Flourishing, Mental Health Professionals and the Role of Normative Dialogue.

This paper explores the dilemma faced by mental healthcare professionals in balancing treatment of mental disorders with promoting patient well-being and flourishing. With growing calls for a more explicit focus on patient flourishing in mental healthcare, we address two inter-related challenges: the lack of consensus on defining positive mental health and flourishing, and how professionals should respond to patients with controversial views on what is good for them. We discuss the relationship dynamics between healthcare providers and patients, proposing that 'liberal' approaches can provide a pragmatic framework to address disagreements about well-being in the context of flourishing-oriented mental healthcare. We acknowledge the criticisms of these approaches, including the potential for unintended paternalism and distrust. To mitigate these risks, we conclude by suggesting a mechanism to minimize the likelihood of unintended paternalism and foster patient trust.

"From doing to knowing": medical students' experiences of working as Healthcare Assistants.

There is growing recognition that doctors need to deliver person-centered care. More evidence is needed on how to best equip students in an already busy curriculum. Providing medical students with the opportunity to work as Healthcare Assistants (HCAs) can help them develop the desired skills. This study examined medical students' experiences of working as HCAs and perceived impact on their future practice. Adopting an Interpretative Phenomenological Analysis approach, we analyzed narratives from two focus groups of 13 'Year 0' and 'Year 1' medical students, who had completed an HCA project. This project allowed participants to experience a new dimension of patient care whereby learning by "doing" evolved to a deeper level of "knowing" patients, the HCA role and the wider team. Four major themes were identified: seeing the doctor: gaining new perspectives; building confidence: learning from and about patients; understanding the overall patient experience: providing personal care; finding "the person behind the patient": exploring beyond the diagnosis. This study suggests that working as an HCA enables participants to develop sustainable skills that equip them for their future role as doctors able to deliver person-centered care as part of an interprofessional team. Recommendations for inclusion of this type of intervention into the medical curriculum are discussed.

Values-based interprofessional education: how interprofessional education and values- based practice interrelate and are vehicles for the benefit of patients and health and social care professionals.

The 2016 All Together Better Health VIII Oxford conference brought together interprofessional education (IPE) and values-based practice (VBP) communities. As there is a paucity of research and publications in the area, following the event a working party consisting of representatives from both communities continued to meet and has developed a joint community of practice. This report describes the work achieved by the group so far and is intended for those involved in the planning and implementation of IPE and collaborative working. The authors consider that incorporating principles of VBP within a framework of IPE can provide a different perspective and understanding of the complexities involved in delivering realistic, student centered learning for collaborative practice, relevant in the 21st century workplace. In particular the authors suggest that using the principles of values and VBP in this way can inform the transition between IPE and collaborative practice facilitating effective person centered collaborative care. This process will require not only the incorporation of these principles within IPE sessions, but also incorporation within the training and support of new and established teachers involved in IPE.

Promoting the freedom of thought of mental health service users: Nussbaum's capabilities approach meets values-based practice.

This article clarifies how the freedom of thought as a human right can be understood and promoted as a right of mental health service users, especially people with psychotic disorder, by using Martha Nussbaum's capabilities approach and Fulford's and Fulford et al's values-based practice. According to Nussbaum, freedom of thought seems to primarily protect the capability to think, believe and feel. This capability can be promoted in the context of mental health services by values-based practice. The article points out that both Nussbaum's approach and values-based practice recognise that people's values differ. The idea of involving different actors and service users in mental healthcare is also common in both Nussbaum's approach and values-based practice. However, there are also differences in that values-based practice relies on a 'good process' in decision-making, whereas the capabilities approach is oriented towards a 'right outcome'. However, since process and outcome are linked with each other, these two approaches do not necessarily conflict despite this difference. The article suggests that absolute rights are possible within the two approaches. It also recognises that the capabilities approach, values-based practice and human rights approach lean on liberal values and thus can be combined at least in liberal societies.

An exploration of values-based radiography from the perspective of the service user.

