Phenomenology yesterday, today, and tomorrow: a proposed phenomenological response to the double challenges of contemporary recovery-oriented person-centered mental health care.

This paper argues that a dialectical synthesis of phenomenology's traditional twin roles in psychiatry (one science-centered, the other individual-centered) is needed to support the recovery-oriented practice that is at the heart of contemporary person-centered mental health care. The paper is in two main sections. Section I illustrates the different ways in which phenomenology's two roles have played out over three significant periods of the history of phenomenology in 20th century psychiatry: with the introduction of phenomenology in Karl Jaspers' General Psychopathology in 1913; with the development a few years later of structural phenomenological psychopathology; and in the period of post-War humanism. Section II is concerned with the role of phenomenology in contemporary mental health. There has been a turn to phenomenology in the current period, we argue, in response to what amounts to an uncoupling of academic psychiatry from front-line clinical care. Corresponding with the two roles of phenomenology, this uncoupling has both scientific aspects and clinical aspects. The latter, we suggest, is most fully expressed in a new model of "recovery," defined, not by the values of professionals as experts-by-training, but by the values of patients and carers as experts-by-experience, specifically, by what is important to the quality of life of the individual concerned in the situation in question. We illustrate the importance of recovery, so defined, and the challenges raised by it for both the evidence-base and the values-base of clinical decision-making, with brief clinical vignettes. It is to these challenges we argue, that phenomenology through a synthesis of its twin roles is uniquely equipped to respond. Noting, however, the many barriers to such a synthesis, we argue that in the current state of development of the field, it is by way of a dialectical synthesis of phenomenology's roles that we should proceed. From such a dialectic, a genuine synthesis of roles may ultimately emerge. We conclude with a note on the wider significance of these developments, arguing that contrary to 20th century stereotypes, they show psychiatry to be leading the way for healthcare as a whole, in developing the resources for 21st century person-centered clinical care.

High-resolution fiber imaging for pulsed power experiments.

This work presents a novel approach for imaging the visible emissions from plasmas in pulsed power experiments using high-resolution plastic optical fibers. The diagnostic consists of a 2 mm diameter core commercial cable constructed of 13 000 individual acrylic fibers. The fibers are fused together to create a single high-resolution bundle. Different designs were investigated to cover a wide range of resolutions and fields of view (3-700 µm and 0.05-45 mm, respectively). The system was tested on the 1-MA Mykonos accelerator at Sandia National Laboratories and successfully imaged visible emission from a hybrid x-pinch target. Diagnostic development and preliminary results are presented.

The Dialectics of Altered Experience: How to Validly Construct a Phenomenologically Based Diagnosis in Psychiatry.

In this paper, we present how a dialectical perspective on phenomenological psychopathology, called Dialectical Phenomenology (DPh), can contribute to current needs of psychiatric diagnosis. We propose a three-stage diagnostic methodology: first- and second-person stages, and synthetic hermeneutics stage. The first two stages are divided into a pre-dialectical and a dialectical phase. The diagnostic process progresses in a trajectory of increasing complexity, in which knowledge obtained at one level is dialectically absorbed and intertwined into the next levels. Throughout the article, we offer some examples of each step. In overall, the method starts off from the patient's own narrative, proceeds to two stages of phenomenological reduction designed to guarantee the scientific validity of the object, and concludes with a hermeneutical narrative synthesis that is dialectically composed of the patient's and psychopathologist's shared narratives. At the end of this process, the initial first-person narrative is transformed into a specific scientific object, a full dialectical phenomenological psychiatric diagnosis. This form of diagnosis constitutes a comprehensive alternative for an integral assessment of the complexities of human psychological alteration, bringing together both the interpretation of the suffering person and the scientific categories of psychiatry.

Interactions between persons-Knowledge, decision making, and the co-production of practice.

