精神神経学雑誌
第 112 巻 第 2 号（2010) 116‑179 頁

第回日本精神神経学会総会

特 ⃞
別 ⃞
講 ⃞
演
⃞

Bearing Values on Clinical Decisions
Ho Young Lee（Dasarang Center Hospital）

Psychiatry is more value‑laden than any other ﬁeld of medicine because it is concerned ofhuman experience and behavior. It is natural that psychiatry should recognize the role of values,
alongside facts, in all areas of clinical practice‑diagnosis, treatment and rehabilitation. Thereis a considerable concern on the development and the current form of evidence‑based psychiatry
whether this being suﬃcient in decision making in complex environment of mental healthservices of today. Psychiatric diagnosis derived from observed symptoms silence the interpersonal dialogues. The clinical encounter is narrowly focused on the forms instead of contents,
meanings and background of human mental distress. We need a complementary value model,
value‑based approach,which runs parallel to evidence‑based psychiatry. Value‑based approach,like evidence‑based,is a resource for eﬀective decision‑making in psychiatric practice. It starts
from equal respect for all values, individual patients, their families and communities, and therecognition of the fact that various value terms already exist in DSM or ICD diagnostic systems.
To respect values, psychiatry must step down to be equal with service users. Current development of mental health services are based on the principles of patient centered decision‑making
and multidisciplinary teamwork. This should provide basis for value‑based as well as fact‑
based psychiatric practice.
Key words: value‑based practice, classiﬁcation, patient‑centered

Symptom‑centered approach and DSM ‑ICD

ful to identify symptoms. This professional

We are all trained psychiatrists and natu-

sieve that only pass symptom‑related informa-

rally medical thinking comes to the fore whention may have become our disposition, for

we see patients with mental health problems.

establishing an accurate diagnosis is the ﬁrst

We try to establish a diagnosis ﬁrst because it

duty of a medical doctor.

is a primary task of our practice. During theThis diagnosis‑ﬁrst trend became morecourse of diagnosis, since we are so imbued tosolidiﬁed after the publication of DSM and ICD

look for symptoms, we may selectively pickmanuals. It has become an obsession that we

those information considered relevant and use-must identify symptoms ﬁt to the criterions of

第 105回日本精神神経学会総会＝会期：2009年 8月 21〜23日，会場：神戸国際会議場・神戸商工会議所・クオリティーホテル神戸・ポートピアホテル
総会基本テーマ：わが国精神医学のめざす地平，坂の上の雲
特別講演

Bearing Values on Clinical Decisions 座長：守田 嘉男（兵庫医科大学精神神経科学講座）

特別講演：Bearing Values on Clinical Decisions

117

the manuals to make an ʻ
authenticʼdiagnosis.

contributed to the simpliﬁcation of psychiatricAccuracy and authenticity that go with thepractice. Changed concept of time of people ismanuals are the essence of ʻscientiﬁcʼpsychia-

one thing. Nowadays, people are impatient of

tryand to following this line is the royal road to

waiting, expecting to see the outcomes quickly

the standard psychiatric practice. Thus, DSM

at doing or receiving ends of services. There is

and ICD became the bible of psychiatry, char-

not enough time for people to visit doctors

tered and blessed by two utmost authorities ofoﬃces often,and to spend lengthy time waiting,world medicine and psychiatry‑World Healthexplaining and listening to the details of their

Organization and American Psychiatric Associ-illnesses at sessions. They like quick services

ation.

as they like to eat fast food. For psychiatrists,

After the decades of experience with DSM

this has changed the pattern of practice; in-and ICD, in a way, mental disorders have be-creased the number of patientʼs visits counting

come limited treatable mental symptoms. As

more than lengthy services which attributed tothe diagnosis‑centered psychiatric practicebetter quality. Ex‑student of mine,a staﬀof aprevailed, the mental patient is reduced to theuniversity medical center conﬁded with me thatʻ
walking embodiment of a psychiatric diagno-

he sees about 50 out‑patients a day, includingsisʼ. The symptom‑oriented psychiatric prac-

new patients. Psychiatric practice is simpliﬁed

tice based on the medical model reduced humanin Korea.

to a diagnostic category and the range of human experience to the symptoms of illnesses.

Psychiatry is a discipline of depth. Traditionally, psychiatry always stressed thesigniﬁcance of personal experience and thePsychiatric practice simpliﬁed

empathic listening to patientsʼstories.

