Shared decision making in the recovery of people with schizophrenia: The role of metacognitive capacities in insight and pragmatic language use

In the development of consumer-centered care for mental health consumers with schizophrenia, one key ingredient is consumer participation in health care decisions together with their healthcare providers, termed “shared decision making” (SDM). SDM requires consumers to form a number of complex ideas about themselves and their providers then use that knowledge to make sense of the illness and reach medical and psychosocial decisions. However, metacognitive deficits widely observed in schizophrenia might lead to poor insight and pragmatic language deficits in some consumers, disrupting the whole process by which a personal and consensually valid narrative account of psychiatric challenges is synthesized and flexibly evolved. Given the current understanding that it is possible to improve metacognition, in this article we summarize how Metacognitive Training (MCT) and individual psychotherapy could potentially be tailored, or modified, to help consumers to develop metacognitive capacities with an end goal of facilitating the SDM process. Consistent with the principles of consumer-defined recovery, we also suggest a strategy for engaging consumers in SDM dialogue based on “where the consumers are at”. Providers are advised to be cognizant of their medically driven perspective and attempt to work with the consumers in the perspective of the consumers' own recovery goals.

► Shared decision making (SDM) promotes consumer participation in healthcare decisions.
► We raise concerns as to the feasibility of SDM for people with schizophrenia.
► Poor insight and pragmatic dysfunction could serve as a barrier to implementing SDM.
► We discuss the metacognitive roots of poor insight and pragmatic language deficits.
► We discuss how Metacognitive Training and psychotherapy could bolster the SDM model.