There is now broad agreement that ideas like person-centred care, patient expertise and shared decision-making are no longer peripheral to health discourse, fine ideals or merely desirable additions to sound, scientific clinical practice. Rather, their incorporation into our thinking and planning of health and social care is essential if we are to respond adequately to the problems that confront us: they need to be seen not as "ethical add-ons" but core components of any genuinely integrated, realistic and conceptually sound account of healthcare practice. This, the tenth philosophy thematic edition of the journal, presents papers conducting urgent research into the social context of scientific knowledge and the significance of viewing clinical knowledge not as something that "sits within the minds" of researchers and practitioners, but as a relational concept, the product of social interactions. It includes papers on the nature of reasoning and evidence, the on-going problems of how to 'integrate' different forms of scientific knowledge with broader, humanistic understandings of reasoning and judgement, patient and community perspectives. Discussions of the epistemological contribution of patient perspectives to the nature of care, and the crucial and still under-developed role of phenomenology in medical epistemology, are followed by a broad range of papers focussing on shared decision-making, analysing its proper meaning, its role in policy, methods for realising it and its limitations in real-world contexts.

Between the Reasonable and the Particular: Deflating Autonomy in the Legal Regulation of Informed Consent to Medical Treatment.

The law of informed consent to medical treatment has recently been extensively overhauled in England. The 2015 Montgomery judgment has done away with the long-held position that the information to be disclosed by doctors when obtaining valid consent from patients should be determined on the basis of what a reasonable body of medical opinion agree ought to be disclosed in the circumstances. The UK Supreme Court concluded that the information that is material to a patient's decision should instead be judged by reference to a new two-limbed test founded on the notions of the 'reasonable person' and the 'particular patient'. The rationale outlined in Montgomery for this new test of materiality, and academic comment on the ruling's significance, has focused on the central ethical importance that the law now (rightfully) accords to respect for patient autonomy in the process of obtaining consent from patients. In this paper, we dispute the claim that the new test of materiality articulated in Montgomery equates with respect for autonomy being given primacy in re-shaping the development of the law in this area. We also defend this position, arguing that our revised interpretation of Montgomery's significance does not equate with a failure by the courts to give due legal consideration to what is owed to patients as autonomous decision-makers in the consent process. Instead, Montgomery correctly implies that doctors are ethically (and legally) obliged to attend to a number of relevant ethical considerations in framing decisions about consent to treatment, which include subtle interpretations of the values of autonomy and well-being. Doctors should give appropriate consideration to how these values are fleshed out and balanced in context in order to specify precisely what information ought to be disclosed to a patient as a requirement of obtaining consent, and as a core component of shared decision-making within medical encounters more generally.

Montgomery and shared decision-making: implications for good psychiatric practice.

The 2015 Supreme Court judgment in Montgomery v Lanarkshire Health Board [2015] UKSC 11 established that consent to medical treatment requires shared decision-making based on dialogue between the clinician and patient. In this editorial, we examine what Montgomery means for standards of good psychiatric practice, and argue that it represents an opportunity for delivering best practice in psychiatric care.Declaration of interestNone.

Search terms and a validated brief search filter to retrieve publications on health-related values in Medline: a word frequency analysis study.

OBJECTIVE: Healthcare debates and policy developments are increasingly concerned with a broad range of values-related areas. These include not only ethical, moral, religious, and other types of values 'proper', but also beliefs, preferences, experiences, choices, satisfaction, quality of life, etc. Research on such issues may be difficult to retrieve. This study used word frequency analysis to generate a broad pool of search terms and a brief filter to facilitate relevant searches in bibliographic databases. METHODS: Word frequency analysis for 'values terms' was performed on citations on diabetes, obesity, dementia, and schizophrenia (Medline; 2004-2006; 4440 citations; 1,110,291 words). Concordance® and SPSS 14.0 were used. Text words and MeSH terms of high frequency and precision were compiled into a search filter. It was validated on datasets of citations on dentistry and food hypersensitivity. RESULTS: 144 unique text words and 124 unique MeSH terms of moderate and high frequency (≥ 20) and very high precision (≥ 90%) were identified. Of these, 19 text words and seven MeSH terms were compiled into a 'brief values filter'. In the derivation dataset, it had a sensitivity of 76.8% and precision of 86.8%. In the validation datasets, its sensitivity and precision were, respectively, 70.1% and 63.6% (food hypersensitivity) and 47.1% and 82.6% (dentistry). CONCLUSIONS: This study provided a varied pool of search terms and a simple and highly effective tool for retrieving publications on health-related values. Further work is required to facilitate access to such research and enhance its chances of being translated into practice, policy, and service improvements.