The

Once diagnosis is made then the next step

promotion of personal growth and development

is to treat the symptoms on which the diagnosis

is the core spirit of all the psychiatric interven-is based. Of course, the ﬁrst is treatment with

tions. M any of us, as medical students, were

drugs. The initial pharmacotherapyis a routine

attracted to this humanistic element of psychia-

practice today. And the decision to select thetry which led us to choose this ﬁeld as career.

drug of choice is easy because drug algorithms

Have those humanistic element abide with thisdesigned by experts are readily available. It

tradition not been curtailed because of thecovers all the contingencies along the courses

over‑emphasis of symptom‑oriented approachof drug therapies for most of the diagnosed

and the dominance of scientiﬁc side of disci-

mental disorders. After initiating a drug ther-pline?

apy, all you have to do is to wait and see the

Of course,this is not to discount the contri-

result,how the given drug brings changes to thebution and the importance of scientiﬁc knowl-treated symptoms. In essence, the process ofedge and the development of other technologies

psychiatric diagnosis and treatment is now

contributed to mental health services. Neither

formularized ; the rise of a new ʻ
psychiatricto call a return to the past model practicetechnology.ʼ And the psychiatric practice be-

stressing onlythe value of humanistic side. The

came simpliﬁed.

point is that the future progress of psychiatryis

There are other important cultural factors

not to be made by science alone. For a better

精神経誌（2010）112 巻 2 号

118

psychiatric practice of tomorrow, more bal-Diagnosis also bears power of control andanced priorities of references to be set including

coercion. We are confronted with situations

both value‑side and humanistic‑side issues inwhen the patient appears dangerous to either

all areas of psychiatric practice.

himself or others due to his disturbed psychotic
state. And the patient refuses anyhelp while heDiagnosis and the implications

or she remains in a state of extreme agitation.

Human mind is complex, and so are the

The diagnosis of an acute psychotic disorder ismental symptoms because theyare the products

inevitable which legally permits the use ofof this mind. In the last few decades, in ordercoercive methods to hospitalize the patient

to improve studies of human mind, psychiatry

against his will. Psychiatric diagnosis,further-has established a professional model the means

more,mayshape the realityof a person throughthrough which complex human experiences anddiscourses. For example, if the patientʼs par-

maladies are structured. Psychiatry invested

anoid delusion is acute and his competence on

considerable eﬀorts in attempts to establish areality testing may be open for doubt. Only adiagnostic system that are ʻ
validʼand ʻ
reliableʼ.

psychiatric diagnosis can clear the air arbitrat-

The DSM and ICD are products of this purpose,

ing that the reality testing is impaired. Impor-

and with many revisions and additions, thetant human right can be overruled with a psy-

manuals are voluminous today with valuable

chiatric diagnosis, and a coerced treatmentchanges and additions. We now heavily depend

may be justiﬁed with the diagnosis.

on this tool to establish authentic psychiatric

The point is that a psychiatric diagnosis isdiagnoses which has become a fundamental

not solely a medical decision identifying apart of psychiatric practice. DSM and ICD are

mental disorder, it embraces complicated hu-

the compasses of our professional voyage.

man issues of vital importance; legal, social

Psychiatric diagnosis, however, hasand ethical.

brought on concerns for the implications andinﬂuences particularly of power and control.

Diagnosis does not representLetʼs examine what control and power a psychi-

the essential truth of the patient

atric diagnosis may yield.
First of all, insurance companies will not
pay for your service unless there is a diagnosis.

The next issue is the downgrade of humanistic values in symptom‑centered psychiatricpractice.

This is why psychiatrists try to establish a

Since establishing a diagnosis is important,quick, clear and authentic diagnosis. In some

psychiatrists are so prepared to look for symp-

occasions, you may not be certain of diagnosis

toms. While we were preoccupied with search-just after an initial interview. For warranted

ing for symptoms,however,we might leave out

the third party payment, however, you may

important information of personal experiences.

tend to make an ultimate diagnosis in consen-

Though it may seem trivial and irrelevant tosus with DSM or ICD at the very beginning anddiagnosis, the part dismissed may have helpful

initiate treatment accordingly. Diagnosis con-information to understand ʻ
the personʼwho isscious approach may inﬂuence the pace and theaﬀected with mental disorder. And to under-order of your practice.

stand patientʼs personality is important for特別講演：Bearing Values on Clinical Decisions

119

planning treatment and the prediction of thethe religious, cultural, personal and family im-course and the prognosis of the treatment.

plications are mere “suicidal ideation”.

