Exploring the Relationship Between Psychological Constructs and Decision-Making Preferences in Psychiatric Outpatients

Introduction

Integrating advancements in clinical psychology into psychiatry fosters a more holistic understanding of mental health, enhancing patient-centered care and improving treatment outcomes.^1–5 In psychiatric outpatient care, understanding psychological constructs—health locus of control, psychological reactance, attitudes toward psychiatric treatment, and patient decision-making preferences—is essential. These constructs are central to patient engagement and treatment efficacy, highlighting the importance of considering individual psychological profiles.^6–8

Health locus of control (HLC) refers to an individual’s belief about the extent to which their health is controlled by internal versus external factors.⁹ Patients with a strong internal HLC tend to be more engaged in their healthcare, showing higher levels of treatment adherence and participation in therapeutic activities.^10–16 Conversely, psychological reactance occurs when an individual perceives their freedom to choose or engage in certain behaviors as being threatened, leading to resistance against treatment recommendations.^17–23

Attitudes toward psychiatric treatment, influenced by personal and cultural beliefs, previous healthcare experiences, and societal stigma, significantly impact patients’ willingness to seek treatment and their adherence to prescribed interventions. Positive attitudes facilitate treatment engagement and enhance the therapeutic alliance, while negative attitudes can act as barriers to care.^24–28

Patient participation preferences in decision-making are crucial in psychiatric care. Some patients prefer an active role, while others trust their healthcare providers to make decisions on their behalf.^29–31 Recognizing and respecting these preferences is vital for fostering a therapeutic relationship and improving treatment adherence.^32–36

This study aims to investigate the interplay between health locus of control, psychological reactance, attitudes towards psychiatric treatment, and participation preferences in a psychiatric outpatient population. By elucidating the relationships among these constructs, we seek to enhance patient engagement and optimize treatment strategies in psychiatric settings.

Methods

Study Design

This study is a cross-sectional, observational study designed to explore the relationships between health locus of control, psychological reactance, attitudes toward psychiatric treatment, and patient decision-making preferences.

Study Setting

The study was conducted at a community mental health center located on Tenerife Island, Canary Islands, Spain.

Study Duration

Data collection occurred over six months, from September 2023 to March 2024.

Sample Size

A total of 200 consecutive psychiatric outpatients were approached for participation. Of these, 151 patients agreed to participate, providing a sufficient sample size for statistical analysis.

Sampling Method

Convenience sampling was used, with participants selected based on their availability and willingness to participate in the study. Patients were approached consecutively during their visits to the mental health center.

Inclusion and Exclusion Criteria

• Inclusion Criteria: Patients aged 18 and older receiving outpatient psychiatric care at the community mental health center, who provided informed consent to participate.
• Exclusion Criteria: Patients who declined to participate or did not provide informed consent, those unable to complete the questionnaires due to cognitive impairments, and those under the age of 18.

Study Variables

• Independent Variables: Health locus of control, psychological reactance, and attitudes toward psychiatric treatment.
• Dependent Variable: Patient decision-making preferences.

Data Collection Procedure

Participants were provided with a comprehensive explanation of the study’s aims, procedures, and potential impacts upon their visit to the mental health center. After obtaining informed consent, participants completed a sociodemographic survey along with the Patient’s Health Belief Questionnaire on Psychiatric Treatment (PHBQPT) and the Control Preferences Scale (CPS).

