Values permeate all aspects of psychiatry from aetiology, through classification, to treatment. This is unsurprising, as psychiatry is concerned with areas of human experience and behaviour in which human values are particularly diverse. Evidence-based medicine (EBM) can be immensely helpful at guiding us about the efficacy and safety of diagnostic and treatment interventions, but it is silent about the personal importance attached to these by patient and doctor, that is, about patients’ and doctors’ relevant values. This is problematic because these values are of crucial importance when it comes to various aspects of person-centred care, such as patient choice, treatment adherence, recovery, and clinician attitudes. This is where values-based practice (VBP) comes into play.

Whilst VBP is often portrayed through contrasting it with EBM, this can be somewhat misleading because VBP is also evidence-based; it is just that its evidence has a different provenance and format. Evidence-based medicine was developed to replace the use of intuition, anecdotal evidence, and subjective clinical experience with examination of objective evidence from clinical research, using formal rules to appraise it. The gold standard of EBM is the randomized controlled trial (RCT). Results from sufficiently similar RCTs can be meta-analysed to produce an overall statistic, which is considered to be the highest level of evidence in EBM. High-quality meta-analyses, such as those in the Cochrane Library, also provide ratings of the quality of the evidence. By now, EBM has developed into an essential clinical tool, but, for the clinician to be able to make the most of it, another step is required. This next step is to apply the group-level evidence in individual cases in a person-centred way. This is where VBP comes in as it offers a parallel framework of clinical theory and skills through which to do, among other things, exactly that.

The development of VBP started largely at the same time as that of EBM, around the turn of the last century. The pioneering work of Bill Fulford, a British philosopher-psychiatrist, was instrumental in working out the main principles of VBP, including ten pointers to a ‘good process’, which refers to the inclusion and balancing of the values of those involved during clinical decision-making (Fulford, Reference Fulford and Radden2007; Woodbridge and Fulford, Reference Woodbridge and Fulford2004). These include four practice skills: awareness, reasoning, knowledge, and communication about values. Two important concepts in VBP are user-centredness and multidisciplinarity. They were originally described in the context of models of service delivery, but we have developed these further in this book in other contexts, such as clinical theory and research. Partnership between the patient and the clinician is also a key principle in VBP. The nature of this partnership in psychiatry and the relevance and impact of other stakeholders on clinical decision-making are examined in detail throughout this book.

Psychiatry is both an academic field and an area of medical practice. Ideally, research should seek answers to the main questions of clinical practice and advances in research should translate into practice. Unfortunately, in recent years there has been an increasing disconnect between academic and clinical psychiatry (de Haan, Reference De Haan2020). Furthermore, despite significant investment in research, progress in our understanding of the pathomechanism and the mechanism of recovery from major forms of mental illness or in the development of new treatments has been slow. At the same time, strong criticisms have been levelled against current psychiatric practice (e.g. owing to the epidemic proportions of benzodiazepine and antidepressant use or the ever-increasing number of detentions to hospital for assessment and treatment in certain countries) and even though many people with mental illness clearly benefit from psychiatry, despite the substantial investment into psychiatric care, rates of mental illness have not reduced as a result (Jorm et al., Reference Jorm, Patten, Brugha and Mojtabai2017), a situation known as the treatment–prevalence paradox (Stein et al., Reference Stein, Shoptaw, Vigo, Lund, Cuijpers, Bantjes, Sartorius and Maj2022). In writing this volume, we wanted to understand what might be at the root of all this and what could help us overcome the current stagnation in psychiatry. We believed that an approach that takes into consideration the hybrid nature of psychiatry in that it combines forms and practices from both the natural and the social sciences holds the key to this. We also believed that there were important opportunities for making progress if we could only capture the role of values all over psychiatry from aetiology, through diagnosis, to treatment. And VBP would provide an invaluable theoretical apparatus for this.

To achieve our goals, we set out to examine the relevant values of the stakeholders, that is, patients, psychiatrists, and others involved in or with psychiatry. Furthermore, we also sought to showcase the positive values and contribution that psychiatry brings. We felt that, in order to achieve any real breakthrough, it was important to do this focussing not just on the here and now but also diachronically and from the different perspectives of not just medicine but also history, social work, art, and philosophy, and to include the voice of those with lived experience of mental illness. Our team of authors represent the multidisciplinarity required for this.