In

We claim that we are experts on “
personal-

essence, psychopathology is not the content ofity”. We underwent extensive post‑graduate

what the patient says but the terms experts

training to studyvarious psychiatric theories on

formulated and conceptualized through inten-

humansive studies on the manifestations of mental

behavior.

We

also

studied“phenomenology of psychopathology”, the phe-disorders.

nomenon of various manifestations of abnor-

Notwithstanding, the contribution ofmal mental states. It is an important tool

phenomenology to psychiatry is resplendently

through which the mental symptoms are conce-

fertile. To ensure the tradition of making ʻac-ptualized and makes apparent of the nature ofcurate scientiﬁcʼdiagnosis, phenomenologicalpsychiatric symptoms. It also tells us how toapproach laid out the basis of psychiatric prac-

explore symptoms. The exploratory process

tice upholding the principles to be very precise,

begins with careful listening to the explanations

clear cut and ultimately scientiﬁc. With thisof patientʼs experiences; the perceptions oftool, a psychiatrist is trained to understand a‑feelings, thoughts and beliefs.
ʻ
inner sideʼ

patient and we believe that we are so capable ofThus, information of the ʻ
inner sideʼis verbal-

understanding patientsʼworld through this ap-

ized through language and coming to the ʻouterproach.

sideʼ. The externalized patientʼs subjective

Now the question is whether the under-

experiences then undergo diagnostic screening,

standing we appropriated through this ap-

sorting out to ﬁnd what seems to be pathologi-

proach fullyrepresents patientsʼinner world. Is

cal and identiﬁable with psychopathology al-

it not for ʻ
our view of themʼin doctorʼ
s perspec-

ready conceptualized. For example,if a patient

tive? The answer to this question is negative.

says he is tired, moody, lost general interest,

Psychiatric diagnosis does not represent thehas diﬃculty in falling asleep, the condition

essential truth of the patientʼs condition. It‑a psychopathology.
becomes ʻ
depressionʼ

If

may even obscure the truthful part of theanother says that he believes that he has apatientʼs condition because the diagnostic ex-

special mission to save the world,he is suspect-ploration usually does not go into the ʻcontentʼ

ed to have a delusion, a standard criterion forof symptoms, but it side‑tracks to the ʻformʼ
.

identifying a serious mental disorder. If you
further prove that the personʼs reality testing isContent set aside

impaired with his belief of saving‑the‑world

Philosophers argue that the naming a dis-mission rigidly ﬁxed, then he has a delusion.

ease represents to set theʻformʼof illness,while

What you are doing here is to explore thethe illness experienced in particular patientpatientʼ
s mind, bring a part of the contents out

corresponds to the notion of ʻ
contentʼ. The

to identify it with the one already deﬁned as adiagnosis of schizophrenia for example is uni-

psychopathology. Some experiences the pa-

versally same for every patient regardless oftient expressed are reformulated and translated

contexts. But the content of symptoms vary

into psychiatric terminology. Painful thoughts

according to individuals. For the psychiatrist,

about ending oneʼs life, for example, with allʻformʼis the central concern. But the patient is

精神経誌（2010）112 巻 2 号

120

more concerned about the content of symptoms.

ble covering all the contingency angles throughThe meaning of an auditory hallucination can

the course of drug therapy, including the sug-be very disturbing to the patient. While psychi-

gestion of alternative drugs in case initiallyatrists are preoccupied in identifying symp-

chosen drug is either not eﬀective or yields

toms, the true experience of fearful thoughts

untoward side eﬀects. Drug therapy has be-

and feelings interwoven with psychological,

come the routine of psychiatric practice.

cultural and practical realities may be left out.

The contribution of pharmaceutical compa-

The experience expressed in his language thatnies to the simpliﬁed drug‑oriented psychiatricbears meanings and contents may be lost.

practice is another knotty issue.

Philosophers also argue that “the world of
psychiatry, involving

emotions, thoughts,

Context and meaning

beliefs and behaviors is a world of meaning and

Mental symptom is a manifestation ofthus of context. The centrality of these twinpatientʼs inner struggles; a way of coping,issues of meaning and context that separates

ﬁghting, avoiding, negotiating, compromising

the world of ʻ
mentalʼfrom the rest of medi-with troubling conﬂicts. It may be a primitivecine” .

Postpsychiatrists also suggest that

coping behavior for survival to prevent an im-ʻmental medicineʼ,psychiatry,must reverse thepending catastrophe that the patient is fearfultraditional approach.