INTRODUCTION: This article presents the patient outcomes of a CoRIPS funded study which investigated the values of patients in both a diagnostic and therapeutic setting. Little work has been conducted to ascertain patient values and these have previously been presumed. METHOD: The study used focus groups, conducted by two experienced researchers, to allow participants the opportunity to discuss their values during imaging examinations and therapeutic treatments. The resultant discussions were audio recorded and transcribed before a thematic analysis was conducted. A sample of the data was reviewed by both researchers to demonstrate credibility and confirmability. RESULTS: The main themes identified were related to radiographer professional skills, communication and compassion. Both diagnostic and therapeutic participants shared values despite the difference in their examinations and treatments. They valued being seen as an individual and felt that radiographer communication contributed to this. Patients value being able to access information to help them prepare for their examination or treatment. During the examination they value the skills of the radiographer which they assumed. The patients also value the radiographer taking their time over the examination as they relate this the quality of the examination or treatment. After the imaging or treatment they valued being able to see their images and have their questions answered. Patient responses suggested that their values were not always met in practice. CONCLUSION: The values of the patients were successfully explored using focus groups. Patient values relate to radiographer professional skills, communication and compassion. Patients do not always have their values met during their examinations and treatments. Radiographers in practice should be mindful that patients value being treated as individuals and be provided with information throughout their imaging and treatment. Recommendations for practice were identified.

Phenomenology yesterday, today, and tomorrow: a proposed phenomenological response to the double challenges of contemporary recovery-oriented person-centered mental health care.

This paper argues that a dialectical synthesis of phenomenology's traditional twin roles in psychiatry (one science-centered, the other individual-centered) is needed to support the recovery-oriented practice that is at the heart of contemporary person-centered mental health care. The paper is in two main sections. Section I illustrates the different ways in which phenomenology's two roles have played out over three significant periods of the history of phenomenology in 20th century psychiatry: with the introduction of phenomenology in Karl Jaspers' General Psychopathology in 1913; with the development a few years later of structural phenomenological psychopathology; and in the period of post-War humanism. Section II is concerned with the role of phenomenology in contemporary mental health. There has been a turn to phenomenology in the current period, we argue, in response to what amounts to an uncoupling of academic psychiatry from front-line clinical care. Corresponding with the two roles of phenomenology, this uncoupling has both scientific aspects and clinical aspects. The latter, we suggest, is most fully expressed in a new model of "recovery," defined, not by the values of professionals as experts-by-training, but by the values of patients and carers as experts-by-experience, specifically, by what is important to the quality of life of the individual concerned in the situation in question. We illustrate the importance of recovery, so defined, and the challenges raised by it for both the evidence-base and the values-base of clinical decision-making, with brief clinical vignettes. It is to these challenges we argue, that phenomenology through a synthesis of its twin roles is uniquely equipped to respond. Noting, however, the many barriers to such a synthesis, we argue that in the current state of development of the field, it is by way of a dialectical synthesis of phenomenology's roles that we should proceed. From such a dialectic, a genuine synthesis of roles may ultimately emerge. We conclude with a note on the wider significance of these developments, arguing that contrary to 20th century stereotypes, they show psychiatry to be leading the way for healthcare as a whole, in developing the resources for 21st century person-centered clinical care.

Shared decision-making across the specialties: Much potential but many challenges.

Shared decision-making (SDM) is a collaborative process through which patients and clinicians work together to arrive at a mutually agreed-upon treatment plan. The use of SDM has gathered momentum, with it being legally mandated in some areas; however, despite being a ubiquitously applicable intervention, its maturity in use varies across the specialties and requires an appreciation of the nuanced and different challenges they each present. It is therefore our aim in this paper to review the current and potential use of SDM across a wide variety of specialties in order to understand its value and the challenges in its implementation. The specialties we consider are Primary Care, Mental Health, Paediatrics, Palliative Care, Medicine, and Surgery. SDM has been demonstrated to improve decision quality in many scenarios across all of these specialties. There are, however, many challenges to its successful implementation, including the need for high-quality decision aids, cultural shift, and adequate training. SDM represents a paradigm shift towards more patient-centred care but must be implemented with continued people centricity in order to realize its full potential.

Values-based practice and phenomenological psychopathology: implications of existential changes in depression.

