Overall, 21 subthemes across ten domains of the TDF  were identified as factors that were barriers or facilitators to SDM. These spanned all three areas related to capability, opportunity and motivation . The results are highlighted in Table 1.
An awareness of the philosophy of SDM but not always the term
The majority of clinicians in this sample were aware of SDM as a concept, and as such what SDM entailed. When asked to provide a definition, they outlined examples such as partnership, eliciting patient values and preferences, as well as identifying treatment options.
It’s about us not being the expert all the time, it’s about being very explicit about what we can offer, what we’ve got… asking them what helps, what’s been helpful, as well as what we automatically think we may be able to offer them…and not us always sitting in that medical expert model…to keep the parents and families as the experts in their own lives really (Mental Health Nurse 4).
However, some clinicians highlighted they would not use the term SDM. Despite not knowing or using the specific term, all the clinicians believed that the concept of SDM was something that they clinically practiced.
It’s been only recently that I have been told about this shared decision-making, the term specifically…. I know what the meaning is. I think we have used the shared decision issues [for] a very long time… I mean, when we see patients in our clinic, when we think about treatments, when we offer treatments … asking their opinions and taking that into consideration (Psychiatrist 2).
When asked what terms they use instead, some clinicians mentioned ‘informed consent’, (Psychiatrist 2). This concept, which is related to SDM, has some underlying similarities though does not aim to actively involve the patient, nor elicit values or preferences.
A lack of knowledge regarding care and treatment options
A particular barrier for the clinicians was a lack of knowledge regarding the available care and treatment options for patients. This was particularly prominent when it came to the resources available outside of CAMHS.
Five years ago, there were a lot more resources out there, you felt comfortable signposting outside, you had better links, and I think over the years, as things have dwindled, I find myself struggling to see what’s out there as well (Clinical Psychologist 5).
The clinicians reported that funding cuts to community resources and voluntary organisations meant they did not know where to signpost with regard to other services. Even when resources were available, the clinicians tended to be cautious in making referrals due to long waiting lists or not knowing the quality of the service.
The interviews with the clinicians also demonstrated that some were not aware of certain options within their own service.
I am just thinking of us trainees for example, moving from placement to placement, how are you aware of all the options available? Or if you are aware of the three options rather than the five, you’re only going to present the three that you know about (Trainee Psychologist 2).
This was true for trainees who were on rotation as part of their training, but it was also the case for new members of staff who had just joined the service. In both situations, the clinicians acknowledged the possibility of not knowing all of the options within their service.
The overlap between core therapeutic skills and the skills needed for SDM
When asked to outline the skills that were needed for SDM, clinicians suggested being ‘open’, (CBT Therapist 1) ‘honest’, (Clinical Psychologist 3) ‘transparent’ (Clinical Psychologist 2), and ‘listening to young people and parents’ (Psychiatrist 1) as being important.
I think the basics, just to be listening well, to be a little bit more involved—to be actually listening properly and using what is being said rather than make your own points around it. I think it’s just the ability to connect with the people they work with really; I think that’s the main thing. It’s just about rapport-building and being quite transparent in what you’re doing (Therapist 1).
The clinicians commented on how this overlapped with skills acquired as part of their professional training. Clinical Psychologist 2 outlined how training had helped to improve their SDM skills through ‘thinking about how it looks and how it works’ and adapting their skillset to work with different groups.
Negotiation and containment as ‘new’ skills needed for SDM
The clinicians discussed how SDM in child and youth mental health incorporates multiple stakeholders’ preferences, values and views, which could lead to disagreements between parties on how to proceed with care and treatment. To navigate this situation, clinicians identified negotiation and containment as key skills.
Containment and negotiation…the dance of reciprocity, two steps forward and four steps back, and onto the side, a little jiggy then move forward again…you need to be careful not to alienate one individual (Mental Health Nurse 4).
The clinicians worried that the loss of engagement with an individual due to a lack of inclusion was potentially very detrimental. They explained that a disengaged young person who had not been included in choosing their treatment may be less likely to participate in therapy. Conversely, by not including a parent, the clinicians worried that the parent may choose not to bring the young person back to a subsequent session.
Memory, attention and decision-making processes
The availability of options may affect what is presented to the young person and family
The clinicians acknowledged that as part of their role, they were responsible for outlining the different treatment options to young people and their families. However, the clinicians were divided about which options to make patients aware of. Some clinicians highlighted that they would only suggest options that were available within their service.
