Can individuals who have serious mental illness make decisions for themselves?

Individuals who have SMI are far more informed than they were a few decades ago. Yet they still are often left out of decision-making about their physical and mental health. This can cause people who have SMI to feel frustrated and undervalued by the mental health care team. They may not feel like they have adequate – if any – input into their treatment plan and targeted outcomes. We can do better and should do better.

Clinicians have an ethical obligation to let people have a role in choices around their physical and mental health care. They also often support shared decision-making but do not know how to make it happen. Decision-making capacity is impaired in only a subset of individuals who have SMI. This may change over time and depends on a person’s emotional state.

All meetings between the care team and individual who have SMI should account for the two experts in the room. One is the clinical team. They are experts who have knowledge about treatment choices and the evidence that informs those options. The other is the individual. They know best their own goals, supports, and history. Together they should develop a treatment plan that represents the results of their shared decision making. This plan should be shared with the whole treatment team and revisited on a routine basis.

Learn more about common myths around SMI and character. See our infographic on this topic.




  • Ganzini L, Volicer L, Nelson WA, Fox E, Derse AR. Ten myths about decision-making capacity. J Am Med Dir Assoc. 2004 Jul-Aug;5(4):263-7. doi: 10.1097/01.JAM.0000129821.34622.A2. PMID: 15228638.
  • Palmer BW, Dunn LB, Appelbaum PS, Jeste DV. Correlates of treatment-related decision-making capacity among middle-aged and older patients with schizophrenia. Arch Gen Psychiatry. 2004 Mar;61(3):230-6. doi: 10.1001/archpsyc.61.3.230. PMID: 14993110.
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