Jump to ContentJump to Main Navigation
DepressionLaw and Ethics$

Charles Foster and Jonathan Herring

Print publication date: 2017

Print ISBN-13: 9780198801900

Published to Oxford Scholarship Online: October 2017

DOI: 10.1093/oso/9780198801900.001.0001

Show Summary Details
Page of

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (www.oxfordscholarship.com). (c) Copyright Oxford University Press, 2019. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use.  Subscriber: null; date: 17 September 2019

Depressions Plural

Depressions Plural

Pathology and the Challenge of Values

Chapter:
(p.145) 14 Depressions Plural
Source:
Depression
Author(s):

K W M (Bill) Fulford

David Crepaz-Keay

Giovanni Stanghellini

Publisher:
Oxford University Press
DOI:10.1093/oso/9780198801900.003.0014

Abstract and Keywords

This chapter examines how values influence the heterogeneity of depression. The plurality of values is increasingly significant for contemporary person-centred mental health care with its emphasis on quality of life and development of self-manvnagement skills. Values-based practice is a partner with medical law invn working with the plurality of personal values. The chapter explains what values are, shows how the plurality of values influences the heterogeneity of depression at several levels, and provides an overview of values-based practice. It looks at the resources available for combining values-based practice with medical law in contemporary person-centred care and indicates some of the challenges this raises. It concludes with a brief reflection on these challenges understood as an instance of what the political philosopher Isaiah Berlin called the challenge of pluralism.

Keywords:   values, depression, plurality of values, heterogeneity of depression, values-based practice, mental health, medical law, person-centred mental health care, pluralism

The term ‘depression’ is misleading. It suggests a well-defined medical entity comparable with, say, migraine or appendicitis. But depression is heterogeneous at many levels. The boundary between normal sadness and depression is contested. There are competing professional models of depressive disorder (medical, psychological, social, and so forth). Medical diagnostic classifications recognize phenomenologically distinct subtypes. Above all, and crucially for practice, individual experiences of depression vary widely.

In this chapter we focus on the contribution of values to the heterogeneity of depression. Although relatively neglected, the plurality of values (of what is important or ‘matters to’ a given individual) is increasingly significant for contemporary person-centred mental health care with its emphasis on quality of life and development of self-management skills. Values-based practice, as we describe, offers a clinical approach to working with the plurality of personal values. However, values-based practice works best in partnership with other resources including, importantly, law.

The chapter has three main sections. The first section, entitled ‘Values and Depression’, draws on research findings and case examples to illustrate some of the many ways in which plurality of values contributes to the heterogeneity of depression. The second section, ‘Values-based Practice’, gives an outline of values-based practice and its role in contemporary person-centred approaches to mental health. Finally, the third section, ‘Values, Law, and Depression’, describes, with an example from experience in the United Kingdom (UK), the resources but also some of the challenges presented by combining values-based practice with medical law in contemporary person-centred care. We conclude with a brief reflection on these challenges—which we see as an instance of what the political philosopher Isaiah Berlin called the challenge of pluralism. First, however, just what are values?

(p.146) Values

Seminars in values-based practice often start with what is called the ‘three words exercise’.1 Participants are asked to write down just three words ‘that mean “values” to you’. The invariable result is that, as Figure 1 illustrates, everyone comes up with different words.

This exercise and others like it give participants first-hand experience of values pluralism. Particularly in a healthcare context it is natural to assume that ‘for values read ethics’; or perhaps a received list of aspirational institutional values (like the ‘Core Values of the NHS’2). This simple word-association exercise spells out graphically that values, although including ethical and institutional values, extend well beyond these to include needs, wishes, preferences, and so forth—indeed anything that is important or ‘matters to’ a given individual. It is this plurality of values that is (in part but importantly) behind the heterogeneity of depression.

Values and Depression

In this section we outline the role of values in the heterogeneity of depression at each of the four levels noted at the start of the chapter: (1) at the boundaries of normal and pathological depression; (2) among competing conceptualizations; (3) in defining diagnostic and phenomenological subtypes; and (4) within and between individual experiences of depression.

The boundaries of normal and pathological depression

Debate in recent decades about the boundary between normal and pathological depression has turned largely on whether, and if so in what way, it can be defined value-free. So far as theory goes there are persuasive arguments on both sides. But that values are involved in practice is suggested by their inclusion in no less an authority than the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) in the form of what it calls ‘criteria of clinical significance’.3

Depressions PluralPathology and the Challenge of Values

Figure 1 Sample responses to ‘three words that mean “values” to you’

(p.147) The relevant Criterion B (as the DSM’s criterion of clinical significance is called in this instance) for Major Depressive Disorder includes ‘[i]‌mpairment in social, occupational, or other important areas of functioning’.4 For a patient to be diagnosed with depression of this type they must of course have low mood and other symptoms of depression as well (covered in the manual’s Criterion A). But these are not sufficient. Nor is it sufficient that there should be merely a change in functioning. To satisfy Criterion B (and this is where values come in) there must be impairment in functioning.

