Values and Ethics in Mental Health

An Exploration for Practice

Alastair Morgan, Anne Felton, Bill Fulford

• Publisher: Bloomsbury Academic
• Year: 2015
• Print ISBN: 9781137382580
• eBook ISBN: 9781350313187
• Edition: 1
• Topic: Social Sciences
• Subtopic: Social Work
• Index: Social Sciences

Mental health is the one area of health care where people are often treated against their will, with the justification that it is in their own interest. This raises significant ethical questions and value dilemmas; questions of autonomy, human rights, power and treatment. An understanding of how values matter is of vital importance across all disciplines working within the mental health field. This book provides a comprehensive and exploratory text for practitioners, students and all those interested in developing a knowledge of both ethics and the wider framework of values-based practice. It is unique in being fully co-written by authors representing both service user and service provider perspectives. This exciting new text will enable the mental health practitioner to work more co-productively with service users within a humane and just approach to care. With an emphasis on rights-based compassionate care throughout, this book: - Tackles the issues of how mental health is understood through key theoretical debates about mental distress, values and labelling;
- Encourages readers to think critically about their understanding of key issues such as recovery, autonomy, power, knowledge, diagnoses and empathy;
- Draws on a wide range of case examples and exercises to help readers deepen their knowledge of values-based practice and ethics in mental health.

1

Ethics and values in mental health practice

Chapter Summary

This chapter will:

• Introduce the importance of ethical thinking and ethical questions for mental health practice.

• Show the need for values and values-based practice as a complement to ethical thinking.

• Emphasise the plurality and diversity of values, and the aim of balanced decision making where values are in conflict.

• Discuss the context of power, in which both ethics and values operate.

• Raise the question of what it means to put people who use services at the centre of values-based practice.

• Raise issues about narratives and how they are presented in this book.

Ethics in mental health practice

Any person involved in the mental health system, either as a practitioner or as a recipient of care and support (although the two are not mutually exclusive), immediately realises that mental health care raises significant and important ethical questions and dilemmas. Working in mental health care and psychiatry raises questions that are central components of ethical and philosophical deliberation. Radden writes that:

“Conceptions of rationality, personhood and autonomy, the preeminent philosophical ideas and ideals grounding modern-day liberal and humanistic societies such as ours, also frame our understanding of mental disorder and rationales for its social, clinical and legal treatment” (Radden, 2004: 3).

Questions of what it means to reason, what it means to be a person and how we can determine our own lives are raised acutely when we work with or experience states of mental distress. Jamison (2011) has written of how experiencing mental distress inevitably raises larger questions of identity, meaning and one’s place in society. These questions of meaning cannot be separated from the experience of distress itself as this experience is intrinsically bound up with identity, personhood and our position in society.

Ethical questions in mental health care, though, relate not only to questions of identity, meaning and culture, but also to how people who experience mental distress are treated and how we can justify that treatment. Mental health care remains the one area of health care where people can be treated against their will, even if they have capacity to understand the treatment ( Department of Health, 2008). What right do mental health practitioners have to enforce treatment, label distress in medical terms and determine how people live their lives, often on the basis of imprecise formulations of risk and dangerousness (Szmukler and Holloway, 2000)? These questions are vital, inescapable and not open to easy answers.

One central way of trying to respond to these dilemmas is by taking a traditional biomedical approach. This approach emphasises the necessity of familiarising the reader with ethical theories and then offering a framework or guide for thinking through ethical dilemmas (such as the principlist approach offered by Beauchamp (1999) and Beauchamp and Childress (2012)). This approach to mental health ethics is vitally important and we begin our book in this relatively familiar territory by exploring four approaches to ethical theory: deontology, consequentialism, virtue ethics and narrative ethics. We then consider the four principles of biomedical ethics and their application in mental health contexts. However, it rapidly becomes clear that a pure approach focussing on ethics alone is not sufficient for equipping the modern mental health practitioner to work in the complex arena of twenty-first-century mental health care.

Our book is labelled as an exploration for mental health practice, as we focus on exploring key dilemmas and skills for working with values and ethics in everyday practice. We are not claiming to present an exhaustive survey of all of the issues that are concerned with ethics and professionalism in mental health care. There are many texts which approach the topic of ethics in mental health practice with different lenses and perspectives (for example, Dickenson and Fulford (2000), Banks and Gallagher (2009), Bloch et al. (2009), Barker (2011), Sadler et al. (2015)).

The distinctive contribution that this volume provides is a focus on the integration of working with ethics and values, and an approach to working with contested values, alongside an emphasis on recovery-focussed and compassionate care. The focus on ethics needs to be supplemented with a consideration of how ethical principles fit into the wider context of values, and how awareness of values can lead the practitioner to a more informed and inclusive mental health practice. Therefore, we also emphasise a skills-based approach to developing practitioners who are competent at working with a variety of values and negotiating conflicts in an inclusive manner.

However, working with values and ethics is not sufficient. Any considered analysis of the issues of working ethically and in a values-based manner has to take account of the context of power in mental health practice. All mental health policy acknowledges the need to put the recipient of services at the heart of any health care. The current mantra in UK health services is “no decision about me without me” (Coulter and Collins, 2011). However, there is little detailed consideration of how this can happen, given a context in which there remain significant inequalities of power and in which the voice of service users is often not heard and occasionally is silenced. Integral to this volume is an emphasis on narratives, the concept of recovery, and the question of diversity and minority voices. We cannot consider a truly values-based ethical practice without negotiating the inequalities of power that exist within mental health care and in wider society.

