Values are closely linked to emotions and patients with BPD experience significant fluctuations in their emotions. Psycho-education about the hierarchy, proximity, and temporality of values offers an opportunity to reduce impulsivity and increase hope.

Most effective forms of therapy address personal agency. For this, the clinician needs to create a non-blaming, non-judgemental, and compassionate milieu which can enable the patient to take responsibility for their actions. Values-based interventions can improve agency, increase motivation, and help the patient find meaning, which is negatively associated with depression, suicidality, and self-harm. Early empirical evidence supports the usefulness of working with the patient’s values in therapy using acceptance and commitment therapy (ACT), a modality that focusses on acting in accordance with one’s stated values. Empirical evidence from longitudinal observation suggests that an increase in agency in the patient’s life narrative is part of the recovery process.

Patients with BPD follow a different path in terms of recovery. Patients often find the word ‘recovery’ problematic and many feel that ‘discovery’ describes their journey more accurately. A significant proportion of people with BPD feel that they are not ill in the same way as people with other major mental illnesses but that they need help and support.

The person’s values determine the meaning structure of the world they live in and drive their actions. The depressed patient’s values tend to change dramatically over the weeks and usually return to normal. At the height of their illness, patients can constantly feel that they are transgressing important personal and group values.

Examining the values at play is similar to creating a map with three dimensions: (1) the level of organization/proximity to primary stakeholders; (2) the hierarchy; and (3) the temporality of values. The patient’s values can be misaligned with those of others temporarily owing to the illness, and value-mapping can facilitate realignment. Changes in value hierarchy are often necessary for recovery. These changes can be dramatic and can happen at a faster pace whilst the person is becoming ill and during recovery.

The patient can be temporarily cut off from the values they would normally hold. Besides records of their former wishes and collateral information, sources of knowledge about value changes include peer support workers, first-hand narratives, philosophical and social scientific studies, media reports, and art portrayal of depression. Changes in one’s life narrative are also essential for recovery and resilience. The patient’s social environment, including the professionals, can facilitate (or hinder) this.

The different needs, concerns, and preferences of the professions constituting the multidisciplinary team (MDT), including medicine, psychology, nursing, and social work, reflect the hybrid nature of psychiatry and the knowledge and skills required for clinical practice.

Neuroscience has evolved at impressive speed over recent decades. Many of its findings have relevance to psychiatry but are rarely directly translatable into clinical practice. Improving understanding of the psychological dimension of mental illness has led to new treatments with similar efficacy to medications. Our current approach to treating mental illness has also benefited greatly from insights from sociology and anthropology. The value conflicts relating to liberty and personal autonomy versus the medical value of restoring health and societal values around managing risk have led to the development of legal frameworks to aid clinical decision-making. These are, however, far from perfect, and values-based practice (VBP) principles could meaningfully contribute to improving them.

Although traditionally medicine sat at the top of the hierarchy in the MDT, this hierarchy has become more horizontal in recent decades. Close working together with social care is key, but there are pros and cons for both integrated and separate services. Values-based practice can ease some of the tensions in MDT working.

Current and historical practice, personal life history, and culture have a significant impact on the values of practitioners in psychiatry. Most psychiatrists have a strong medical identity but recognize that to be a good clinician they need more than just their biomedical knowledge and skills.

The new UK training curricula reflect the changing value landscape, shifting away from the biological and the psychological and the increasing emphasis on safeguarding. Now explicitly included are VBP principles such as partnership; person-centred care; practice being based on both evidence and values; multidisciplinary working; a model drawing on the social sciences, neurosciences, and the humanities; and clinicians needing to understand the impact of culture, religion, and social systems. Co-production, the doctor–patient power imbalance, protected characteristics, the relevance of the history of psychiatry, and sustainability appear as new additions.

The media portrayal of psychiatry helps the public to understand mental illness and psychiatry, shapes public attitudes and stigma, influences treatment-seeking, scrutinizes how people with mental illness are treated by psychiatry and wider society, and has the potential to protect (but also to harm) people. Despite some improvements in recent decades, there are still examples of coverage maintaining negative stereotypes, and appropriate guidelines are needed.

Psychopathological phenomenology and existential psychotherapy may help us overcome the challenges of integrating the different dimensions of mental illness and developing new treatments. Better characterization of symptoms/syndromes can improve classification and causal modelling, whereas existential psychotherapy has added to our understanding of the influence of our position in the world and in history.

