Bill Fulford

Evaluating the influence of implicit models of mental disorder on processes of shared decision making within community-based multi-disciplinary teams

This paper reports findings from a qualitative study concerning the influence of implicit models of mental disorder on shared decision making within community-based mental health teams. One-hundred participants representing five distinct multi-agency groups: psychiatrists, community psychiatric nurses, approved social workers, patients and informal carers operating within Leicestershire, England were interviewed using a standard case vignette describing a person whose behaviour suggests he may have schizophrenia. The results showed that each of the studys multi-agency groups implicitly supports a complex range of model dimensions regarding the nature of schizophrenia, the appropriateness of specific forms of treatment and care, and their respective rights and obligations towards each other. The influence of these implicit model patterns on processes of shared decision making are discussed through evaluating their contribution to our understanding of the power relationships existing between various practitioner groups (including informal carers), and between practitioners and patients during clinical encounters.

History and philosophy.

Antipsychiatry is dead ± long live antipsychiatry! Dramatic advances in the neurosciences in the ®nal decade of the twentieth century have led many in psychiatry to believe that the ®nal triumph of the biological model of mental disorder, which was the target of so much antipsychiatric sentiment in the debate about mental illness in the 1960s and 1970s, is just around the corner. This years articles in the history and philosophy of psychiatry show, to the contrary, that the debate between psychiatry and antipsychiatry is far from over.

The slide to pragmatism : a values-based understanding of 'dangerous' personality disorders

Abstract This paper reports on a qualitative study of UK mental health practitioners’ experiences of working with the contested condition, dangerous and severe personality disorder (DSPD). Our interviews focused on the issues of treatability, risk assessment and decision-making in multi-disciplinary teams. We discuss the approach of values-based medicine (VBM) as a useful framework for interpreting the data: respondents cited both explicit values (based on occupational training) and implicit values (based on personal beliefs and subjective perceptions). There was evidence of conflicting values – within individuals, between occupational groups, and between individuals in occupational groups – which led to widespread uncertainty and caution about whether and how those with ‘dangerous’ personality disorders could be treated. These disputes were resolved by a ‘slide to pragmatism’, whereby practitioners, reluctantly acknowledging their own empowerment in the process, sought to make whichever choice was least risky for their own professional reputation, and most pragmatic, given the resources available.

Recovery, Values and e-learning

During the ‘decade of the brain’ in the 1990s the scientific community faithfully believed that by the end of the century biological solutions to the treatment of diagnosed mental disorders would become available (Kramer, 1993). However, the end of the century has come and gone and it would seem that biologically we are not much further advanced. Significant concerns have been expressed about the openness of some pharmaceutical industry research in relation to the effects of some medications, thus highlighting the need to put ‘consumers at the heart of T medicines regulation against the concerted interest of pharma’ and recognising that ‘randomized controlled trials do not show what is happening at an individual level’ (Brooke, 2004). It is now recognised that recovery can occur despite the continuing presence of ‘symptoms’ for which medications are most often prescribed. An increasing focus on diagnosis has led to the marketing of pharmaceuticals being diagnosis-centred, with the resultant influence on prescribing practices that are often based on diagnosis alone. This narrow approach ignores the heterogeneity of the needs of people diagnosed with mental illness and fails to recognise that though people are often very ill, their illness can be a stimulus to personal growth.

Values and ethics in mental-health education and training: a different perspective

Purpose – The purpose of this paper is to review the challenges of teaching values and ethics in mental-health, explore the differing perspectives of the key stakeholders and stimulate further questions for debate in this area; leading to a proposal of an alternative approach to educating mental-health professionals on values and ethics. Originality/value – In current mental-health care settings, very few professionals work with homogeneous populations. It is imperative that mental-health education and training ensures health professionals are competent to practice in diverse settings; where ethics and values are bound to differ. Establishing professional practice not only involves considering concepts such as values and ethics, but also equality, diversity and culture. Incorporating values-based practice and cultural diversity training holds promise to education and training, that is truly reflective of the complexity of clinical decision making in mental-health. Further research is needed as to how thes...

