://ps.psychiatryonline.org/)

[https://psychiatryonline.org/servlet/linkout?type=rightslink&url=startPage%3D461%26pageCount%3D3%26copyright%3D%26author%3DYaara%2BZisman-Ilani%252C%2BPaul%2BH.%2BLysaker%252C%2BIlanit%2BHasson-Ohayon%26orderBeanReset%3Dtrue%26imprint%3DAmerican%2BPsychiatric%2BPublishing%26volumeNum%3D72%26issueNum%3D4%26contentID%3D10.1176%252Fappi.ps.202000156%26title%3DShared%2BRisk%2BTaking%253A%2BShared%2BDecision%2BMaking%2Bin%2BSerious%2BMental%2BIllness%26numPages%3D3%26pa%3D%26issn%3D1075-2730%26publisherName%3Dnone%26publication%3Dps%26rpt%3Dn%26endPage%3D463%26publicationDate%3D04%252F01%252F2021](https://psychiatryonline.org/servlet/linkout?type=rightslink&url=startPage%3D461%26pageCount%3D3%26copyright%3D%26author%3DYaara%2BZisman-Ilani%252C%2BPaul%2BH.%2BLysaker%252C%2BIlanit%2BHasson-Ohayon%26orderBeanReset%3Dtrue%26imprint%3DAmerican%2BPsychiatric%2BPublishing%26volumeNum%3D72%26issueNum%3D4%26contentID%3D10.1176%252Fappi.ps.202000156%26title%3DShared%2BRisk%2BTaking%253A%2BShared%2BDecision%2BMaking%2Bin%2BSerious%2BMental%2BIllness%26numPages%3D3%26pa%3D%26issn%3D1075-2730%26publisherName%3Dnone%26publication%3Dps%26rpt%3Dn%26endPage%3D463%26publicationDate%3D04%252F01%252F2021)

risks, such as relapse, present high potential for legal lia-
bility, particularly if the risk is accompanied by symptoms
potentially related to harm, such as suicidality or homi-
cidality. For patients, these risks may take the form of re-
duced quality of life, which might stem from symptom
exacerbation, hospitalization, or the psychological or po-
tentially permanent physical side effects of treatment (7).

Yet the path to recovery from serious mental illness re-
quires more than minimizing safety-related risks. Recovery-
oriented care involves a broad array of risks inherent in all
domains of patients’ lives, such as employment, education,
and relationships. For a patient, a decision to stop working
poses economic and mental health risks, whereas returning
to work after a psychiatric hospitalization may be associated
with high risks of humiliation or failure, which pose other
sets of emotional and psychological risks. Nevertheless,
recovery-related decisions do not usually pose significant
risks for either clinician or patient, and SDM can be en-
couraged. Therefore, there is a greater chance of success-
fully implementing and using SDM in recovery-related
decisions, such as those concerning employment or educa-
tion, and a lower chance of using SDM in health-related
decisions, such as tapering medications, that involve safety
risks for both patients and clinicians.

Shared Risk Taking

With the understanding that risk is both unavoidable and a
core element of any decision (8), the challenges of SDM for
persons with serious mental illness become apparent. How
should clinicians and patients make decisions with poten-
tially negative outcomes or when a patient’s decision-making
capacity is unclear? These dilemmas point to the reality that
in some situations and for some decisions, joint decision
making with people with serious mental illness will likely
involve decisions about risk and thus might be better char-
acterized as shared risk taking.

We introduce shared risk taking as a new perspective that
aims to emphasize the often-overlooked risks associated
with SDM with patients with serious mental illness that
might inhibit SDM usage, implementation, and effective-
ness. For example, clinicians might involve patients in
choosing between different medications but will not present
the option of abstaining from medication (9). Patients, for
their part, might conceal certain information relevant to
SDM from their clinician—for example, that they have tapered
or stopped taking their medications—to avoid the risk of
losing disability stipends or other benefits or of being seeing
negatively by the psychiatrist (10). We offer shared risk
taking as a way to attend to, via processes of intersubjectivity
and metacognition, unspoken risks that the SDM literature
does not explicitly discuss or offer ways of addressing.