Instead of identifying

of. Boss wrote that “
A symptom evolves fromsymptoms ﬁrst, psychiatrists must understanda complicated disturbed human mind, and thethe context ﬁrst ; social,cultural,temporal andaﬄicted person is impaired of his ability tobodily factors .

relate himself through perception to what re-

The humanistic element once was anveals itself to him in the world” . This tells us

attraction of psychiatry. Psychoanalytic theo-

the fact that there are reasons behind symp-

ry certainly enriched the humanistic side oftoms and these reasons should not be overloo-

psychiatry. Humanistic spirit was the core ofked.

the development of dynamic psychiatry, which

Things happen while we live for reasons. Iftaught us to listen to the content of the patientʼs

we do not know what that reason is, then we

experience. Dynamic psychiatry encouraged us

create one. This is a part of what makes us

to look into context while exploring the mean-human. Also, there is a need to explain things

ings of the patientʼs experience. It is unfortu-

that happens. Some explained reasons makenate that this humanistic spirit of psychiatry

sense,but others do not. Some are possible andhas been fading, along with the decline of psy-others are not probable. But it is important tochoanalytic thinking in contemporary psychia-

respect the desire that drives us to look fortry.

ʻmeaningʼin our lives.
Since DSM and ICD, mental disorders be-

In out practice, we should look for mean-came limited treatable psychiatric symptoms;

ings of patientsʼexperiences together withtreatable mainly with drugs to suppress thosepatients because we are not only dealing withsymptoms. Today, drug therapy is the mostthe patientsʼsymptoms but also with their lives.

popular treatment model in psychiatry. Fur-

We should look for a moral of their stories andthermore,the drug therapy algorithm is availa-

discuss it with them ; meanings and contexts.

特別講演：Bearing Values on Clinical Decisions

121

Desirably, we should do this before identifying

his work and family to participate a religious

symptoms because this helps us to understandretreat to pray for the world peace may besomething more signiﬁcant to the patientʼs real-thought ofʻ
good thingʼin one country. But in aity.

work‑oriented country like Japan or Korea, it
How do we do this? At ﬁrst, we listen to

may be considered ʻ
functioning badlyʼfor the
Value‑judgment iswhat the patient says carefully, paying atten-

company or the family.

tion to the patientʼs perspectives, particularly

very much involved while assessing

to his or her ʻvaluesʼ. This leads us to exploring

patientʼ
s behaviors in personality disorders.

the content of symptoms. While we discuss

Beside the behavioral diagnostic criteria of thecontents with patients, we will ﬁnd ourselves

manual,the inclusion line says ʻwhen the behav-

already dealing with contexts and meanings

ior is considered pathologicalʼ
. To judge whatpertained in the patientʼs experiences.

is pathological, personal factors of informants

theand the assessing psychiatrist can be determinaValue‑based psychiatry

tive. To draw a line when a behavior apper-

There is a growing importance of ethicaltains to psychopathology is a challenge. We

issues in medicine. With this background,ʻ
val-

should not solely depend on facts but our deci-ue‑based medicineʼ has arisen.

sion also bears value judgment.

Just asevidence‑based medicine oﬀers a process of

There has been a signiﬁcant international

working more eﬀectively with complex anddevelopment to explore the role of values in

conﬂicting evidences in medicine, value‑based

psychiatric assessment and diagnosis.

medicine also oﬀers a process for working

World Psychiatric Association, NIM HE（Na-more eﬀectively with complex and conﬂicting

tional Institute of M ental Health in England）

values in medicine.

and other international organizations held semi-The

M ore than any other ﬁeld of medicine,nars to deal with this issue. Consensus was

psychiatry is value‑laden. Starting from therepeatedly arrived from discussions that thediagnostic assessment, psychiatrists not only

value‑based psychiatric practice is an essential

rely on facts but to be involved in number ofpartner to the evidence‑based psychiatry.

value judgments based on these facts. When
DSM was ﬁrst published, the diagnostic deci-

