Talking values

Our values are the principles by which we make judgments about what is important in life. We often make the assumption that because we consider ourselves to be ‘reasonable’ people, share a professional title or have similar political views we must feel basically the same way about everything- but we don’t.

I was reminded of this at a recent conference when I was talking (as I sometimes get asked to) about the importance of and ways of helping people with common mental health problems in primary care. One member of the audience expressed concern that directing resources to people with anxiety and depression was being promoted at the expense of people diagnosed with ‘real’ mental illness and told us that a member of a team working in primary care had complained to him that there was ‘nothing wrong’ with people they were being asked to see. Another asked the panel how we might help people to stop asking for help with such problems and be more ‘resilient’ instead.

If you know me at all you will be able to imagine my reaction. I’m one of those people who get help with a ‘non-psychotic’ illness, although what has been of great benefit to me is so much harder to access these days, not easier. I was also thinking of the depressed colleagues of these professionals who would find it quite difficult to admit they needed help in the face of people around them expressing these values and beliefs. I objected passionately to the use of the word ‘resilience’, as I always do and probably alienated the young woman who asked the question rather than convinced her with my reply- she disappeared soon afterwards.

Some time ago there was a push towards ‘values based practice in mental health’. According to the Oxford psychiatrist and philosopher Bill Fulford ‘Values-Based Practice’ is the theory and skills for effective health care decision making where different (and hence potentially conflicting) values are at play. Not only do health professionals hold many different values from patients and service users, they often differ considerably between each other- both between and within their respective groups. Discussion of all of our respective values is essential in those difficult areas such as the role of diagnosis, how to make care more patient-centred in the face of feeling ‘hit over the head with evidence’ (as someone said recently on twitter) and ethical dilemmas such as involuntary treatment. It is never so simple as something being ‘right’ or ‘wrong’. All of these require time to reflect, on how and why we hold particular values of our own and why completely different ones may be so important to another person- and being able to admit honestly ‘maybe I don’t have all the answers’.

On social media there is little opportunity for reflection and arguments about value-laden topics can quickly become abusive. I do think its crucial to remember how many people with mental health problems look to social media for support, and abrupt questioning by mental health professionals of the personal values they hold on topics, such as being given a diagnosis and treatment that they believe has helped them, should be viewed as ethically unacceptable by their membership organisations- just as it would be in a direct clinical encounter. Values based practice is not simply about educating a person about what is wrong with their beliefs, but starting from where that person is at and trying to understand and make sense of their values and beliefs. Neither of you is ‘right’.

I should try to understand how and why fellow professionals come to hold the views they have about people with common mental health problems. Telling them they are wrong isn’t the right way to approach the problem- I know that- but sometimes, as with all of us, emotions get in the way.  And, as I’ve witnessed in so many meetings, we can assume we are all ‘on the same page’ (or hope we are to avoid conflict) but attempted execution of the task at hand soon reveals that we all do it entirely differently because we never wanted to have those difficult discussions about our basic values. The national roll out of services- such as implementing stepped care services for depression, and IAPT, were good examples of this- approached very differently depending on the values and beliefs of those leading the process in each place, and varying considerably in effectiveness. If we do have time and place for both self-refection and conversations with fellow professionals and service users we often find we have much more in common that we imagine. We can even agree to disagree on certain topics but still work together if there is mutual respect.

I have much more time now to talk and think about those powerful emotional responses, so influenced by my personal experience and those of friends who have felt unable to disclose their problems- and how these have affected my decision-making. Can we please have more opportunities in the training of mental health professionals not just to talk with people who reinforce our values- but those who might challenge them? and I don’t mean in the setting of a conference presentation where discussion is limited and things can easily degenerate into a shouting match too. A first step, according to Gwen Adshead,  might be to ‘respect’- to be mindful of another persons differing beliefs and values. To care about their experience as much as your own. The people I have disagreed with will have arrived at their position perhaps because of particular experiences they have had- just like I have. How and why?

All of practice- not only psychiatry, is influenced by values- but insufficient attention is paid to not only what is best for the patient from the viewpoint of the doctor or therapist, but what is right for that person, at that point in their life given the situation in which they find themselves. A professional cannot and should not assume that they always have the ‘right’ values or the correct answer.

7 thoughts on “Talking values”

  1. Your blog reminded me of a discussion I had recently. It was around the time that Princes William, and in particular Harry were speaking about their experiences following the death of their mother. I seem to recall that they had donated money for mental health work. The discussion was aroung whether grief and loss was a ‘real mental illness’ or life events that happen to everybody. I was struck by the incongruity of the person I was speaking too, their anger at having being labelled with one of the ‘real mental illnesses’ and yet their apparent desire for it to be some kind of exclusive club, that only a few could belong to. There were obvious parallels to Szazs thoughts about ‘problems with living’. I remember I tried to gently remind this person that life is hard for us all, without exception, it is just the nature of the hardness or difficulties that is different. As a priest I often have conversations with people who exclaim that life is so unfair, and they are a bit stunned when I wholeheartedly agree, even for those who follow a belief system, it is unfair, and we all muddle along trying the best we can to get through it, enjoy what we can and hopefully support those who are finding it particularly hard. Having divisions as to what is a real mental illness and what it not, is unhelpful. I was unsuccessful in my attempts to bring compassion into the conversation.

    I also know that as someone who has suffered numerous episodes of depression, and has now gone onto be diagnosed with bipolar disorder, you are treated differently by all sorts of agencies. Depression is talked about as being recoverable from, bipolar is a severe and enduring illness spoken of as life-long. Even with the Church of England, depression is an accepted experience, to be supported and seen through, return to ministry expected. Bipolar is different, more dangerous, talk is about reliability, quality of judgements, of what parishoners might think if they knew the person in the pulpit had a ‘madness’, invariably it is seen as a weakness in you, rather than the result of non-existent support, unkindness and arse covering.

  2. A beautifully written & insightful post, Linda. It makes me even more thankful for my psychiatrist, a person who treats me with the utmost respect and never assumes he has all the answers despite his advanced training and experience.

  3. As a person who struggles with anxiety, I am appalled but sadly not surprised by the fact that some consider anxiety to be not a ‘real’ health problem, and one I should not ask for help with. I have experienced difficulties that impact all aspects of my life – and have done almost every day since I was a young teenager, if not before. I cannot help but wonder what difference it would have made if my illness had been treated with more respect when I first presented to healthcare services, at around the age of 14, and I had received appropriate help and support. Would I still be struggling more than 20 years later? Perhaps so but maybe not as much, and I cannot begin to describe how grateful I would have been to suffer even just a small fraction less than I have, and continue to.

    As ever, thank you for your compassionate words.

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