In shared risk taking, the clinician and patient should
jointly reflect on the inherent risks of any decision and
discuss issues related to the patient’s and clinician’s stig-
matizing or paternalistic beliefs regarding their inability to

participate in decision making. The clinician and patient
should explicitly conduct a risk assessment of the decision,
its safety implications, and the patient’s capacity to be in-
volved in the decision making. A shared-risk-taking ap-
proach is valuable not only in psychiatry and mental health
settings but also in populations of individuals with de-
velopmental disorders, Alzheimer’s disease, or drug abuse
and even with children, whose capacity for decision making
is questioned and who are often exposed to stigmatizing and
paternalistic beliefs.

The recognition of risks in SDM with patients who have
serious mental illness calls for a deeper exploration of at
least two aspects of the SDM process that have been rela-
tively unrecognized. First, SDM focuses more on presenting
medical options and discussing their risks and benefits than
on sharing emotions pertaining to risk taking. We believe
that the success of SDM relies on a set of fundamentally
intersubjective patient-clinician processes that involve a
shared experience of anxiety, worry, and fear when certain
decisions are made (11). Patients’ and clinicians’ expression
of both worries and hopes during SDM can serve as a
foundation for joint reflection and can lead to a better
decision-making process, an informed decision, and a greater
commitment and motivation to attain a positive outcome.
Of note, appointment lengths and professional attitudes
in some setting are less likely to leave room for sharing
thoughts and feelings than in other settings. Nevertheless,
we recommend that clinicians at least attempt to share
thoughts and feelings related to risk taking when making
decisions.

The second aspect of SDM that may have been previously
unrecognized involves considering the process of meaning
making and the metacognitive abilities that enable it (12, 13).
Certainly, any decision to take a risk must involve meanings
assigned to the behavior in question. For example, deciding
whether a risk isworth takingwhen considering discontinuing
a medication, seeking a romantic relationship, or applying
for a new job must be a function of how meaningful a
medication, a relationship, or a new job could be to the de-
cision maker (8, 14). Often, SDM does not invite broader
explorations of meaning, and SDM principles do not ade-
quately translate into existing SDM tools. Thus, to improve
SDM in mental health care, clinicians must acknowledge that
through joint reflection, risks are given meaning in the context
of the patient’s unique life—that is, they are interpreted as
more than simply generic medical risks.

Conclusions

There is a gap between recommendations to disseminate and
implement SDM in mental health care and the limited use
of SDM in practice. We suggest a new conceptualization,
shared risk taking, to explain this gap and to facilitate the
implementation of SDM and adherence to its principles,
when applicable. This is not simply a matter of semantics:
reframing SDM as shared risk taking poses important

462 ps.psychiatryonline.org Psychiatric Services 72:4, April 2021

SHARED DECISION MAKING IN SERIOUS MENTAL ILLNESS

[http://ps.psychiatryonline.org](http://ps.psychiatryonline.org/)