• Patient’s Health Belief Questionnaire on Psychiatric Treatment (PHBQPT): A 17-item self-reported questionnaire assessing attitudes toward psychiatric medication, psychological reactance, and health locus of control.³⁷ The PHBQPT is divided into five pivotal subscales yielding five distinct scores: Positive and Negative Aspects of Medications, Doctor-Health Locus of Control, Internal-Health Locus of Control, and Psychological Reactance, thereby providing a multifaceted understanding of factors influencing medication adherence. With an approximate completion time of 15 minutes, the PHBQPT is both efficient and practical for use in clinical settings, allowing for a refined assessment of beliefs and attitudes that could significantly affect treatment outcomes. The scores from five different dimensions of the questionnaire can be simplified into groups based on their median values. This lets us identify patients’ attitudes and beliefs which are important for understanding how likely they are to follow their treatment plans. Scores on how patients view the positives and negatives aspects of their medications can be categorized into four groups: those wary of medications (pharmacophobic: low positive, high negative), those unsure about medication benefits (indecisive: high positive, high negative), those not worried about medication effects (unconcerned: low positive, low negative), and those positive towards medication (pharmacophilic: low negative, high positive). Similarly, by combining how patients perceive their own control over their health and the control they attribute to their doctors, we identified four belief patterns regarding who is responsible for managing their psychiatric disorder: the patient themselves (low doctor, high internal), both the patient and the psychiatrist (high doctor, high internal), neither (no control: low doctor, low internal), or primarily the psychiatrist (low internal, high doctor). Finally, by looking at patients’ willingness to accept their psychiatrists’ guidance combined with their views on control, we created four profiles describing their relationship with their psychiatrist: resistant (defiance: low doctor, high reactance), conflicted (struggle: high doctor, high reactance), detached (apathy: low doctor, low reactance), and agreeable (trust: low reactance, high doctor).
• Control Preferences Scale (CPS): A validated instrument measuring the degree of control patients desire in medical decision-making, ranging from active to passive roles.^38,39 This validated scale offers a structured approach to understand the degree of control patients desire over their treatment choices, articulating this continuum of preferences through five well-defined categories. These range from an active role—where the patient independently decides on their treatment after considering their doctor’s advice—to a passive role—where the patient defers all decision-making responsibilities to their healthcare provider. Between these extremes lie the semi-active role(decision-making is a shared process with the doctor), the collaborative role (a balanced partnership in decisions), and the semi-passive role (the doctor decides, but patient’s preferences are considered).

Ethical Consideration

The study adhered to the ethical principles outlined in the Declaration of Helsinki. Informed consent was obtained from all participants, and their rights and well-being were safeguarded throughout the study. The study protocol, including consent forms and procedures, was reviewed and approved by the Ethics Committee of the University Hospital Nuestra Señora de la Candelaria in Santa Cruz de Tenerife.

Statistical Analysis

Data were analyzed using descriptive statistics to summarize participant characteristics and responses. Correlation analyses were conducted to examine the relationships between health locus of control, psychological reactance, attitudes toward psychiatric treatment, and decision-making preferences. One-way ANOVA was used to assess the impact of control preference scales on health beliefs. Cross-tabulation and chi-square analysis were performed to explore the relationships between control preferences and attitudinal groups towards medications, types of psychiatric relationships, and perceptions of treatment control. All statistical analyses were performed using SPSS software, version 25.

Results

Participant Characteristics

The study included 151 psychiatric outpatients (64 males, 87 females) from a community mental health center on Tenerife Island, Canary Islands, Spain. Participants ranged in age from 18 to 86 years (mean age = 43.21 years, SD = 14.961 years). The duration of psychiatric treatment varied from 1 to 516 months (mean = 94 months, SD = 124 months). Educational attainment varied, with 4% able to read and write, 16.6% having primary education, 47.7% having secondary education, and 31.8% having university-level education. Diagnoses included schizophrenia (11.4%), bipolar disorder (7.9%), depressive disorder (32.1%), anxiety disorder (35%), personality disorder (3.6%), and other diagnoses (10%).

Control Preferences

Control Preferences Scale (CPS) data revealed a spectrum of decision-making preferences among participants: 9.3% favored an active role, 19.9% a semi-active stance, 47% a collaborative role, 15.2% a semi-passive position, and 8.6% a passive role (Figure 1).

Figure 1 Results of the Control Preferences Scale in the global sample.

Attitudes Towards Medications

Participants were categorized into four groups based on their attitudes towards medication: pharmacophobic (30.5%), indecisive (21.9%), unconcerned (17.9%), and pharmacophilic (29.8%) (Figure 2).