Neuroscience and Values: A Case Study Illustrating Developments in Policy, Training and Research in the UK and Internationally.

In the current climate of dramatic advances in the neurosciences, it has been widely assumed that the diagnosis of mental disorder is a matter exclusively for value-free science. Starting from a detailed case history, this paper describes how, to the contrary, values come into the diagnosis of mental disorders, directly through the criteria at the heart of psychiatry's most scientifically grounded classification, the American Psychiatric Association's DSM (Diagnostic and Statistical Manual). Various possible interpretations of the prominence of values in psychiatric diagnosis are outlined. Drawing on work in the Oxford analytic tradition of philosophy, it is shown that, properly understood, the prominence of psychiatric diagnostic values reflects the necessary engagement of psychiatry with the diversity of individual human values. This interpretation opens up psychiatric diagnostic assessment to the resources of a new skills-based approach to working with complex and conflicting values (also derived from analytic philosophy) called 'values-based practice.' Developments in values-based practice in training, policy and research in mental health are briefly outlined. The paper concludes with an indication of how the integration of values-based with evidence-based approaches provides the basis for psychiatric practice in the twenty-first century that is both science-based and person-centred.

Bringing together values-based and evidence-based medicine: UK Department of Health Initiatives in the 'Personalization' of Care.

RATIONALE: Person-centred medicine depends on combining best research evidence with the unique values (including the preferences, concerns, needs and wishes) of individual patients and their families. AIMS AND OBJECTIVES: The paper gives a brief introduction to values-based practice as a new approach to incorporating patients' values into clinical decision making alongside best research evidence as derived from evidence-based practice. METHOD: The role of values-based practice as a partner to evidence-based practice is illustrated through a series of policy, training and service development initiatives in mental health from the UK Department of Health in London. RESULTS: These initiatives have supported person-centred developments in key areas of mental health practice including, (1) the use of involuntary treatment; and (2) a shared approach of assessment. Early moves are underway to extend values-based practice to other areas of health care beyond mental health. CONCLUSION: Values-based practice offers a new approach to incorporating patients' unique values into clinical decision making that is complementary to evidence-based practice as a resource for person-centred medicine.

What is a mental/psychiatric disorder? From DSM-IV to DSM-V.

The distinction between normality and psychopathology has long been subject to debate. DSM-III and DSM-IV provided a definition of mental disorder to help clinicians address this distinction. As part of the process of developing DSM-V, researchers have reviewed the concept of mental disorder and emphasized the need for additional work in this area. Here we review the DSM-IV definition of mental disorder and propose some changes. The approach taken here arguably takes a middle course through some of the relevant conceptual debates. We agree with the view that no definition perfectly specifies precise boundaries for the concept of mental/psychiatric disorder, but in line with a view that the nomenclature can improve over time, we aim here for a more scientifically valid and more clinically useful definition.

Evidence-based and values-based policy, management and practice in child and adolescent mental health services.

Values-based practice is a new approach to working with complex and conflicting values. It is based, primarily, on learnable skills and is being applied across a range of policy, training and service development initiatives in mental health and social care. This article outlines some of the key features of values-based practice including its complementary relationships to both regulatory ethics and evidence-based practice. We describe the systemic links between values-based approaches at the three key levels of policy, service development, prioritization and commissioning, and clinical practice and managing delivery of services, particularly as they are being developed in child and adolescent mental health services. Our article concludes by indicating some of the areas for further development of values-based practice.

Hurly-burly of psychiatric ethics.

This is the introductory paper to the special issue on ethics in psychiatry. We introduce the other papers that follow and set them in a context. Inevitably, they represent only a thin slice of the work going on in psychiatric ethics. But they serve to show two unique features of this discipline. First, it has a tendency to dig deep and to make connections with other philosophical concepts. So, for example, in a number of ways the papers that follow touch on the nature of personhood. We examine this notion. Second, psychiatric ethics, because of its content and its embededness in the real world, tends to hit upon diverse and sometimes conflicting values. We introduce the idea of values-based medicine, which provides both a theoretical framework and a practical approach to the common dilemmas of psychiatric practice. The need to think deeply, but also clearly and coherently, combined with the need to engage with the hurly-burly of the world of patients, users and carers, suggests the reasons why psychiatric ethics offers a paradigm for practical ethics generally.