[https://psychiatryonline.org/servlet/linkout?type=rightslink&url=startPage%3D461%26pageCount%3D3%26copyright%3D%26author%3DYaara%2BZisman-Ilani%252C%2BPaul%2BH.%2BLysaker%252C%2BIlanit%2BHasson-Ohayon%26orderBeanReset%3Dtrue%26imprint%3DAmerican%2BPsychiatric%2BPublishing%26volumeNum%3D72%26issueNum%3D4%26contentID%3D10.1176%252Fappi.ps.202000156%26title%3DShared%2BRisk%2BTaking%253A%2BShared%2BDecision%2BMaking%2Bin%2BSerious%2BMental%2BIllness%26numPages%3D3%26pa%3D%26issn%3D1075-2730%26publisherName%3Dnone%26publication%3Dps%26rpt%3Dn%26endPage%3D463%26publicationDate%3D04%252F01%252F2021](https://psychiatryonline.org/servlet/linkout?type=rightslink&url=startPage%3D461%26pageCount%3D3%26copyright%3D%26author%3DYaara%2BZisman-Ilani%252C%2BPaul%2BH.%2BLysaker%252C%2BIlanit%2BHasson-Ohayon%26orderBeanReset%3Dtrue%26imprint%3DAmerican%2BPsychiatric%2BPublishing%26volumeNum%3D72%26issueNum%3D4%26contentID%3D10.1176%252Fappi.ps.202000156%26title%3DShared%2BRisk%2BTaking%253A%2BShared%2BDecision%2BMaking%2Bin%2BSerious%2BMental%2BIllness%26numPages%3D3%26pa%3D%26issn%3D1075-2730%26publisherName%3Dnone%26publication%3Dps%26rpt%3Dn%26endPage%3D463%26publicationDate%3D04%252F01%252F2021)

challenges for SDM research and practice. It seems imperative
to explore the different experiences of risk for clinicians and
patients. Althoughoutside the scope of thisOpenForum, future
research should explore the institutional and policy factors that
both hinder and enable patients and clinicians in making
adaptive decisions about risk (15). Although SDM occurs in the
interpersonal-intersubjective patient-clinician interaction, cli-
nicians must manage requirements at both the system and
organizational levels simultaneously, which has also been
shown to inhibit the adoption of SDM, even when clinicians
view the practice favorably. Furthermore, current SDM prac-
tice, which often relies on decision aids and decision support
tools (2), is not designed to capture risk taking in the context of
complex decisions with broader life implications. Future re-
search should focus on adapting SDM tools to encompass the
shared risk of decision making in serious mental illness.
Adopting a shared-risk-taking perspective that takes into ac-
count patient capacity, metacognition, and the existence of
intersubjectivity in the experience of risks can facilitate SDM in
mental health care by targeting a blind spot in SDM practice.

AUTHOR AND ARTICLE INFORMATION

Department of Social and Behavioral Science, College of Public Health,
Temple University, Philadelphia (Zisman-Ilani); Veterans Affairs Medical
Center, and Department of Psychiatry, Indiana University School of
Medicine, Indianapolis (Lysaker); Department of Psychology, Bar-Ilan
University, Ramat-Gan, Israel (Hasson-Ohayon). Send correspondence
to Dr. Zisman-Ilani (yaara@temple.edu).

The authors report no financial relationships with commercial interests.

Received March 10, 2020; revisions received June 14 and July 23, 2020;
accepted August 5, 2020; published online February 9, 2021.

REFERENCES
1. Charles C, Gafni A, Whelan T: Shared decision-making in the

medical encounter: what does it mean? (Or it takes at least two to
tango). Soc Sci Med 1997; 44:681–692

2. Zisman-Ilani Y, Barnett E, Harik J, et al: Expanding the concept of
shared decision making for mental health: a systematic and scoping
review of interventions. Ment Heal Rev J. 2017; 22:191–213

3. Salyers MP, Zisman-Ilani Y: Shared decision-making and
self-directed care; in The Palgrave Handbook of American
Mental Health Policy. Edited by Goldman H, Frank RG, Morrissey
JP. Cham, Switzerland, Springer International Publishing,
2020

4. Hamann J, Heres S: Adapting shared decision making for indi-
viduals with severe mental illness. Psychiatr Serv 2014; 65:1483–
1486

5. Simmons M, Hetrick S, Jorm A: Shared decision-making: benefits,
barriers, and current opportunities for application. Australas Psy-
chiatry 2010; 18:394–397

6. Hamann J, Bühner M, Rüsch N: Self-stigma and consumer par-
ticipation in shared decision making in mental health services.
Psychiatr Serv 2017; 68:783–788