Awareness of values

sion‑making was considered purely a scientiﬁcValue that goes by diﬀerent names‑princi-

process hence it is value‑free. As more diag-ples, purpose, convictions, ideals and beliefs‑isnostic criteria emerged and their clinicalan important fundamental belief that we all

signiﬁcances tested, it became clear that thecherish. People usually hold personal values

assessment process not only depends on facts

that are valid and relevant to their self‑con-

but it also includes value judgments. In DSM,

cepts. Psychiatrists are trained to exercise

for example, in the judgment of dysfunction as

empathy with patients to understand their corea part of diagnosis, not only the degree of

emotions and inclined thinking. Equipped withfunctional impairment is assessed but also thethis empirical method, we are in a better posi-value judgment counting on individual and cul-tion to understand others values. Psychiatry

tural values are involved. For instance,leaving

also is a medical discipline where various per-

精神経誌（2010）112 巻 2 号

122

sonal, cultural and social human issues area “
person‑centered” ethos in mental healthinvolved. Psychiatry, therefore, should be theservices. Diagnosis and treatment plan shouldﬁrst branch of medicine to understand the

be a process of exploratory endeavor pursued

value‑laden nature of mental disorders and theby professionals and patients together.

value involvement of medical decisions in prac-should be an attempt to develop a framework

tice.

It

Psychiatrists need to be sensitive toof understanding and explanation looking forvalue‑laden issues and to deal with them

diﬀerent sorts of knowledge. Doctorʼ
s knowl-

eﬀectively through learning.

edge is not a privilege over others. In thisTo learn the value‑based practice, we

process, patientʼs understanding of his world

should begin to focus our attention to the evi-must move to the center stage. It is quite adence ﬁrst. Usually the value‑based approach

challenge.

is closely linked to the evidence‑based. To
consolidate value‑based approach in our prac-

Training psychiatrist of tomorrow

tice,the ﬁrst step is to “listen to the evidence”,

Value‑based psychiatric practice should

to ﬁnd out about values in the traditional areas

start from the beginning of the medical educa-of evidence‑based practice. After listening totion. The ﬁrst thing is to learn to work with thethe patient and identify symptoms, and before

patient and to show compassion to the patient.

you make a diagnosis with these symptoms,you

It is important to start from medical students

should consider variety of diﬀerent treatment

to learn how to be involved with patients and tooptions and their eﬀectiveness. Through yourbecome patient‑centered.

empathy, you see all these options and weight

To be sensitive and aware of values

their pro and cons, but this time, in ʻ
patientʼsinvolved in clinical decisions, it is advised thatperspectivesʼ. This is how you ﬁnd values

the psychiatric training to be partly dehospital-

hidden behind symptoms.

ized, meaning that the training site should in-

By a simple guessing, we are not able toclude practice sites other than hospitals. As theﬁnd values that impinge on our work. Abilityto

training itself moves away from placement

reason on values and developing sensitivity tooriented hospital‑based services to primary

identifying values come from training. A com-practice, community and community organiza-

prehensive training manual for value‑based

tions,the trainees learn to relate to other stake-practice is available. “Value‑Added Practice:holders and to improve understanding and com-A New Partner to Evidence‑Based Practicemunication with them in multidisciplinary con-and A First for Psychiatry?” by K. W. M.

text.

Fulford is an excellent text The training exer-

Training and teaching predominantly ofcises are very helpful to develop awareness of

biomedical theories ﬁx the attitude of thevalues and of the diversity of values.

trainee strictly in medical model. Later on as a

The Department of Health, UK, publishedpractitioner his services may deprive the choiceʻ
New Ways of Working for Psychiatrists”

and control of service users. The new image of

which strongly suggests a new value‑baseda psychiatrist for the coming era is an expert

approach to psychiatry. It calls for ʻ
big culture

practicing evidence‑based medicine at the samechangeʼstressing that psychiatry must adapt totime able to make value‑based clinical deci-Powered by TCPDF (www.tcpdf.org)

特別講演：Bearing Values on Clinical Decisions

123

sions who also sees mental distress in its social

Recognizing the Importance of Social and Culturaland cultural contexts.

Contexts: M ethodological Holism. Oxford University
Press, Oxford, New York, p.13‑14, 2005

References
1）Bracken, P., Thomas, P.: Postpsychiatry,Foregrounding Context : What Kind of Understanding are
Appropriate in the World of Mental Illness? Oxford
University Press, Oxford, New York, p.105‑134, 2005
2）Bracken, P., Thomas, P.: Postpsychiatry,3）Boss, M .: Existential Foundation of M edicine
and Psychology（trans.Conway,S.,Cleaves,A.）.Jason
Aronson, New York, 1979
4）Fulford, K.: Value‑Based Practice: a newpartner to evidence‑based and a ﬁrst for psychiatry?
M ens Sana Monogr, 10‑21, 2008