Narrative Understanding, Value and Diagnosis: A Particularist Account of Clinical Formulations and Shared Decision-Making in Mental Health

In this article, I deploy the notions of narrative and discernment as complementary support tools in understanding the moral significance of the first-person perspective in mental health. My aim is to develop and extend moral particularism’s emphasis on the significance of context and the general problem of relevance in understanding the dynamics of practical judgement and shared decision-making as applied to comprehensive diagnosis and integrated treatment. I argue that it is a mistake to think of the values embedded in responsible integrated care and patient involvement as either determined by the individual patient’s autobiographical narrative or as determined by the ‘top-down’ conception of health as presented in the biomedical model. What is missing in accounting for the idea of clinical decision-making as a shared enterprise is a relational account of the person and the wider diagnostic treatment context in understanding the process of perspective-taking. Such reorientation of focus makes available a distinctive conception of clinical knowledge, in which claims to objective meaning in patient narratives are criticised not as false per se, but as failing to yield the insight into the problem it was the point of those claims to provid

Schizophrenia as a Transformative Evaluative Concept: Perspectives on the Psychiatric Significance of the Personal Self in the Ethics of Recognition

Psychiatric diagnosis serves many functions in the struggle for recognition, such as access to public mental health systems and legal compensation, but it is not necessarily well equipped for the task of self-understanding (Tekin 2019) and re-configuration of personal values in the recovery process – and the likelihood of optimal outcome that is geared to the individual person’s quality of life (see May et al 2020). Call this the transformative dimension of recognition in the complex journey from diagnosis to therapeutic empathy in the doctor-patient relationship. Patients who are diagnosed with a serious and enduring mental health condition often find it difficult to make sense of themselves in relation to their psychiatric diagnosis. Specifically, they have problems with distinguishing their ‘self’, or ‘who they are’, from their mental disorder or diagnosis (Radden 1996; Sadler 2007; Dings & Glas 2020). I argue that what marks out an “owned” and, conversely, “disowned” experience (and behaviour) as such is the wider context of the subject possessing it seen as a whole person as characterised by a sense of oneself as an agent

Hall of Mirrors: Toward an Open Society of Mental Health Stakeholders in Safeguarding against Psychiatric Abuse

This article explores the role of an international open society of mental health stakeholders in raising awareness of values and thereby reducing the vulnerability of psychiatry to abuse. There is evidence that hidden values play a key role in rendering psychiatry vulnerable to being used abusively for purposes of social or political control. Recent work in values-based practice aimed at raising awareness of values between people of different ethnic origins has shown the importance of what we call “values auto-blindness” – a lack of awareness of one’s own values as a key part of our background “life-world” – in driving differential rates of involuntary psychiatric treatment between ethnic groups. It is argued that the vulnerability of psychiatry to abuse stems from values auto-blindness operating on the judgments of rationality implicit in psychiatric diagnostic concepts. Acting like a “hall of mirrors,” an international open society of mental health stakeholders would counter the effects of values auto-blindness through enhanced mutual understanding of the values embedded in our respective life-worlds across and between the diverse perspectives of its constituents. The article concludes by noting that a model for the required open society is available in the contemporary interdisciplinary field of philosophy and psychiatry

Psychosocial health in adolescent unmarried motherhood in rural Uganda: implications for community based collaborative mental health education, and empowerment strategies in the prevention of depression and suicide

Teenage pregnancy rates in Uganda are among the highest in Sub-Saharan Africa. Child marriage is often the result of unmarried teenage pregnancy and recognised by Uganda’s government as a form of sexual violence and an outcome of inequality. However, unmarried motherhood incurs stigma and shame within traditionally-living rural communities. Using co-produced Open Space and ethnographic methods, we examined the psychosocial impact of unmarried motherhood on girls and their communities, and explored problem-solving with key local stakeholders. Findings indicate that girls experience extreme stress and social exclusion and rejection by their families, and experience bereavement from school expulsion and the loss of their career aspirations. Depressive symptoms and suicidal behaviour are reportedly not uncommon amongst this population group. Community and family efforts to promote marriage for these mothers to avoid social stigma increased the mothers’ feelings of depression, while mothers who became independent appeared to fare better psychologically. Community members and local stakeholders demonstrated willingness to act locally to reduce the negative impacts of unmarried motherhood but lacked the knowledge and support resources. Our findings indicate that mental health promotion for teenage mothers is likely to be better served through empowerment strategies rather than marriage, and, in a context of poor mental health service access, there is a substantial role for community mobilisation and promotion of self-help strategies to support teenage mothers. This study raises important points regarding different community understandings of depression and indicates collaboration between professionals and communities for a values-based approach

Psychiatric ethics

The interactive fields of philosophy of psychiatry, philosophy of mind and psychiatric ethics have proved excellent frameworks in which to examine conceptual changes in our understanding of the human being during the last two centuries. Comparatively little has been written in the field of moral philosophy about these insights into the nature of moral agency, subjectivity and other fundamental concepts that enrich our understanding of mental health. The aim of this chapter is to develop Murdoch’s work on moral perception in this novel direction. In doing so, it speaks to recent philosophical and empirical work on therapeutic understanding through literary expressions and illness biographies, which I use to explain why narrative self-creation is central to the recovery process

The phenomenology of mutual trust in psychotherapy: a relational account of meaning-making in recovering the self in Borderline Personality Disorder

In this work, I deploy recent philosophical and empirical work on self-ownership in mental illness and the distinctive phenomenology of mutual trust in healing relational crises, intrapsychic conflicts and identity disturbance to show that the complex relationship between agentic awareness and that of narrative self-creation in dissonance cases is best understood integratively against the wider background of a subject’s intersubjective agency. I argue that the phenomenology of mutual trust is conceptually and ontogenetically prior to individual self-ownership in clinical cases involving an unstable sense of self, for which reason fractions to this and other intersubjective aspects of shared engagements play a significant explanatory role in understanding the phenomenology of identity disturbance in psychological dissociation characteristic of adults with Borderline Personality Disorder (BPD). The intersubjective relational dimension of my account is central because, and in so far as, therapeutic hope points towards as second-person dimension of subjectivity – even in breakdown of social cognition

The participatory turn in museum curation as a model for person-centred clinical care

The participatory turn in museum curation offers a powerful model for person-centred clinical care. The first section gives an outline of contemporary person-centred care focusing on the contested values arising (particularly but not only in mental health) from shared clinical decision-making between clinician and patient. The section then outlines the growing range of philosophical resources available for tackling contested values of this kind. With notable exceptions, aesthetics has to date been largely absent from these resources. The next section describes the participatory turn in museums curating and illustrates it with a museum-based project involving refugee migrants, The Silent University. This is an example of what the curator Maria Lind (2019, 2020, 2021) has characterized as ‘curating in the extended field’. The final section combines the considerations of the first two sections by exploring some of the features of the participatory turn that make it a powerful model for person-centred care. First and foremost in this regard are partnership working and dialogue. Interpreted through the philosopher, Hilde Hein’s (2006), agentic account of the participatory turn, these features point to the need for a similarly agentic understanding of shared clinical decision-making. Further features of the participatory turn important for person-centred care, particularly in mental health, include its focus on strengths. Interpreted within Lind’s concept of ‘curation in the extended field’, recovery in mental health can be described as ‘recovery in the extended field’. We conclude with brief comments on the wider significance of aesthetics in contemporary science-based and person-centred clinical care