7. Ostrow L, Jessell L, Hurd M, et al: Discontinuing psychiatric
medications: a survey of long-term users. Psychiatr Serv 2017; 68:
1232–1238

8. Ponte K. A risk too big not to take: a story of recovery. Psychiatr
Serv. 2020; 71:516–517

9. Zisman-Ilani Y, Shern D, Deegan P, et al: Continue, adjust, or stop
antipsychotic medication: developing and user testing an encoun-
ter decision aid for people with first-episode and long-term psy-
chosis. BMC Psychiatry 2018; 18:142

10. Roe D, Goldblatt H, Baloush-Klienman V, et al: Why and how
people decide to stop taking prescribed psychiatric medication:
exploring the subjective process of choice. Psychiatr Rehabil J
2009; 33:38–46

11. Hasson-Ohayon I, Kravetz S, Lysaker PH: The special challenges of
psychotherapy with persons with psychosis: intersubjective meta-
cognitive model of agreement and shared meaning. Clin Psychol
Psychother 2017; 24:428–440.

12. Chan KKS, Mak WWS: Shared decision making in the recovery of
people with schizophrenia: the role of metacognitive capacities in
insight and pragmatic language use. Clin Psychol Rev 2012; 32:
535–544

13. Lysaker PH, Minor KS, Lysaker JT, et al: Metacognitive function
and fragmentation in schizophrenia: relationship to cognition, self-
experience and developing treatments. Schizophr Res Cogn 2019;
19:100142

14. Deegan PE, Drake RE: Shared decision making and medication
management in the recovery process. Psychiatr Serv 2006; 57:1636–
1639

15. Morrison AP, Hutton P, Shiers D, et al: Antipsychotics: is it time to
introduce patient choice? Br J Psychiatry 2012; 201:83–84

Psychiatric Services 72:4, April 2021 ps.psychiatryonline.org 463

ZISMAN-ILANI ET AL.

[mailto:yaara@temple.edu](mailto:yaara@temple.edu)

[http://ps.psychiatryonline.org](http://ps.psychiatryonline.org/)

[https://psychiatryonline.org/servlet/linkout?type=rightslink&url=startPage%3D461%26pageCount%3D3%26copyright%3D%26author%3DYaara%2BZisman-Ilani%252C%2BPaul%2BH.%2BLysaker%252C%2BIlanit%2BHasson-Ohayon%26orderBeanReset%3Dtrue%26imprint%3DAmerican%2BPsychiatric%2BPublishing%26volumeNum%3D72%26issueNum%3D4%26contentID%3D10.1176%252Fappi.ps.202000156%26title%3DShared%2BRisk%2BTaking%253A%2BShared%2BDecision%2BMaking%2Bin%2BSerious%2BMental%2BIllness%26numPages%3D3%26pa%3D%26issn%3D1075-2730%26publisherName%3Dnone%26publication%3Dps%26rpt%3Dn%26endPage%3D463%26publicationDate%3D04%252F01%252F2021](https://psychiatryonline.org/servlet/linkout?type=rightslink&url=startPage%3D461%26pageCount%3D3%26copyright%3D%26author%3DYaara%2BZisman-Ilani%252C%2BPaul%2BH.%2BLysaker%252C%2BIlanit%2BHasson-Ohayon%26orderBeanReset%3Dtrue%26imprint%3DAmerican%2BPsychiatric%2BPublishing%26volumeNum%3D72%26issueNum%3D4%26contentID%3D10.1176%252Fappi.ps.202000156%26title%3DShared%2BRisk%2BTaking%253A%2BShared%2BDecision%2BMaking%2Bin%2BSerious%2BMental%2BIllness%26numPages%3D3%26pa%3D%26issn%3D1075-2730%26publisherName%3Dnone%26publication%3Dps%26rpt%3Dn%26endPage%3D463%26publicationDate%3D04%252F01%252F2021)

**Dundas20211.pdf**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/dundas20211-pdf)

**## Modelsofshareddecision.docx**

**Please follow APA format, add citations and references from the articles. Document will be verified for plagiarism and AI use. Thank you!**

Topic
**Models of shared decision-making in mental healthcare**

Please read the articles. Please note topics relevant to clinical decision making, including assessment, formulation, diagnosis, and treatment. Take those interesting points and expand form two relevant articles
**from your library journals.** The articles you choose must contribute something new to our understanding of the topic. I frown on rehashes of commonly known or repetitive topics.

