Values and Values-Based Practice in Clinical Psychiatry
K. W. M. Fulford
Introduction
Values-based practice is a new skills-based approach to working more effectively with complex and conflicting values in health and social care. This chapter illustrates some of the ways in which combining values-based with evidence-based approaches supports the day-to-day practice of the clinical psychiatrist, particularly in the context of multidisciplinary teamwork.
What are values?
Perhaps one of the most familiar ways in which values impact medicine is by way of ethics. But values are wider than ethics. Ethical values are indeed one kind of value. But there are many other kinds of values, such as aesthetic and prudential values. Values also extend to needs, wishes, preferences, indeed to any and all of the many different ways in which we express negative or positive evaluations and value judgments. Within each and all of these areas, moreover, there are wide differences in the particular values held by different individuals, by different cultures, and at different historical periods.
Given the breadth and complexity of values, it is small wonder that the term ‘values’ means different things to different people. This is illustrated by Table 1.5.2.1 which lists the responses of a group of trainee psychiatrists when asked, at the start of a training session on values-based practice, to write down three words or short phrases that they associate with ‘values’. As the table shows, although there is some overlap, every member of the group came up with a different set of associations.
If our values are diverse, however, they are not completely idiosyncratic. To the contrary, there are many values that are widely shared, at least within a given group at a particular period. The values of patient autonomy (freedom of choice) and of acting in the patient’s best interests, for example, are shared values that underpin contemporary medical ethics, and these two values are indeed among the values evident in Table 1.5.2.1.
It is the diversity of human values, and how this can be linked with the shared ethical values underpinning clinical practice, that is the starting point for values-based practice. There is a sense in which medicine has always been values-based just as there is a sense in which it has always been evidence-based.(1) The need for values-based practice in contemporary practice, again like the need for evidence-based practice, arises from the growing complexity of medicine; the growing complexity of the evidence underpinning medicine has led to the need for the new tools of evidence-based medicine; the growing complexity of the values underpinning medicine has led to the need for the new tools of values-based medicine.
The growing complexity of values, as well as evidence, is particularly evident in psychiatry. ‘Autonomy’ and ‘best interests’, for example, although both shared ethical values, are often in tension. In the past, most people were content to allow doctors to decide what is in their best interests and this is still the case in many parts of the world.(2) Increasingly though, at least in Europe and North
America, a growing emphasis on patient autonomy has led to complex interactions between these two values in clinical care. In particular, autonomy and best interests come into direct conflict in relation to issues of compulsory treatment (Chapter 1.5.1). Then again, even considered in isolation, ‘best interests’ have highly complex applications in practice, in the sense that what is ‘best’ for one person may be very different from what is ‘best’ for another, according to differences in their personal values and the values of others concerned. Establishing ‘best interests’ thus presents particular challenges in areas such as old age psychiatry, for example, where patients may lack the decision-making capacity to exercise genuine autonomy on their own behalf.
America, a growing emphasis on patient autonomy has led to complex interactions between these two values in clinical care. In particular, autonomy and best interests come into direct conflict in relation to issues of compulsory treatment (Chapter 1.5.1). Then again, even considered in isolation, ‘best interests’ have highly complex applications in practice, in the sense that what is ‘best’ for one person may be very different from what is ‘best’ for another, according to differences in their personal values and the values of others concerned. Establishing ‘best interests’ thus presents particular challenges in areas such as old age psychiatry, for example, where patients may lack the decision-making capacity to exercise genuine autonomy on their own behalf.
Table 1.5.2.1 What are values? | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
One response to the growing complexity of the values bearing on clinical practice is to write ever more detailed rules aimed at fixing in advance the ‘right outcomes’ for any given clinical situation. It is this response that is driving the growing volume of ethical codes and regulatory bodies concerned with medicine. Values-based practice offers quite a different albeit complementary response. It switches the focus from pre-set right outcomes to a reliance on good process. Values-based practice, that is to say, focuses not so much on what is done but on how it is done. Starting from the ‘democratic’ ethical premise of respect for differences of values, values-based practice relies on good process (in particular good clinical skills, see below) to support balanced decision-making within the framework of shared values defined by codes of ethical practice.(3)
Values-based and evidence-based medicine
As a process-based approach to clinical decision-making, values-based practice is complementary not only to regulatory ethics but also to evidence-based practice. The processes of values-based practice and of evidence-based practice are of course very different. Evidence-based practice, as John Geddes describes (Chapter 1.10), relies on statistical and other methods for combining evidence from methodologically sound research. Values-based practice, by contrast, relies primarily on learnable clinical skills. There are other components of the process of values-based practice, including a number of specific links between values-based and evidence-based practice.(3) But at the heart of values-based practice are four areas of clinical skill. As set out more fully in Table 1.5.2.2, these are, raised awareness of values and of differences of values, reasoning about values, knowledge of values, and communication skills.
