Shared decision-making in counselling and psychotherapy

  • Adam Gibson

Student thesis: Doctoral Thesis


Shared decision-making (SDM) is a process for making treatment decisions in healthcare based on a patient’s informed preferences and a practitioner’s knowledge. This thesis examined SDM in counselling and psychotherapy; with three aims. First, to identify the process by which therapists and clients share decisions. Second, to understand how clients experienced SDM. Third, to evaluate the impact of SDM. Four studies were undertaken to achieve these aims.
First, a systematic review examined SDM literature in counselling and psychotherapy. This found no evidence of a positive relationship between SDM and clinical outcomes. However, there were limited indications that SDM was positively related to reduced arousal, reduced hostility, and greater therapist-rated alliance.
Second, a Grounded Theory approach using Interpersonal Process Recall interviewing investigated 14 clients’ experiences of SDM in pluralistic therapy for depression. This indicated that most clients were comfortable taking part in shared decision-making and felt their therapist’s actions supported them to take part in that process.
Third, a Conversation Analysis examined goal negotiations within six therapy dyads. When alignment occurred, dyads worked together to decide relevant goal content. When misalignment occurred, therapists facilitated client involvement by building them towards a contribution, providing accounts, and suggesting candidate answers.
Fourth, multilevel models were developed for psychotherapy outcomes using SDM observation ratings for 14 clients. This found a trend in which higher SDM scores were associated with greater reductions in anxiety and depression over the course of therapy, greater goal attainment, greater therapist satisfaction, and higher ratings of session effectiveness.
This thesis showed that therapists can adopt a hierarchy of methods to facilitate clients who want to take part in the SDM process but have difficulty doing so. Clients’ preferences for conducting SDM may change across clients, across decisions. Moreover, SDM may have a beneficial clinical and experiential impact on clients.
Date of Award5 Mar 2019
Original languageEnglish
Awarding Institution
  • University of Roehampton
SupervisorMick Cooper (Supervisor), Jac Hayes (Supervisor) & John Rae (Supervisor)


  • shared decision-making
  • client-therapist communication
  • pluralistic therapy

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