Values-based practice (VBP), developed as a partner theory to evidence-based medicine (EBM), takes into explicit consideration patients' and clinicians' values, preferences, concerns and expectations during the clinical encounter in order to make decisions about proper interventions. VBP takes seriously the importance of life narratives, as well as how such narratives fundamentally shape patients' and clinicians' values. It also helps to explain difficulties in the clinical encounter as conflicts of values. While we believe that VBP adds an important dimension to the clinician's reasoning and decision-making procedures, we argue that it ignores the degree to which values can shift and change, especially in the case of psychiatric disorders. VBP does this in three respects. First, it does not appropriately engage with the fact that a person's values can change dramatically in light of major life events. Second, it does not acknowledge certain changes in the way people value, or in their modes of valuing, that occur in cases of severe psychiatric disorder. And third, it does not acknowledge the fact that certain disorders can even alter the degree to which one is capable of valuing anything at all. We believe that ignoring such changes limits the degree to which VBP can be effectively applied to clinical treatment and care. We conclude by considering a number of possible remedies to this issue, including the use of proxies and written statements of value generated through interviews and discussions between patient and clinician.

The Ten Essential Shared Capabilities: reflections on education in values based practice: a qualitative study.

BACKGROUND: This paper presents the findings of a study exploring the impact of a values-based training initiative on the practice of mental health workers. This work is set within the context of increasing attention on the values of nurses and other health care workers as a response to national reports on care failure and negative media attention. OBJECTIVE: To examine written response feedback from participants on a national training programme for values-based practice (VBP) in order to examine any intention to change practice. DESIGN: A national evaluation using quantitative and qualitative methodologies was conducted to gather data on reflections and self-report impact of the Ten Essential Shared Capabilities' training programme. SETTING: The training was delivered in a range of hospital, community and third sector training programmes across eight regions in England. PARTICIPANTS: The participants were predominantly nurses but all sectors in the mental health community including service users as co-facilitators and participants were represented. METHODS: This study presents the qualitative findings from a cross-sectional survey. Using NVIVO 10 software, data were analysed using the framework method of qualitative analysis. RESULTS: Four principal themes emerged from the data'Thinking differently''Changes to practice''Creating an effective learning environment and skills for practice development' and 'Increasing self-awareness'. CONCLUSIONS: The quality and safety drive in the NHS has an emphasis on delivery of evidence based practice. It was concluded that an active focus on values based practice merits equal attention and status.

Taking the long view: an emerging framework for translational psychiatric science.

Understood in their historical context, current debates about psychiatric classification, prompted by the publication of the DSM-5, open up new opportunities for improved translational research in psychiatry. In this paper, we draw lessons for translational research from three time slices of 20th century psychiatry. From the first time slice, 1913 and the publication of Jaspers' General Psychopathology, the lesson is that translational research in psychiatry requires a pluralistic approach encompassing equally the sciences of mind (including the social sciences) and of brain. From the second time slice, 1959 and a conference in New York from which our present symptom-based classifications are derived, the lesson is that, while reliability remains the basis of psychiatry as an observational science, validity too is essential to effective translation. From the third time slice, 1997 and a conference on psychiatric classification in Dallas that brought together patients and carers with researchers and clinicians, the lesson is that we need to build further on collaborative models of research combining expertise-by-training with expertise-by-experience. This is important if we are to meet the specific challenges to translation presented by the complexity of the concept of mental disorder, particularly as reflected in the diversity of desired treatment outcomes. Taken together, these three lessons - a pluralistic approach, reliability and validity, and closer collaboration among relevant stakeholders - provide an emerging framework for more effective translation of research into practice in 21st century psychiatry.

Neuroscience and Values: A Case Study Illustrating Developments in Policy, Training and Research in the UK and Internationally.

In the current climate of dramatic advances in the neurosciences, it has been widely assumed that the diagnosis of mental disorder is a matter exclusively for value-free science. Starting from a detailed case history, this paper describes how, to the contrary, values come into the diagnosis of mental disorders, directly through the criteria at the heart of psychiatry's most scientifically grounded classification, the American Psychiatric Association's DSM (Diagnostic and Statistical Manual). Various possible interpretations of the prominence of values in psychiatric diagnosis are outlined. Drawing on work in the Oxford analytic tradition of philosophy, it is shown that, properly understood, the prominence of psychiatric diagnostic values reflects the necessary engagement of psychiatry with the diversity of individual human values. This interpretation opens up psychiatric diagnostic assessment to the resources of a new skills-based approach to working with complex and conflicting values (also derived from analytic philosophy) called 'values-based practice.' Developments in values-based practice in training, policy and research in mental health are briefly outlined. The paper concludes with an indication of how the integration of values-based with evidence-based approaches provides the basis for psychiatric practice in the twenty-first century that is both science-based and person-centred.