Nothing about us without us

Earlier in the week of this writing, one of us (JZS) after a book-planning teleconference realized that he had not properly heard and digested the full names of the other participants. He followed up with an e-mail to his primary contact, humbly requesting the names of the other participants because ‘I’m not good with remembering spoken names’ – an old foible of his. His colleague was gracious in sending a list of participants and a short description. Difficulty assimilating newly spoken proper names – a disability or handicap?

Value-based practice: introducing a skills-based approach to balanced clinical decision-making

Whilst the importance of evidence-based practice is well recognised by most GPs, perhaps less well recognised is that there are two bases or feet’ on which sound clinical decision-making is based—the other being values-based practice (V-BP). This article does not attempt to be a comprehensive manual on the processes of V-BP. We aim to help you understand the rationale of V-BP and to demonstrate some of its processes which, as you will see, build on your existing clinical skills and knowledge. In view of the importance of clinical decision-making, it is unsurprising that the GP curriculum underlines the importance of values-based practice.

History, philosophy and practical psychiatry: neither gap nor contradiction, but mutual enrichment.

When working in the field of history and philosophy of psychiatry, one will sooner or later be confronted with the sceptical question of whether there is any practical use of such activities for psychiatry – both as a therapeutic discipline and as a continuously growing area of research. This years history and philosophy section provides the readers with five reviews that address this issue from quite different perspectives, while they share (and, in a way, prove) the basic attitude that theoretical and practical levels of psychiatry are intertwined much more closely than one usually realizes.Focussing on the history of psychiatric institutions, Engstrom concludes that the shift from the carceral narrative of earlier decades to the present interest in the extramural dimensions of psychiatric work should not undermine the need for thorough research into the changing, but still important, roles of institutions. Haack and Kumbier review the literature on the concept of social psychiatry and its multifold, albeit often contradicting, practical consequences, for example, for professional role models or the interplay of different methodological approaches like neurobiological and psychopathological ones. They provide a broad range of perspectives from the 19th century to the reform and antipsychiatry movements in the second half of the last century and to the very recent developments in the interprofessional organization of psychiatric care.The latter aspect is emphasized by Jaeger and Hoff, who summarize and comment on recent articles on the recovery model. This concept, increasingly popular and widely used, but still partly fuzzy, enriches the classical symptom-oriented approach (the medical model, so to speak) by focusing on the patients (and, not to forget, the relatives’) perspective and initiative. In this case, attention is not so much invited to the historical, but to the ethical and anthropological, dimension of psychiatric work.Two reviews show how intensely, but often implicitly, shifts in theoretical frameworks may alter clinical practice: Millard elucidates the evolving conceptualization of deliberate self-harm in postwar Britain. This is by no means only a matter of theoretical consideration, as it strongly reflects profound changes in the organization of mental healthcare. These changes made the ‘stories behind physical injuries’ accessible and interesting to psychiatrists and researchers. Woodbridge-Dodds review of recent publications on values-based practice in mental health and psychiatry opens two perspectives: in the first place, she reports on new practical and research options made possible by implementing the dimension of values into basic psychiatric work. In the second place, this approach in itself is debated as connected with certain values, especially with a radical liberal approach – values that also have to be (and, indeed, are) acknowledged and discussed.The section editors hope that readers will arrive at a similar conclusion as they did: the complex interface between the historical and philosophical underpinnings of psychiatry on the one hand and its practical dimensions of diagnosis, therapy and research on the other hand has developed into a stimulating and rich scientific area that successfully operates within and beyond classical methodological or conceptual frameworks. In other words: the practical relevance of these topics for psychiatry is no longer in question.

Values, Mental Health and Mental Capacity: Debates in Cyberspace

There is growing recognition of the very important role that values play within the fields of mental health and mental incapacity. Values may differ between disciplines, teams, frontline services and corporate management, and, most significantly, between service users, carers and practitioners. Identifying, respecting and responding to service users’ values pose major challenges to practitioners, but are ones they encounter on a day-to-day basis. This article describes how online conferencing has been used as a way of meeting these challenges, particularly in the context of a national commitment to place values more explicitly at the centre of mental health work in England.