Figure 2 Graphic representation of the interaction between the dimensions positive and negative aspects of medication and Control Preference Scales results.

Types of Psychiatric Relationships

The study identified four profiles describing patient-psychiatrist relationships: apathy (13.9%), defiance (23.8%), trust (25.2%), and struggle (37.1%) (Figure 3).

Figure 3 Graphic representation of the interaction between the dimensions doctor health locus of control and psychological reactance and Control Preference Scales results.

Perceptions of Control

Out of 151 participants, 21.2% felt they had no control over their treatment, 25.8% believed their psychiatrist was in control, 16.6% felt they personally had control, and 36.4% perceived shared control with their psychiatrist (Figure 4).

Figure 4 Graphic representation of the interaction between the dimensions internal and doctor health locus of control and Control Preference Scales results.

One-Way ANOVA Results

As Table 1 shows, the one-way ANOVA revealed significant differences among control preference groups regarding insight into mental illness (F(4, 146) = 10.534, p < 0.001), doctor health locus of control (F(4, 146) = 11.931, p < 0.001), and perceptions of the positive aspects of psychiatric medications (F(4, 146) = 9.434, p < 0.001).

• Insight into Mental Illness: Patients with a more passive control preference reported higher insight (mean scores: active = 9.64, passive = 16.85).
• Doctor Health Locus of Control: Passive participants showed the highest mean score (17.00), indicating a stronger belief in doctors’ control.
• Positive Aspects of Psychiatric Medications: Scores ranged from active (12.43) to passive (24.77), with less active groups having more positive views.

Table 1 Results of One-Way ANOVA Analyzing the Impact of Control Preference Scale on Health Beliefs: Insight in Mental Illness, Internal Health Locus of Control, Doctor Health Locus of Control, Psychological Reactance, and Perceptions of Psychiatric Medications’ Positive and Negative Aspects

No significant differences were found in internal health locus of control (F(4, 146) = 0.861, p = 0.489) or psychological reactance (F(4, 146) = 1.953, p = 0.105).

Cross-Tabulation and Chi-Square Analysis

Significant relationships were found between control preferences and attitudes towards medications (χ²(12) = 40.522, p < 0.001), types of psychiatric relationships (χ²(12) = 28.472, p = 0.005), and perceptions of control (χ²(12) = 30.944, p = 0.002)(see Table 2).

Table 2 Cross-Tabulation and Chi-Square Analysis Results Between Control Preferences and Patients’ Attitudes Towards Medications, Their Relationships with Psychiatrists, and Their Perceptions Regarding the Control of Their Treatment

Discussion

Despite the growing recognition of the importance of shared decision-making (SDM) in mental healthcare,^40–42 there is a notable gap in research specifically exploring the psychological constructs that influence psychiatric patients’ participation in decision-making about their treatment. While several studies have begun to shed light on factors affecting patient involvement across various medical fields,^43–46 the unique context and challenges of psychiatric care necessitate a more focused investigation.

The present study elucidates the relationships among health locus of control, psychological reactance, attitudes toward psychiatric treatment, and patient decision-making preferences within a psychiatric outpatient population. The findings underscore the importance of considering these psychological constructs to enhance patient-centered care and treatment adherence.

Control Preferences and Insight into Mental Illness

Our results indicate that patients with a more passive control preference reported higher insight into their mental illness. This finding aligns with previous research suggesting that patients who defer control to their healthcare providers may be more receptive to information and guidance, thus developing greater insight into their conditions. Conversely, active patients may feel more empowered but might also experience more conflict or doubt regarding their condition, leading to lower insight scores.^47–49

Doctor Health Locus of Control

Participants with a passive control preference also showed a stronger belief in doctors’ control over their health. This result is consistent with studies indicating that patients who trust their healthcare providers are more likely to attribute control to them, enhancing the therapeutic alliance and potentially improving treatment adherence. In contrast, those with an internal health locus of control may experience challenges in accepting external guidance, which could affect their adherence and engagement negatively.⁵⁰