Throughout this volume we use the terms “service user”, “survivor” and “person experiencing distress/mental health problems” to refer to actual people with lived experience of mental distress. There can be no one language that is universally acceptable to this group of people and each term has its own usefulness and problems. We have, however, used terms that have come from the mental health user/survivor movement and avoided terms that represent purely medical ways of thinking about mental distress (Kalathil and Perry, 2014).

Why values?

As we have already noted, this book opens in the relatively familiar territory of ethics for mental health practice, but by the end of Chapter 2, it is clear that ethical decision making needs to be embedded within the wider context of values. With the broadening of horizons to include values within ethical thinking, there is an emphasis on three key elements to values which are central to mental health practice. We set these out briefly here and return to them in more detail in Chapters 3 and 4.

First, there is an emphasis on the plurality of values. Values are various and multiple; they incorporate ethical principles but are wider than ethics, even including the importance of aesthetic questions, as we emphasise in this volume. The variety of values means that we cannot necessarily, and even should not, try to prescribe correct or appropriate values beyond broad frameworks of shared values (such as the four principles, discussed in Chapters 2 and 3). Working with values means the ability to negotiate this plurality, and being aware of the multiplicity of values is a key skill in values-based practice. This emphasis on plurality means that the idea of a correct answer to dilemmas or conflicts over values is a “category mistake”. We cannot attempt to resolve all conflicts over values but, instead, learn to work sensitively with the variety of values and how to make balanced judgements in individual situations.

The diversity of values leads us to a second key point: conflicts over values are the norm, rather than the exception. This is particularly the case in mental health care, but is more the case than we often think in the rest of health care. Furthermore, we cannot look to something called “evidence” to solve these issues of values in practice. Indeed, we suggest that scientific advances in mental health care actually increase choices, rather than giving definitive solutions and, therefore, might increase the scope for values to come into play, as our choices are determined by our values.

Stating that values-in-conflict is the norm is not a pessimistic statement. Reflecting on the diversity of values might inevitably lead us to the idea that conflict will arise. However, a central skill for values-based practice is working with conflicting values, without suppressing them. We emphasise here the important concept of “dissensus” as a way of acknowledging the diversity of values without suppressing different perspectives. This emphasis on plurality and conflict should not obscure the possibility of shared values. Indeed, although conflicts in values are the norm, if we develop the skills to raise awareness of fundamental values, we can often uncover a shared framework for our values that enables us to build collaborative care.

This emphasis on awareness brings us to the third key addition that the move towards values brings to ethical debates and practice in mental health care. Values are pervasive but often pushed into the background. Indeed, we often only become aware of them when something goes wrong or breaks down (what is known as the “squeaky wheel” principle in Values Based Practice (VBP); see Chapter 4, see also Fulford et al. (2012)). Throughout this book, we explore the principles and practice of making values explicit, which initially is often concerned with bringing one’s own values and those of others into the open. Awareness of values is the key skill to working in an inclusive and collaborative manner.

Power and diversity

Supplementing ethical theories and the principles approach with an awareness of values and the skills needed to work with diversity should enable us, in an ideal world, to work towards inclusive mental health practice. However, we do not work or live in an ideal world. Significantly, we work in an environment marked by differentials of power which impact negatively on those of us who receive mental health services. It is easy to pay “lip service” to the necessity of inclusion, but those in receipt of mental health services still often feel disempowered and excluded from the key decisions that are taken about their care (NICE, 2012). The emphasis on recovery principles and social inclusion in recent mental health care internationally has contributed to attempts to transform mental health services into more user-oriented care. These developments have been driven by service users themselves organising politically and therapeutically (Campbell, 2009). However, as we consider in Chapters 8 and 9, even the act of diagnosis in mental health care is an act replete with problems of power, labelling and discrimination.

Any approach to ethics and values in mental health practice has to take account of the key issue of power and how the voices of service users have largely been ignored in the history of psychiatry. We consider this history of silencing of personal narratives in detail in Chapter 6. We need to take account of the manner in which notions of madness have often intersected with notions of race and gender to oppress and discriminate against subjugated groups in society. Throughout this book, we return to the issues of power, and discrimination against minority and subjugated groups in order to take full account of the challenges of inclusive practice. Awareness of values needs to be supplemented with an awareness of power relationships and what we can do to try to introduce more participatory decision making at the heart of mental health care. This is the basis of recovery practice as we describe in the final chapters of the book.

Our narrative in writing this book

Writing this book was a challenge. As co-authors, we all differ in our values, experience and background. This is particularly the case when it comes to our experience of mental health practice and care, either as practitioners, academics, or those who have lived experience of mental distress. In many ways, writing the book was an experiential form of learning what it means to be aware of different values and different voices.

An instructive example of this learning relates to the structure of the book. As part of the structure, the reader will regularly be directed to reflective examples and “case studies” aimed at developing skills for thinking through “real life” scenarios.

However, we questioned ourselves about the writing of these reflective examples. For some of us, the writing of “case studies” and examples had become “second nature”. We were used to producing these narratives to aid with education, and did not consider the ethics of (re)presenting another person’s narrative, of having the audacity to write a fictional story as if it were “real life”. For others, h...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• List of Boxes, Figures and Tables
• Acknowledgements
• Notes on Contributors
• List of Abbreviations
• 1. Ethics and values in mental health practice
• 2. Ethics: Theories, contexts and questions
• 3. Ethics and values: Developing a values toolkit
• 4. Values-based practice
• 5. The importance of power
• 6. Power, knowledge and personal narratives
• 7. Coercion and autonomy
• 8. Diagnosis as an ethical question in psychiatry
• 9. Values-based assessment
• 10. Values, ethics and recovery
• 11. Valuing persons
• 12. Daring to care: Maintaining our values in practice
• Bibliography
• Index