Something [treatment option] that we didn’t offer? I don’t think I would necessarily point that out (Clinical Psychologist 4).
The clinicians justified limiting the options to what was available by explaining that they did not want to rupture the therapeutic relationship, or make therapy more challenging, as then individuals may not be able to have their first choice of treatment.
Conversely, other clinicians spoke of making a conscious choice to inform individuals about all their options, regardless of whether they were available in the service or not.
I think information’s key, I think the whole thing that…families need to be given the information and they can make the decisions for themselves about where they go and what supports they might get, so I think they should [have all options] (Mental Health Nurse 2).
This, clinicians stated, was the ‘spirit’ of SDM, as young people and families had a right to choose to seek treatment elsewhere if they desired, be that within CAMHS or elsewhere.
A lack of clarity around whether there are guidelines and protocols for SDM
There was confusion amongst the clinicians as to whether there were guidelines and protocols for SDM in child and youth mental health. No clinicians described reading explicit guidelines pertaining to SDM. However, some clinicians speculated that such documents could exist.
Well I don’t know [if there are protocols/guidelines], I would assume there might be (Mental Health Nurse 1).
Other clinicians did not believe there were any protocols or guidelines, but they cited similar documentation which may be useful to help embed or facilitate SDM, such as ‘protocols around consent and all that sort of stuff’ (Clinical Psychologist 1).
Some clinicians posited that having protocols or guidelines would be helpful particularly for more junior members of staff and others not familiar with SDM: ‘it would be good to have something standard so that everybody can do it’ (Psychiatrist 1). However, others, such as Clinical Psychologist 2, worried that clinicians would view a protocol with contempt, as they ‘might then see it as something else they’ve got to do’.
Reviews of treatment and goals, whilst considered important, are conducted sporadically
Consistent with models of SDM, the clinicians stated the importance of reviewing treatment progress and goals with young people and families to understand how the young person is progressing.
Reviewing progress is really important, that you review what is happening with that young person, because if you don’t review, you don’t know what has helped, how much progress has been made, and where you next need to go, your next step, so reviewing progress is very important, and making changes if needed (Mental Health Nurse 1).
Despite the perceived importance of reviews by clinicians, it was acknowledged that often these were not completed on time or only on an ad hoc basis.
I will ask about the next one, and the review as such, is usually every 6 sessions, sometimes that happens, sometimes that doesn’t, and sometimes its partial follow up, so it’s not very concrete at the moment (Psychiatrist 1).
Environmental context and resources
Facilities not conducive to SDM
Many of the clinicians spoke of the facilities in CAMHS as not being conducive to SDM with young people and families. For some, this extended to the building in which their CAMHS was located. They explained that the appearance and ambiance of the building, which felt like entering an adult medical environment, contradicted the philosophy of young people being treated as equals when it came to having an appointment.
Our offices are grim. Especially for young people, it’s just horrible. I think because it looks office-y and it looks clinical and it looks really official, that wouldn’t exactly give you—it’s like going into your doctor’s office and being told that you’re an equal partner really; it doesn’t feel particularly believable (Therapist 1).
Several clinicians stated that their appointment rooms were not conducive to SDM with young people. Aspects related to layout, a lack of space or the temperature limited the amount of time clinicians wanted to spend there, resulting in shorter appointments in which different options may not be fully explored.
…You instinctively want to cut down on conversation to get out of there, out of the room, so its basic things like that (Clinical Psychologist 3).
Limited or a lack of psychological interventions for SDM
The clinicians frequently outlined that only certain types of psychological support were available within their services. Not offering particular treatments resulted in the clinicians feeling that families were ‘getting a raw deal with what we can provide’ (Therapist 1). In the most extreme cases, the clinicians felt that there was no decision to be made or shared, as the only choice was between the treatment being offered or no treatment at all.
For example, the family therapist within the community, there’s been a move to the eating disorder team…so for self-harm it is CBT or nothing (Clinical Psychologist 4).
On the other hand, even when different types of psychological support were available, access to them could be precluded by being placed on a long waiting list. This was often more pronounced when therapies were longer, specialist or more intensive.