Motivational interviewing has many similarities to VBP. It can increase the person’s agency by drawing out personal meaning and the importance of change. A crucial insight from it is that saying out loud what our values are can greatly enhance our understanding of them. Treatment may mean reducing conflict between the person’s core values by helping the person recognize their environment’s affordances more efficiently or improve their sense-making and thereby alter their values.

Psychiatry has been pioneering in embracing alternative meanings of recovery. The most important consequence of this was that it enabled discussions about recovery as living well with mental ill-health. Co-production has helped to reframe and enhance the relationship between ‘doctor’ and ‘patient’, leading to better outcomes for all.

Recovery together with co-production will enable constructive partnerships between all those affected by mental ill-health to play their part in progressive psychiatry and more progressive communities.

Developing a satisfactory explanation of the pathomechanism of mental illness, developing biomarkers to aid diagnosis, developing an aetiological classification system, and developing effective treatments to achieve both symptom elimination and functional recovery has so far remained the holy grail of psychiatry for most conditions. To make progress, psychiatric research needs to integrate the biological, psychological, sociocultural, and existential dimensions of mental illness and incorporate and work with values more efficiently. This chapter offers a methodology for this through first describing value-mapping and then elucidating the potential contribution of qualitative and mixed-method studies, phenomenological, hermeneutic, and other idiographic approaches, interpretative phenomenological analysis, analytic induction, quasi-judicial approaches, and the history of psychiatry.

An essential prerequisite of any breakthrough here would be going back to the person level. Research centres would need to become truly multidisciplinary to bring together researchers with expertise in the relevant natural and social sciences and the medical humanities as well as experts by experience for effective co-production.

The history of psychology shows strong parallels with that of psychiatry. At its inception, psychology placed itself between the natural and the social sciences, which was reflected in its conceptual and methodological choices. Historically, no single school of thought within psychology managed to provide a full explanation of mental illness, but they all had the potential to advance our understanding and complemented each other. The usefulness of any psychological approach for psychiatry is determined to a large degree by how much it can incorporate person-centredness and agency into its theory and research. This is an area where psychology has benefited from more (rather than less) social science and humanities input during its history. This chapter contrasts four major schools of thought in psychology from this perspective: psychoanalysis and behaviourism as well as cognitive and humanistic psychology. Psychoanalysis focussed on the whole person and managed to incorporate values and ethics into its epistemology more than other approaches could; in addition to recognizing the role of psychological trauma and conflict and of meaning, this was one of its crucial contributions to psychiatry.

Even though values are crucial to our understanding of psychiatry, prevailing models of mental illness fail to properly integrate them. Neuroscience has produced a large amount of knowledge, but it needs to be augmented to fully integrate other relevant dimensions, such as the experiential, the social, and the existential. Engel’s biopsychosocial model, Leigh’s genetic-memetic model, the enactive model (e.g., in Haan), and the hybrid model by Berrios and Markova all foreshadow a new epistemology that, when worked out fully, will be able to achieve that and provide robust theoretical foundations for psychiatry.

A key problem in psychiatry is resolving disputes about mental capacity that often relate to the patient’s values being at odds with those of others. A new, VBP-informed stakeholders’ tribunal, including a philosopher, a VBP-trained clinician, and optional members with expertise relevant to the case, could provide a good process for working with these values.

Choosing our instrumental values appropriately at the person and societal levels is key to the prevention and treatment of mental illness. However, psychiatry needs to make it clear that it is only one of the players, and if these values are to be fully realized, public health, government, and the public need to work collaboratively.

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.

Working conditions in psychiatry have worsened in many healthcare systems, allowing less time for person-centred care. There is a conflict between management and clinical values. Though IT carries great potential, many current systems fail to free up time for human-to-human contact. All these factors affect retention.

The ever-increasing expectation towards psychiatry to prevent suicides has taken to mean complete elimination in some places. This is problematic as suicide is not completely preventable; it is not a form of harm equivalent to other patient safety errors; and there is a plurality of relevant values. The impact on ‘second victims’ is also an important issue.

Owing to its relatively undeveloped conceptual foundations, psychiatry has often struggled to defend itself against various criticisms. A VBP-based analysis of the terminal and instrumental values of anti-psychiatry can highlight some of the weaknesses of its arguments. Critical psychiatry draws attention to problematic areas of psychiatric theory and practice to provide constructive criticism. Remarkably, much of that has now been adopted by mainstream psychiatry. A self-reflective stance and constructive criticism play an important role in keeping our profession on a sound ethical footing. A genuine dialogue about values among all stakeholders is needed for constant calibration.