You do not need a cover page for discussion. Please include at least two original references from the literature that are not solely from the articles that I provided. Your discussion should be about
**250 words**.  Provide two responses to your peers of about 100 words with at least one original article. You may not use the previous two articles from the original discussion post.
**Please do not submit as attachments**. These posts should be
**innovative, creative, exploratory, thought provoking, and relevant.** Students who include content from the literature with correct references and citations typically earn the highest grades. I am strict about APA. Consult the APA Manual. Do not guess and do not rely on copy and paste, as often it is incorrect APA.

**## Zisman-Ilanietal2021SDM.pdf**

Shared Risk Taking: Shared Decision Making in Serious
Mental Illness
Yaara Zisman-Ilani, M.A., Ph.D., Paul H. Lysaker, Ph.D., Ilanit Hasson-Ohayon, M.A., Ph.D.

Shared decision making (SDM) is an interpersonal health
communicationmodel that is underutilized with people with
serious mental illness. Although research has emphasized
the role of patient capacity–, clinician-, and system-related
barriers in SDM underutilization, the risk taking that affects
SDM with people with mental illness is less often discussed.
ThisOpen Forumpresents a reconceptualization of SDMas a

process of shared risk taking that often occurs during dif-
ferent phases of illness management and recovery. The
concepts of intersubjectivity, meaning making, and meta-
cognition are offered to inform clinical interventions needed
to address risk in SDM.

Psychiatric Services 2021; 72:461–463; doi: 10.1176/appi.ps.202000156

Shared decision making (SDM) aims to facilitate patient-
centered care and treatment adherence by promoting joint
treatment decision making between patients with chronic
conditions and clinicians (1). In mental health care, SDM has
been recommended for people with serious mental illness,
given that self-determination, choice, and autonomy are core
aspects of recovery-oriented care (2, 3).

Despite the proliferating development of SDM interven-
tions (2), SDM implementation for patients with serious
mental illness has been relatively less successful than for
other groups. This disparity has been attributed to a variety
of barriers (4), including clinicians’ paternalistic approach
to care of patients with serious mental illness and stigma-
related beliefs that SDM is inappropriate for such patients.
Unlike other chronic nonpsychiatric conditions, the char-
acteristics of serious mental illness may pose a major barrier
to SDM implementation. For example, psychotic symptoms
and cognitive deficits associated with schizophrenia can
affect decision-making capacity and serve as barriers to
SDM, whereas an elevated blood-glucose level associated
with diabetes does not stop patients from being involved in
SDM. Another potential barrier to SDM among patients
with serious mental illness is negative internalized self-
stigma, a common experience that leads patients to un-
derestimate their own competency for decision making and
autonomy (5, 6).

A greater barrier, though, may be clinicians’ fear of lia-
bility and legal exposure. Clinicians may resist SDM with
patients with serious mental illness because they fear being
held liable for any potentially negative outcome that might
result fromSDM, such as symptom exacerbation, hospitalization,

or death. Burnout, patient load, and limited appointment
time also contribute to clinicians’ reluctance to engage in
SDM (4).