We’re quite often having to have the conversation even if we do have something. Sometimes there’s a wait, which can be difficult for families if they’re wanting something, for example like play therapy, because it’s quite an intensive therapy, there’s always a waiting list (Clinical Psychologist 1).
This was seen by the clinicians as having an effect on SDM, as it resulted in families (who were often desperate and had already been on a waiting list) choosing the option with the shortest waiting time rather than the option that would fit best with their specific values or preferences.
Administration and time constraints that inhibit SDM
A lack of staff members and increased patient demand were perceived factors affecting SDM according to a majority of the clinicians interviewed. During the assessment process, clinicians spoke about having to get through everything needed in the session, leaving little time for SDM.
If you have a time constraint around assessment and you’ve got five bits of paper to fill out, you’re going to try your best to get the information from the client; you’re not necessarily going to be thinking about the client in the longer term, if that makes sense…so it might be that rash decisions get made or it’s a short-term decision rather than thinking about the child’s needs as a whole and how they would engage in that longer term (Clinical Psychologist 1).
Time constraints were not just limited to assessment appointments. A few clinicians also highlighted the shift from shared to more directive decision-making when clinics were busy to try to keep to time.
I try to do [SDM] without overrunning, but it becomes difficult to manage the rest of the cases, because one has taken over more than an hour, then you begin to feel your own anxiety gets in the way…you become more dominant in a way, to say this is what you should do, this is what will help you, and you become more directive I suppose (Psychiatrist 1).
Procedural influences stopping decision-making
Clinicians highlighted that a young person’s presenting problem could lead them down a specific treatment path, leaving few options to be explored when it came to SDM. For one clinician, this was particularly relevant in the ‘best practice’ pathway for anxiety and depression where CBT was the emphasised treatment modality in their service.
So for anxiety and depression… we’ve had quite a few people going for training—so, the anxiety and depression pathway. So within that is CBT, because we know that’s what evidence—because that’s what we’ve been trained in—… the evidence shows CBT is effective… now we’d say CBT [to young people and families for treatment] (Clinical Psychologist 2).
Team members positively and negatively influencing decisions
All the clinicians in this sample felt that SDM was part of the service culture as well as part of their professional role. Clinicians highlighted speaking to colleagues to come up with ideas for options for treatment.
As a team, we often feedback cases to the team, or talk about a client that you know is struggling, or we’d like to get more ideas, can we talk about it as a whole team, then we’ll come back as a team and present that and talk about that and get a lot more ideas coming through about what we can do (Mental Health Nurse 2).
The majority of clinicians found this helpful. However, some of the clinicians questioned whether too much input from other professionals might be unhelpful, as a larger number of voices increased the probability that a young person could then be forgotten about.
So yes, certainly dynamics, relationship….I suppose, between other professionals and that can be within the team or outside the team as well. It’s sometimes hard to hold the young person in mind if you’ve got too many voices kind of going over them, really (Clinical Psychologist 2).
Several clinicians reported that sometimes parents demanded their children be seen in CAMHS even if the assessment suggested they did not meet the threshold.
She’s pretty much dragged him to an appointment. So the care plan with my patient, I’m saying “What do you want to do?” and [the young person’s] like, “This is actually quite manageable really. I don’t really want to do anything about it,” whereas Mum’s really clear that it’s causing tension in the home and it can’t carry on; that she wants zero habits all the time (Therapist 1).
In such circumstances, the clinicians reported feeling obligated to keep these cases open, even though they felt that there was little they could do for the young person and family. This meant overriding the young person’s feelings or wishes to placate the parent.
Professional role and identity
Shared decision making is something CAMHS clinicians already ‘do’
All the clinicians interviewed mentioned they felt that SDM was a routine part of their practice that was intertwined with their role in child and youth mental health.
That’s always been my approach. And, to be honest, I try to do that with everything else, so for example, if I’m using CBT, I try to do so in a collaborative way, asking for their views and opinions (Trainee Psychologist 3).
The clinicians outlined that to develop an effective treatment and care package for young people and families, it was important to take into account their preferences and cultural values, as these were ‘aspects in themselves, their culture and their lives’ (Nurse 2).
Overruling a young person’s wishes due to professional standards
Whilst the clinicians acknowledged that SDM was part of their practice, many spoke of the professional boundaries and standards that needed to be upheld which were sometimes at odds with SDM. The clinicians frequently cited capacity issues around mental health difficulties which meant that a young person could make risky decisions which would not be in their best interests if they compromised their safety.