The close interdependence of values-based and evidence-based approaches has been well recognized by many of those involved in the development of evidence-based medicine. Indeed, there is perhaps no clearer statement of this inter-dependence than the very definition of evidence-based medicine given by David Sackett and his colleagues in their book, Evidence-Based Medicine: How to Practice and Teach EBM.(1) Evidence-based medicine is standardly thought to be concerned only with research evidence, as outlined above. To the contrary, Sackett et al. say (p. 1), evidence-based medicine combines three distinct elements. The first element is, certainly, best research evidence. In clinical practice, however, best research evidence has to be combined with the experience and skills of practitioners, and, crucially, with patients’ values. ‘By patients’ values’, Sackett et al. continue, ‘we mean the unique preferences, concerns and expectations each patient brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patient’. Furthermore, they conclude, it is only ‘when these three elements (best research ‘evidence, clinicians’ experience and patients’ values) are integrated, (that) clinicians and patients form a diagnostic and therapeutic alliance which optimizes clinical outcomes and quality of life.’
Table 1.5.2.2 The four key skills areas underpinning values-based practice | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
|
Values in the multidisciplinary team
In many parts of the world, psychiatric services are increasingly delivered through multidisciplinary and multi agency teams (Chapter 1.8.1). The move to multidisciplinary team-working reflects a broadly evidence-based recognition that different professional groups offer different but complementary resources of knowledge and skills. It was realized early on, however, that differences of perspective (which include different value perspectives) between different professional groups may lead to communication and other problems of effective team-working.(4,5) This is where values-based practice can help to support the leadership role of the clinical psychiatrist in the multidisciplinary team. To anticipate a little, values-based practice, as we will see in this section and the next, 1) helps to make differences of perspective between team members more transparent, thus improving communication and shared decision-making; and 2) converts these differences of perspective between team members from a barrier into a positive resource for decision-making that is sensitive to the particular and
often very different values—the needs, wishes, preferences, etc.—of individual patients and their families.
often very different values—the needs, wishes, preferences, etc.—of individual patients and their families.
First, then, what are the differences of perspective between different team members? The perhaps surprising extent of these differences is illustrated by Table 1.5.2.3. This is based on a study, led by the British social scientist, Anthony Colombo, of multidisciplinary teams in the UK concerned with the community care of people with long-term schizophrenia.(6) To understand the significance of Table 1.5.2.3, we need to look briefly at the background to Colombo’s study and how it was carried out.
Colombo was interested in implicit models of disorder and how such models might influence the processes of decision-making in day-to-day clinical care within multidisciplinary teams. Asked directly, most team members, from whatever professional background, will indicate that they share much the same broadly biopsychosocial model of schizophrenia. This is their shared explicit model, then. The hypothesis guiding Colombo’s study, however, was that, notwithstanding their explicit commitment to a shared biopsychosocial model, in actual practice different team members would be guided by different implicit models. These different implicit models reflected different weightings or priorities (hence values), in turn reflecting differences of professional background and training, that different team members might attach to the different aspects of a given case. Their different implicit models, furthermore, just in being implicit rather than explicit, could help explain the difficulties of communication and other problems of shared decision-making within multidisciplinary teams that had been identified in the literature (as above).
The aim of Colombo’s study, therefore, was to access the implicit models (including values) guiding different professional groups in their responses to patients with schizophrenia. Colombo’s method, correspondingly, was indirect rather than direct. He presented subjects with a standardized case vignette, of a man called ‘Tom’, with features of schizophrenia (though without using that term as such), and then explored their responses using a semi-structured interview and carefully validated scoring system. In previous work, Colombo had shown how different models of disorder (six of which are represented by the columns in Table 1.5.2.3) could be analysed
and compared along 12 key dimensions (diagnosis, causal factors, etc.) as represented by the lines in Table 1.5.2.3. Responses to the semi-structured interview thus allowed a profile to be developed for each subject, and cumulatively for each professional group, of their implicit models. These profiles, or ‘models grids’, gave an overall picture of the implicit model on which an individual or group was drawing in their responses to Tom.
and compared along 12 key dimensions (diagnosis, causal factors, etc.) as represented by the lines in Table 1.5.2.3. Responses to the semi-structured interview thus allowed a profile to be developed for each subject, and cumulatively for each professional group, of their implicit models. These profiles, or ‘models grids’, gave an overall picture of the implicit model on which an individual or group was drawing in their responses to Tom.
Table 1.5.2.3 Comparison of models grids for psychiatrists and social workers (shared elements of models shown highlighted) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
