Curing Psychiatry's Schizophrenia: A Commentary in Values-Based PHD Mental Health Practice

From the perspective of values-based practice (VBP), there is much of interest in Lorenzo Gilardi and Giovanni Stanghellini's "I am a Schizophrenic." Their dialogue exhibits many of the key elements of VBP, it exemplifies the particular challenges presented by VBP in mental health, it illustrates the power of phenomenology in meeting these challenges, and it points by extension to an insight into contemporary psychiatry's professional identity as a medical profession.

VBP is a resource for working with values—with what matters or is important to those concerned—in healthcare (Fulford, Peile, & Carroll, 2012). Avoiding preset answers, it offers instead a process that supports those concerned in a given situation finding answers for themselves. Developed first in mental health as a practical offshoot of analytic philosophy and psychiatry (Fulford, 1989; Fulford & van Staden, 2013), VBP is now being extended to other areas of health and social care: the Director of the VBP Centre in Oxford is the vascular surgeon and Oxford's Tutor for Surgery, Ashok Handa (Handa et al., 2016; see also: www.//valuesbasedpractice.org).

That "I am a schizophrenic" should be transparently values-based is unsurprising given Giovanni Stanghellini's important contributions to the field (more on this below). Evident in the dialogue between LG and GS are many of the key skills of VBP (notably, awareness of values and listening skills); the approach is dialogic (it is a conversation not a medical monologue); and the dialogue is patient-values-centered (it focuses on what matters or is important to LG). Evident, too, is the importance of narrative. Relegated to the bottom of the evidence hierarchy, narrative comes at the top of the corresponding values hierarchy (Fulford, 2020): and the LG/GS dialogue convincingly illustrates why this should be so.

Then again, coming to VBP in mental health, the LG/GS dialogue is co-productive (it is a dialogue between equals); it is positive (it is concerned as much with LG's strengths as with his needs and difficulties (National Institute for Mental Health in England and the Care Services Improvement Partnership, 2008); and it is recovery oriented (it is aimed not at symptom control but rather at rebuilding a good quality of life as defined by what matters to LG as an individual (Slade, 2009).

Importantly, there is nothing in the LG/GS dialogue that from the perspective of VBP is peculiar to psychiatry. True, it would be surprising, even in Oxford, if Schopenhauer, Blankenburg and Nietzsche were all to come up within minutes of each other in a values-based consultation in Ashok Handa's aortic surgery outpatient clinic. But this is a difference only of content. In a consultation about aortic surgery the material values (the things that matter or are important) involve such (conceptually) straightforward issues as side effects (including death), length of stay in hospital, and the likelihood of relapse. The corresponding values in the LG/GS dialogue, by contrast, involve the (conceptually) far-from-straightforward nature of personal identity.

Hence, then, the resort in the LG/GS dialogue to Schopenhauer, Blankenburg, and Nietzsche. Hence, too, the more challenging nature of VBP as a whole in mental health as compared with areas of bodily medicine such as surgery. Which is where Giovanni Stanghellini has been early in the field in adding to the originating analytic philosophical resources of VBP, the resources of phenomenology. There is, of course, a long tradition of phenomenological research in psychiatry (Stanghellini & Fuchs, 2013). There have been other initiatives, too, in phenomenological VBP (e.g., in addictive disorders; Messas and Soares, forthcoming, 2020). Stanghellini has given us what he calls a "PHD" model of therapy (Stanghellini, 2019).

The LG/GS dialogue nicely illustrates how the PHD model combines the life-world insights of phenomenology with the heuristic methods of the hermeneutic circle in a dialogical form of person-centered phenomenological-dynamic psychotherapy. LG, it is true, is a particularly well-read and philosophically insightful patient. This is perhaps why as their dialogue nicely illustrates, GS and LG speak the same language. But this, again...