Someone’s decision making may be impaired due to a psychotic episode, low BMI [Body Mass Index] due to an eating disorder, or suicidal… and the decision of the child or young person may that they don’t want to go into hospital, or talk to the professional, but again it is about keeping the young person safe (Trainee Psychologist 2).
Beliefs about consequences
Shared decision making empowers young people and families
The majority of clinicians outlined a benefit of SDM with young people and families related to patient empowerment.
They are empowered, it helps therapy so much and in so many ways, that it moves the process that they are engaged in things that you are doing and the throughput happens (Clinical Psychologist 5).
Giving the patient a sense of autonomy and control to help meaningfully shape treatment was seen by the clinicians as crucial if care and treatment were ultimately going to be successful.
Shared decision making takes too much time
Time was an important factor for the clinicians when it came to SDM, with many feeling that it took longer to implement treatments involving SDM as opposed to a more paternalistic approach in which the clinicians made the decisions.
[SDM] could slow down the pace or slow down the work because you’ve got to work at their pace, when they’re ready to access and take in that information (Mental Health Nurse 3).
The clinicians felt that it could take longer to make decisions in certain circumstances or with particular individuals. This included situations with very young people, individuals with learning disabilities, when patients did not come prepared to make a decision or when there were multiple parties involved. However, not all the clinicians mentioned time as a factor that affects SDM, and one clinician felt that it actually did not take any extra time as it was ‘not something that was separate’ and should be ‘built into normal practice’ (Clinical Psychologist 1). Another clinician outlined that whilst SDM may initially take longer, it could result in more engaged and motivated patients over the long term which would then positively impact on the initial time invested.
Initially it is more time consuming, I don’t think that would bear out over time as it helps with motivation, but initially I think yeah (Clinical Psychologist 3).
Shared decision making can make psychological problems worse
One clinician outlined that SDM may not be in the ‘interests’ of the young person and family as they were likely to choose treatments which may minimise psychological distress or discomfort. The example here was specifically in relation to phobias, where the clinician described how not engaging in exposure therapy could exacerbate problems in the longer term.
When someone is behaving in a way which in the short-term might alleviate their anxiety, so, for example, ‘I don’t want to go outside because it’s scary’. Okay, in the short term that’s going to make the anxiety go away but then the behaviour reinforces and they stay in the house for six months. So the disadvantage of being person-centred and going along with their decision there is actually that sometimes they can remain stuck if they’re unwilling to engage in a therapeutic technique for which there is pretty good evidence works really well (Trainee Psychologist 3).
In the longer term, the clinician felt this could affect the young person’s chances of making a good recovery.
Beliefs about capabilities
Feeling confident in engaging in SDM
In most instances, the clinicians stated that they were capable and confident in engaging in SDM with young people and families.
…I feel comfortable and confident [in engaging in SDM], yes… (Psychiatrist 1).
This was often attributed to the concept being part of their professional training, as well as a culture within CAMHS which aims to foster SDM with young people and families.
Feeling less confident due to a lack of knowledge around options
A few clinicians outlined that they did not feel confident discussing particular psychological therapies or medications with young people and families.
There’s something in our service called cognitive analytic therapy and when I explain it to families I don’t really feel that confident because I’ve never really worked within that model or understand it that much. But I guess, that’s just about my learning that I need to go and speak with somebody and get more information and get people to help me understand it a bit more (Clinical Psychologist 4).
The clinicians conceded that to address this they needed to obtain more information so that they felt more comfortable talking about different therapies.
Feeling overwhelmed which inhibits SDM
Many of the clinicians reported needing to be ‘in the right state of mind’ to engage properly in SDM with young people and families. The majority of clinicians in this sample reported feeling stressed and overwhelmed with the amount of work that they had to do and the number of patients they had to see. In some instances, this impacted on SDM, as clinicians could forget to mention the availability of some options.
Everyone’s really, really overstretched, overwhelmed. So maybe for some staff, what might happen is that they maybe think actually there could be this other treatment option that we could consider with the family, but then they might forget (Clinical Psychologist 4).
Other clinicians outlined how stress impacted on their ability to participate in SDM, as it stopped them from asking questions and listening to the young person and family, and instead they ‘prescribed’ the normal treatment without taking into account the values and preferences of the young person and family.