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“A doctor needs to know what’s important to each individual”

As individuals, we all have different needs and wants – and it’s important these values are taken into account during important decisions.

Bill Fulford is a Fellow of St Catherine’s College and a Member of the Philosophy Faculty at the University of Oxford. His work focuses on making sure that the values of people living with mental illness can be incorporated into decisions about the treatment they receive. We caught up with Bill, ahead of his appearance at this year’s Mental Health Science Meeting.

Thanks for taking the time to chat to us, Bill. Can you tell us a bit about how you chose this field of research?

Great to meet you! I’m a bit of a hybrid, I suppose – my background is in medical science, including immunology and the study of bacteria. But I’ve always had lots of other interests, one of which is philosophy, which I studied alongside my medical degree. I saw psychiatry as a field where philosophy overlaps with medicine – where the question of what constitutes a disease rises to the surface and becomes part of the practice.

For example, if we take someone with appendicitis, there isn’t a debate as to whether they have a disease or not – there’s only the practical question of how you treat it. But for a person with depression, the issue of whether it is a disease they have, or whether it is a different aspect of them as a person – that philosophical question has a direct impact on how we might treat that person.

Going into psychiatry allowed me to bring my interests in medicine and philosophy together.

Your work centres around something called ‘Values-Based Practice’ – firstly, what do we mean by ‘values’?

When we talk about ‘values’, we’re talking about anything that matters or is important to us as individuals.

In most cases, it’s obvious that having a disease is something important to a person, in a negative way. Pain, for example, would be something that almost everyone would want to get rid of.

But in mental health it’s more challenging. For with the things we’re dealing with in psychiatry – emotion, motivation, desire, sexuality, and so on – what is ‘good’ or ‘bad’ varies widely between people.

For example, take something like hearing voices. For many people, that may be a bad experience – but others may consider hearing voices to be a positive experience. This is because a person’s values, the things that matter to them, are specific to that individual.

How does considering a person’s values impact on treating mental illness?

Values-Based Practice is a process of working with values which are complex and conflicting, as they often are in mental health.

Going back to the example of hearing voices – a person experiencing that may feel it is a positive experience, but it may have negative consequences for family and friends around them, and their doctors may also see the voice-hearing negatively.

So how do we best go about treating that person? Values-Based Practice can help make a balanced judgement on their individual case. It’s about making the best use of the science of medicine, while also taking into account the individuality of people and their needs, wishes, and wants.

Can you give us an example of Values-Based Practice in action?

Certainly – I know a woman who was being treated for a mental illness, and she had been given some medication by her psychiatrist which was controlling her symptoms effectively. However, she said that the medication was making her “a bit fuzzy”. She had a teaching job coming up and was worried that she wasn’t going to be able do it while she was feeling this way.

After having spoken with her psychiatrist about the fuzziness, she told me, “I was able to change my medication, with permission”. She felt empowered that she could have a dialogue with her psychiatrist and explain that, although the medication was working, it was more important to her to get rid of the side-effect of fuzziness. She was prepared to accept that changing medication may make her feel a bit worse overall if it meant she could do the teaching, because that was what mattered most to her at that time.

Doctors ought to know what will work best for a majority of patients. What Values-Based Practice adds on top of this is that the doctor should also look at what’s important for their patient as an individual. This will mean that, presented with a range of treatments available, the doctor and the person can come to a shared decision on what will be best way forward.

Why do we need Values-Based Practice now?

When I was starting in medicine, there was a pervasive attitude that ‘the doctor knows best’. Previously, there may have been only one treatment option for a condition, so it may have seemed that there was no need to consult people on what was best – there was simply no choice.

But today, as a result of 50 years of medical advances, there is often a range of options available which didn’t exist before. Whilst the doctor may know the risks and benefits for any particular option, they also need to consider what matters to the individual. That’s what Values-Based Practice can help with, and why it’s becoming increasingly important – not only in mental health, but in other areas of medicine too. 

So what are the challenges of implementing Values-Based Practice?

Let’s use treatments for psychosis as one example. Anti-psychotic drugs can have side-effects such as weight gain, which is generally undesirable, as it can be detrimental to physical health and self-esteem. Values-Based Practice would suggest that it is important to discuss these side-effects, but it is possible that, as a result, people may decide not to take them.

The problem arises if the psychosis is acute – perhaps the individual is very distressed, may be having dangerous hallucinations or delusions, or possibly poses a danger to other people. From the doctor’s perspective, it’s important that their condition is controlled as quickly as possible.

So you can see the dilemma: should a doctor discuss the possibility of side-effects with a person who urgently needs medication, even if they may refuse it as a result? There is no overall ‘right’ or ‘wrong’ answer to this – but Values-Based Practice can help us to come to a balanced decision in the particular circumstances presented by a given situation.

Finally, what are your hopes for the future, and how we treat people experiencing mental illness?

I hope that we move towards increased shared-decision making, based on the model of ‘co‑production’, where there is an equality of voices between the patient and the doctor.

And I hope we can expand this model of co-production to other areas too -so that mental health service users have a voice in decisions about what research we do and how we do it, how we translate the science into practice, how we teach and train medical professionals, and how our healthcare services operate.

For some people facing mental illness, a medical approach is what they find helpful, but for others they would prefer a psychological or social approach. We need that range of provision and the ability to provide a mental health service that is responsive to individual people and their values.  

Bill will be speaking at this year’s Mental Health Science Meeting – an event bringing together researchers across different disciplines to explore cutting-edge new ways to understand, treat and prevent mental illness. To find out more, click here.

Last updated: 18 January 2019

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