Although promising, research and implementation of
SDM in mental health care have overlooked the fact that
SDM is sometimes at odds with clinicians’ training to miti-
gate the risk of harm and with organizational policies that
are inherently risk averse. To promote the implementation
and usage of SDM with people with serious mental illness,
clinicians must acknowledge and directly confront issues of
risk, which are inherent in psychiatry and which hinder
SDM with individuals who have serious mental illness. In
this Open Forum, we offer a new conceptualization, shared
risk taking, as a unique way to view SDM with people with
serious mental illness. We argue that risks are an inevitable
part of the SDM process and are not related only to the
decision at hand and that joint reflection by the clinician and
patient should be used to address SDM-related risks.

Inherent Risks in Serious Mental Illness Management
and Recovery

Across many psychiatric settings, different levels of risk and
standards of risk management are used to mitigate harm
and minimize negative health outcomes while prioritizing
management of some risks over others. In psychiatry, re-
ducing risks to safety is the highest priority, because it is a
key part of one aspect of clinicians’ professional training and
responsibility and is the common institutional policy among
mental health services. Perceived risks to safety affect both
clinicians and patients, but differently. For clinicians, safety

Psychiatric Services 72:4, April 2021 ps.psychiatryonline.org 461

OPEN FORUM

[http://ps.psychiatryonline.org](http://ps.psychiatryonline.org/)

[https://psychiatryonline.org/servlet/linkout?type=rightslink&url=startPage%3D461%26pageCount%3D3%26copyright%3D%26author%3DYaara%2BZisman-Ilani%252C%2BPaul%2BH.%2BLysaker%252C%2BIlanit%2BHasson-Ohayon%26orderBeanReset%3Dtrue%26imprint%3DAmerican%2BPsychiatric%2BPublishing%26volumeNum%3D72%26issueNum%3D4%26contentID%3D10.1176%252Fappi.ps.202000156%26title%3DShared%2BRisk%2BTaking%253A%2BShared%2BDecision%2BMaking%2Bin%2BSerious%2BMental%2BIllness%26numPages%3D3%26pa%3D%26issn%3D1075-2730%26publisherName%3Dnone%26publication%3Dps%26rpt%3Dn%26endPage%3D463%26publicationDate%3D04%252F01%252F2021](https://psychiatryonline.org/servlet/linkout?type=rightslink&url=startPage%3D461%26pageCount%3D3%26copyright%3D%26author%3DYaara%2BZisman-Ilani%252C%2BPaul%2BH.%2BLysaker%252C%2BIlanit%2BHasson-Ohayon%26orderBeanReset%3Dtrue%26imprint%3DAmerican%2BPsychiatric%2BPublishing%26volumeNum%3D72%26issueNum%3D4%26contentID%3D10.1176%252Fappi.ps.202000156%26title%3DShared%2BRisk%2BTaking%253A%2BShared%2BDecision%2BMaking%2Bin%2BSerious%2BMental%2BIllness%26numPages%3D3%26pa%3D%26issn%3D1075-2730%26publisherName%3Dnone%26publication%3Dps%26rpt%3Dn%26endPage%3D463%26publicationDate%3D04%252F01%252F2021)

risks, such as relapse, present high potential for legal lia-
bility, particularly if the risk is accompanied by symptoms
potentially related to harm, such as suicidality or homi-
cidality. For patients, these risks may take the form of re-
duced quality of life, which might stem from symptom
exacerbation, hospitalization, or the psychological or po-
tentially permanent physical side effects of treatment (7).

Yet the path to recovery from serious mental illness re-
quires more than minimizing safety-related risks. Recovery-
oriented care involves a broad array of risks inherent in all
domains of patients’ lives, such as employment, education,
and relationships. For a patient, a decision to stop working
poses economic and mental health risks, whereas returning
to work after a psychiatric hospitalization may be associated
with high risks of humiliation or failure, which pose other
sets of emotional and psychological risks. Nevertheless,
recovery-related decisions do not usually pose significant
risks for either clinician or patient, and SDM can be en-
couraged. Therefore, there is a greater chance of success-
fully implementing and using SDM in recovery-related
decisions, such as those concerning employment or educa-
tion, and a lower chance of using SDM in health-related
decisions, such as tapering medications, that involve safety
risks for both patients and clinicians.

