New resources for understanding patients’ values in the context of shared clinical decision‐making
Authors: Kenneth W.M. Fulford, Ashok Handa
Journal: World Psychiatry (2021)

The importance of shared decision-making between clinician and patient as the basis of personalized care is increasingly widely recognized. In the UK, for example, a recent Supreme Court decision, developed in part from precedents in international human rights law, made shared decision-making the basis of consent to treatment1, and there have since been corresponding updates in regulatory guidance. Shared decision-making, so understood, means clinician and patient coming through dialogue to a shared understanding of the relevant evidence (of the risks and benefits of the evidence-based interventions available) and how this connects with the patient's values (i.e., what matters or is important to the individual patient concerned). Both the evidence side and the values side of this model of shared decision-making present particular challenges for psychiatry2. The result, as a recent paper published in this journal pointed out3, is a gap between principle and practice: the principle of shared decision-making is widely endorsed by psychiatrists, but in practice decisions continue to be largely clinician-led. It is here – in bridging the gap between principle and practice – that new resources from values-based practice have a role to play. It is widely assumed that it is the evidence side of shared decision-making that is the more problematic (and, certainly, it may be). But, in many contexts, the values side – understanding what matters or is important to the patient in question – may be at least equally problematic4. This is why values-based practice has from the start aimed to provide training and other resources to support improved understanding of values5. Recent developments in values-based practice have extended these resources in two respects, from individual to cultural values, and from overt to hidden values. Both are relevant to the challenges of shared decision-making in psychiatry. That understanding cultural values is increasingly important in psychiatry needs hardly be said. The expansion of transcultural psychiatry in recent years is a direct response to the growing impact of factors such as globalization, multiculturalism and migration. Illustrative of the resources from transcultural psychiatry for shared decision-making is the "cultural formulation", introduced first in DSM-IV and upgraded in DSM-5 with an explicit focus on personalized care. Among new resources from values-based practice for understanding cultural values is a recently published open access collection of some fifty case studies and commentaries illustrating the diversity of mental health policy and practice from around the world6. Like the cultural formulation, this collection is comprehensive in scope, covering not only different geographical regions (Western as well as non-Western) but also psychiatry's different stakeholder groups (e.g., it includes a number of autobiographical accounts by service users). The collection complements and extends the resources of the cultural formulation in two key respects: in its focus on values (implicit in, but not highlighted by, the cultural formulation), and in a shift of focus from negative to positive. The latter shift is of particular relevance for recovery in psychiatry: as the paper cited above reminds us3, recovery in psychiatry depends critically on an individual's protective factors and resilience. A similar shift from negative to positive is evident in new resources from values-based practice for meeting the challenges presented by hidden values. Like cultural values, hidden values are not, as such, new to psychiatry. Much of psychoanalytic practice after all involves making unconscious (hence hidden) wishes, values and beliefs accessible to consciousness. Contemporary values-based practice offers a range of new resources for accessing hidden (including unconscious) values. Phenomenology, for example, the foundation of traditional descriptive psychopathology, has been applied to the challenge of understanding hidden values in anorexia nervosa7, and in alcohol and addictive disorders8. Other resources for understanding hidden values are available from hermeneutics, from aesthetics and related areas of the humanities, from analytic moral philosophy, from the history of ideas, and from models used in cognitive sciences. As with cultural values, each of these, consistently with the approach of values-based practice as a whole, encompasses not only the negatives of a patient's needs and difficulties, but also the positives of his/her protective factors and resilience as assets for recovery. There is, of course, more that is required to bridge the gap between principle and practice in shared decision-making than just understanding patients' values (important as this is). Other relevant areas of values-based practice currently being developed include a number of policy and service development initiatives: for example, a guidance for employers on the needs of people who hear voices (https://valuesbasedpractice.org/more-about-vbp); a shared learning initiative on race equality in mental health (https://valuesbasedpractice.org/what-do-we-do/webinars); and a recently funded co-produced national programme exploring new models of public mental health (https://valuesbasedpractice.org/what-do-we-do/webinars). A further key area of development of values-based practice is training. Again, training has from the start been foundational to values-based practice. Among new training initiatives is an international web-based masters-level programme in Phenomenology and Values-based Clinical Care (PVbCC). Jointly sponsored by the Collaborating Centre for Values-based Practice in Oxford and the Santa Casa de São Paulo School of Medical Sciences in Brazil, with international partners (including the WPA Section on Philosophy and Humanities), the programme offers a series of master classes delivered by experts from different parts of the world (see https://metamastersonline.com). Participating students will thereby gain an additional international level of experience over and above their respective national home study programmes. As such, the PVbCC programme will help to build what, many years ago, and anticipating contemporary developments, a former President of the Royal College of Psychiatrists, J. Birley9, called an international "open society" of mental health stakeholders underpinning best practice in personalized mental health care.