The structure of our book also reflects our intentions. In Part I, we look at the historical origins of psychiatry. To open, in Chapter 1, German E. Berrios and Ivana S. Marková provide an analysis of the birth of psychiatry as a medical specialty, the forces that brought it forth, and the consequences of that for its epistemology and approach to mental illness. In Chapter 2, Robert B. Dudas explores the history of person-centredness and agency in psychology by contrasting some of its main schools of thought, such as psychoanalysis and behaviourism, as well as cognitive and humanistic psychology. Mathew Thomson presents, in Chapter 3, a historical analysis of the social, cultural, and political value context in which British psychiatry has evolved since the late nineteenth century and lays the foundations for future studies of this kind.

In Part II, we turn our attention to value-laden and controversial issues in the present practice of psychiatry as well as some of the current developments that will be influential on the future of psychiatry. In Chapter 4 on ailments of the mind, Robert B. Dudas investigates the role of values in defining mental illness and psychiatry. He also explores the questions of ‘Who decides what is pathological?’ and ‘What determines or influences mental well-being?’ from a values perspective. Chapter 5, also by Robert B. Dudas, investigates the values of psychiatry as seen from within the profession at a personal as well as a collective level and also how psychiatry is viewed from outside, in the public discourse. In Chapter 6, Femi Oyebode explores how psychiatry and psychiatrists are portrayed in literature and the usefulness of such portrayals. Chapter 7, written by Robert B. Dudas, Elizabeth Fistein, and Toby Williamson, approaches multidisciplinarity from the perspectives of medicine and neuroscience, the social sciences, and nursing and social work, respectively. The next two chapters describe progressive developments in psychiatry from a theoretical and a practical point of view, respectively. On the theoretical side, Chapter 8 begins with Robert B. Dudas looking at promising new developments in psychiatric treatment, especially existential psychotherapy and motivational interviewing, and what they have to offer in terms of refining our understanding of mental illness and the role of values in it. In the second half of Chapter 8, David Crepaz-Keay provides insight into recovery and co-production and the potential they carry for improving psychiatric care. Then, on the practical side, in Chapter 9, Benjamin R. Underwood and John Martin present an example of using VBP principles in reorganizing clinical services for the elderly by integrating mental and physical healthcare. To round off Part II, Chapter 10 takes a closer look at the current climate in which psychiatry operates, especially in the UK. Robert B. Dudas first examines the value context of specializing and working in psychiatry. This is followed by Elizabeth Fistein’s analysis of the recent extreme focus on managing risk, especially preventing suicide, in psychiatry. Finally, in a section on values questioned and debated, Robert B. Dudas contrasts the approaches of anti-psychiatry and critical psychiatry.

Part III of the book focusses on three common psychiatric conditions and the benefits of taking a values-based approach to them. In Chapter 11, Robert B. Dudas describes a philosophically informed approach to understanding depression and its treatment and presents a methodological description of clinical value-mapping, which can facilitate a good process and reduce moral injury. In Chapter 12, Tom Dening and Malarvizhi Babu Sandilyan explore how during the progression of dementia the person’s choices and preferences and the clinicians’ philosophy of care may change over time, and how VBP can contribute to addressing the challenges this presents. Chapter 13, by Robert B. Dudas, explores value conflicts in borderline personality disorder and further elaborates on the use of clinical value-mapping.

Finally, as VBP has much to offer for research, too, Robert B. Dudas explores this in Chapter 14, a separate chapter at the end of the book. Owing to its richly value-laden nature, psychiatry is particularly well-placed to play a leading role in developing VBP. More than in other specialties, psychiatrists need to know their patients as people in order to arrive at the correct diagnosis or formulation and to be able to develop effective therapeutic relationships. Cultural and social factors can contribute powerfully to the development of psychiatric conditions and to the recovery from them. Consequently, psychiatry needs to call upon a range of cognate fields, such as psychology, sociology, anthropology, and law, and – to navigate this immensely complex, multidisciplinary endeavour – philosophy. This book is about the unique contribution of psychiatry to bringing about this collaboration and managing this complexity.