Shared Risk Taking

With the understanding that risk is both unavoidable and a
core element of any decision (8), the challenges of SDM for
persons with serious mental illness become apparent. How
should clinicians and patients make decisions with poten-
tially negative outcomes or when a patient’s decision-making
capacity is unclear? These dilemmas point to the reality that
in some situations and for some decisions, joint decision
making with people with serious mental illness will likely
involve decisions about risk and thus might be better char-
acterized as shared risk taking.

We introduce shared risk taking as a new perspective that
aims to emphasize the often-overlooked risks associated
with SDM with patients with serious mental illness that
might inhibit SDM usage, implementation, and effective-
ness. For example, clinicians might involve patients in
choosing between different medications but will not present
the option of abstaining from medication (9). Patients, for
their part, might conceal certain information relevant to
SDM from their clinician—for example, that they have tapered
or stopped taking their medications—to avoid the risk of
losing disability stipends or other benefits or of being seeing
negatively by the psychiatrist (10). We offer shared risk
taking as a way to attend to, via processes of intersubjectivity
and metacognition, unspoken risks that the SDM literature
does not explicitly discuss or offer ways of addressing.

In shared risk taking, the clinician and patient should
jointly reflect on the inherent risks of any decision and
discuss issues related to the patient’s and clinician’s stig-
matizing or paternalistic beliefs regarding their inability to

participate in decision making. The clinician and patient
should explicitly conduct a risk assessment of the decision,
its safety implications, and the patient’s capacity to be in-
volved in the decision making. A shared-risk-taking ap-
proach is valuable not only in psychiatry and mental health
settings but also in populations of individuals with de-
velopmental disorders, Alzheimer’s disease, or drug abuse
and even with children, whose capacity for decision making
is questioned and who are often exposed to stigmatizing and
paternalistic beliefs.

The recognition of risks in SDM with patients who have
serious mental illness calls for a deeper exploration of at
least two aspects of the SDM process that have been rela-
tively unrecognized. First, SDM focuses more on presenting
medical options and discussing their risks and benefits than
on sharing emotions pertaining to risk taking. We believe
that the success of SDM relies on a set of fundamentally
intersubjective patient-clinician processes that involve a
shared experience of anxiety, worry, and fear when certain
decisions are made (11). Patients’ and clinicians’ expression
of both worries and hopes during SDM can serve as a
foundation for joint reflection and can lead to a better
decision-making process, an informed decision, and a greater
commitment and motivation to attain a positive outcome.
Of note, appointment lengths and professional attitudes
in some setting are less likely to leave room for sharing
thoughts and feelings than in other settings. Nevertheless,
we recommend that clinicians at least attempt to share
thoughts and feelings related to risk taking when making
decisions.

The second aspect of SDM that may have been previously
unrecognized involves considering the process of meaning
making and the metacognitive abilities that enable it (12, 13).
Certainly, any decision to take a risk must involve meanings
assigned to the behavior in question. For example, deciding
whether a risk isworth takingwhen considering discontinuing
a medication, seeking a romantic relationship, or applying
for a new job must be a function of how meaningful a
medication, a relationship, or a new job could be to the de-
cision maker (8, 14). Often, SDM does not invite broader
explorations of meaning, and SDM principles do not ade-
quately translate into existing SDM tools. Thus, to improve
SDM in mental health care, clinicians must acknowledge that
through joint reflection, risks are given meaning in the context
of the patient’s unique life—that is, they are interpreted as
more than simply generic medical risks.

