Obstacles to shared decision-making in psychiatric practice: Findings from three observational studies

This thesis was submitted for the degree of Doctor of Philosophy and awarded by Brunel University.This thesis aims to make contributions at substantive, methodological and theoretical levels. First, the findings from three observational studies are combined to identify obstacles to the use of shared decision-making in modern psychiatric practice. Particular attention is paid to how patients' choices about their treatment are facilitated or constrained by the actions of mental health professionals. A typology of pressure is constructed, based on detailed analyses of how pressure is applied and resisted in routine encounters (outpatient consultations) and "crisis' situations (assessments for compulsory admission to hospital, and ward rounds in acute inpatient care). Findings from two ethnographies and one conversation analysis (CA) study are presented. 'Meaning' is central to the write-up of each set of findings, however while the analytic focus of the ethnographies is 'insider' knowledge and meanings, in the CA study it is gn the activities that make those meanings possible in the first place. The methodological contribution of the thesis stems from its demonstration of how to produce a coherent, unified research account from two very different versions of qualitative inquiry. Despite the potential for analytic inconsistency, the thesis arguably has far greater force and persuasiveness as a result of the attempt to combine, compare and contrast findings from three studies. It is contended that a sound theoretical base for sociological research may be created by combining Goffman's micro-sociology with Foucault's analyses of disciplinary power/knowledge in one of a number of ways. A Goffmanian 'home base' is adopted for this thesis, with Foucauldian thinking applied to add a historical, 'macro' dimension to the analysis that Goffman's work so conspicuously lacks. Foucault's work also provides the conceptual tools for examining the more subtle form of control through expertise that would be missed in a purely Goffmanian study.Department of Health, Eli Lilly, and Dr Jim Birle