Attitudes Toward Medications

Our study found that participants with less active control preferences had more positive views of psychiatric medications. This is in line with findings from previous studies where patients who rely on their doctors’ expertise tend to trust prescribed medications more and exhibit better adherence. On the other hand, patients with active control preferences often have more skepticism toward medications, possibly due to a desire for more control over their treatment decisions.^51,52

Psychological Reactance and Decision-Making Preferences

Psychological reactance was not significantly different among the control preference groups, although a pattern was noted. Active participants showed higher psychological reactance, suggesting a resistance to perceived threats to their autonomy. This aligns with the theory of psychological reactance which posits that individuals with high autonomy needs resist externally imposed control.^17,26 Reducing reactance in these patients might involve strategies that emphasize patient autonomy and choice within the treatment plan.^53,54

Types of Psychiatric Relationships

The study identified four distinct profiles in patient-psychiatrist relationships, with collaborative control preferences correlating with more trustful relationships. This finding supports existing literature that emphasizes the importance of collaboration in enhancing therapeutic relationships and improving treatment outcomes.⁵⁵ Contrastingly, defiant and apathetic relationships often stem from a lack of perceived control and engagement, highlighting the need for tailored communication strategies to address these attitudes.⁵⁶

Perceptions of Control

Patients with shared control perceptions reported better outcomes in terms of treatment adherence and engagement. This is corroborated by studies advocating for shared decision-making as a means to enhance patient satisfaction and health outcomes.^57–59 The challenge lies in balancing patient preferences with clinical expertise to foster a cooperative therapeutic environment.

Limitations of the Study

Despite its valuable insights, this study has several limitations that warrant consideration. The reliance on self-reported questionnaires may introduce biases, including social desirability and recall biases, potentially compromising the accuracy of the collected data. Additionally, the utilization of a consecutive convenience sampling method, while practical, may limit the generalizability of the findings to the broader psychiatric outpatient population. The non-participation of some individuals introduces the possibility of selection bias, potentially biasing the results towards those more likely to engage in research studies.

A critical limitation is the study’s cross-sectional design, which constrains our ability to infer causal relationships between the psychological constructs examined and patient outcomes in psychiatric care. This design provides a snapshot in time; thus, it is challenging to determine whether the psychological constructs cause changes in patient outcomes, or if patients with specific outcomes are predisposed to exhibit certain psychological characteristics. Longitudinal research is necessary to establish causality and to explore the evolving dynamics among these constructs, patient engagement, adherence, and overall satisfaction with psychiatric treatment over time. Furthermore, the cross-sectional approach does not accommodate potential shifts in psychological constructs or patient attitudes throughout treatment, factors that could significantly influence treatment outcomes and the dynamics of patient-provider interactions.

Acknowledging these limitations is essential for an accurate interpretation of the study’s findings and for directing future research endeavours to address these shortcomings.

Implications for Practice

The findings suggest that understanding and integrating patients’ psychological constructs into psychiatric care can improve treatment adherence and outcomes. Tailoring treatment approaches to align with patient preferences for control and engagement can foster a more supportive and effective therapeutic environment.

Future Research

Future research should explore longitudinal and interventional studies to further understand the impact of aligning treatment approaches with patient preferences and psychological profiles. Investigating the dynamic nature of these constructs over time and their influence on long-term treatment outcomes will be essential.

Conclusion

This study reveals significant relationships between health locus of control, psychological reactance, attitudes toward psychiatric treatment, and patient decision-making preferences in a psychiatric outpatient population. Key findings indicate that patients with passive control preferences show higher insight into mental illness, greater trust in doctors, and more positive attitudes towards medications. Active participants display higher psychological reactance, highlighting the necessity of emphasizing patient autonomy. Collaborative control preferences correlate with more trustful psychiatrist relationships, and shared control perceptions improve treatment adherence and engagement. These insights advocate for personalized, patient-centered psychiatric care strategies, aligning treatment with individual psychological profiles to enhance outcomes. Future research should examine the long-term effects of these tailored approaches and explore methods to reduce psychological reactance.