Conclusions

There is a gap between recommendations to disseminate and
implement SDM in mental health care and the limited use
of SDM in practice. We suggest a new conceptualization,
shared risk taking, to explain this gap and to facilitate the
implementation of SDM and adherence to its principles,
when applicable. This is not simply a matter of semantics:
reframing SDM as shared risk taking poses important

462 ps.psychiatryonline.org Psychiatric Services 72:4, April 2021

SHARED DECISION MAKING IN SERIOUS MENTAL ILLNESS

[http://ps.psychiatryonline.org](http://ps.psychiatryonline.org/)

[https://psychiatryonline.org/servlet/linkout?type=rightslink&url=startPage%3D461%26pageCount%3D3%26copyright%3D%26author%3DYaara%2BZisman-Ilani%252C%2BPaul%2BH.%2BLysaker%252C%2BIlanit%2BHasson-Ohayon%26orderBeanReset%3Dtrue%26imprint%3DAmerican%2BPsychiatric%2BPublishing%26volumeNum%3D72%26issueNum%3D4%26contentID%3D10.1176%252Fappi.ps.202000156%26title%3DShared%2BRisk%2BTaking%253A%2BShared%2BDecision%2BMaking%2Bin%2BSerious%2BMental%2BIllness%26numPages%3D3%26pa%3D%26issn%3D1075-2730%26publisherName%3Dnone%26publication%3Dps%26rpt%3Dn%26endPage%3D463%26publicationDate%3D04%252F01%252F2021](https://psychiatryonline.org/servlet/linkout?type=rightslink&url=startPage%3D461%26pageCount%3D3%26copyright%3D%26author%3DYaara%2BZisman-Ilani%252C%2BPaul%2BH.%2BLysaker%252C%2BIlanit%2BHasson-Ohayon%26orderBeanReset%3Dtrue%26imprint%3DAmerican%2BPsychiatric%2BPublishing%26volumeNum%3D72%26issueNum%3D4%26contentID%3D10.1176%252Fappi.ps.202000156%26title%3DShared%2BRisk%2BTaking%253A%2BShared%2BDecision%2BMaking%2Bin%2BSerious%2BMental%2BIllness%26numPages%3D3%26pa%3D%26issn%3D1075-2730%26publisherName%3Dnone%26publication%3Dps%26rpt%3Dn%26endPage%3D463%26publicationDate%3D04%252F01%252F2021)

challenges for SDM research and practice. It seems imperative
to explore the different experiences of risk for clinicians and
patients. Althoughoutside the scope of thisOpenForum, future
research should explore the institutional and policy factors that
both hinder and enable patients and clinicians in making
adaptive decisions about risk (15). Although SDM occurs in the
interpersonal-intersubjective patient-clinician interaction, cli-
nicians must manage requirements at both the system and
organizational levels simultaneously, which has also been
shown to inhibit the adoption of SDM, even when clinicians
view the practice favorably. Furthermore, current SDM prac-
tice, which often relies on decision aids and decision support
tools (2), is not designed to capture risk taking in the context of
complex decisions with broader life implications. Future re-
search should focus on adapting SDM tools to encompass the
shared risk of decision making in serious mental illness.
Adopting a shared-risk-taking perspective that takes into ac-
count patient capacity, metacognition, and the existence of
intersubjectivity in the experience of risks can facilitate SDM in
mental health care by targeting a blind spot in SDM practice.

AUTHOR AND ARTICLE INFORMATION

Department of Social and Behavioral Science, College of Public Health,
Temple University, Philadelphia (Zisman-Ilani); Veterans Affairs Medical
Center, and Department of Psychiatry, Indiana University School of
Medicine, Indianapolis (Lysaker); Department of Psychology, Bar-Ilan
University, Ramat-Gan, Israel (Hasson-Ohayon). Send correspondence
to Dr. Zisman-Ilani (yaara@temple.edu).

The authors report no financial relationships with commercial interests.

Received March 10, 2020; revisions received June 14 and July 23, 2020;
accepted August 5, 2020; published online February 9, 2021.

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Psychiatric Services 72:4, April 2021 ps.psychiatryonline.org 463

ZISMAN-ILANI ET AL.

[mailto:yaara@temple.edu](mailto:yaara@temple.edu)

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