The value judgments required in applying Criterion B in a particular instance may be straightforward: for example, in an extreme form of depression called ‘depressive stupor’ the patient becomes mute and immobile and their functioning in all areas is clearly impaired. In most instances, however, the required value judgments are likely to present challenges of interpretation and balancing. Values-based practice, as we describe in the next section, aims to support decision-makers in meeting such challenges. Our point for now is that value judgments are there at the boundary between normal and pathological and, if the DSM is any indication, they are essential to the way the boundary is defined.

Competing conceptualizations

When it comes to mental disorders, the medical model is far from being the only game in town. Other widely endorsed models include psychological, social, psychotherapeutic, psychoanalytic, and political. Models should be understood heuristically, as tools to aid understanding, rather than as comprehensive descriptions or rigid frameworks. It is perhaps understandable that theoretical debate (p.148) about which model is ‘best’, reflecting as it does different professional interests, should at times have been heated. Work by the British social scientist Anthony Colombo,5 however, suggests that, understood heuristically, it is the range of models rather than any one model that is required to meet the plurality of patients’ values.

The essential points from Colombo’s work are: (1) that whereas team members when asked directly all claimed a similar biopsychosocial model, their implicit models (the models actually guiding their practice) were very different; (2) that these differences in implicit models reflected differences in implicit team values (psychiatrists were more concerned with medication, for example, and social workers more with family engagement); and (3) that patients showed the same range of implicit values as team members.

These findings, as we describe further in the next section, gave team members’ differences of values (as reflected in their respective implicit models) a key role in delivering the person-values-centred care of values-based practice.

Diagnostic and phenomenological subtypes

Diagnostic subcategories of depression vary to some extent between classifications. Most, however, distinguish depressive disorder (ranging from the more serious major to less serious minor forms) from depressive personality disorder and abnormal depressive reactions to loss (such as bereavement).6

These distinctions are made in part descriptively: depressive personality disorder, for example, is distinguished from depressive mental disorder in being a life-long aspect of the personality rather than arising de novo. Values, however, come into these differentiations as well: for example, what counts as a traumatic rather than non-traumatic loss (as in the diagnosis of an abnormal depressive reaction) turns critically on what matters to the person concerned.7

Further values are reflected in the more nuanced subtypes of depression derived from phenomenological analysis. The German psychopathologist Hubertus Tellenbach’s ‘typus melancholicus’, for example, described a personality type predisposed to major depressive disorder. This personality type was defined in large part by what matters to the individual in question (a strong (p.149) sense of social responsibility, for example, and seeking not to disagree with others8). Depression arising in the ‘typus melancholicus’ is characterized by delusions of guilt—the contents of which in any given case are linked to the values of the individual.

The implications for practice of the values defining these subtypes of depression are complicated by the extent to which depression and related affective disorders influence the values of those affected. The challenges here are well illustrated by bipolar disorder. In this condition, the person concerned swings from depression to hypomania or mania (forms of pathological elation), with corresponding shifts from a negative to a positive perspective on the world. Case studies have shown that the values of the person concerned (what matters to them) may be radically different in the two states with no unambiguous view of which are the person’s ‘real’ values.9

Individual variation

In addition to the above variations, the way a given episode of depression is experienced may vary widely between individuals, ranging from despair to acceptance and even to mystical exaltation. Contrast for example the writer William Styron’s anguished account of his own depression10 with the no less anguished yet ultimately accepting account by mystics of the ‘dark night of the soul’.11 Again, significant historical figures from many walks of life suffered depression: examples include the artist Claude Monet, the composer Robert Schumann, the philosopher Søren Kierkegaard, and the politician and war leader Winston Churchill. Whether the remarkable outputs of these and similar figures were achieved as a result of or despite their depression is moot. However, there is evidence that at least mild depression may be associated with cognitive strengths, as well as difficulties.12 In addition, the elated-mood counterpart of depression, mania, with which periods of depression are often associated (as in bipolar disorder), has been widely linked with creativity.13

This is not to romanticize depressive disorder. Its links with suicide should be enough to dispel the idea that depression is somehow a ‘good thing’. But depression, unlike, say, a heart attack, is in and of itself not necessarily, nor to everyone, wholly a bad thing. And just what exactly is bad about any given (p.150) individual’s experience of depression is not reducible to standardized diagnostic norms. There will be consistencies and continuities across cases certainly. However, because of our individually unique values, experiences of depression—what a given experience means to the individual concerned—will be individually unique as well.

Recognizing individual variation of this kind has become even more important in recent years with the move away from disorder-based treatments to person-centred approaches in clinical care. Such approaches focus less on the reduction of symptoms and more on recovery of a good quality of life—where ‘good’ is defined primarily by the values (by what matters to) the individual concerned.14 Symptom control may of course have a part to play in this. But symptom control is subservient to, rather than at the expense of, individual quality of life.

Recovery practice then, as it is called, hinges critically on individual values. However, as we noted above, individual values are inherently pluralistic. This is where values-based practice comes in.

Values-based Practice

Values-based practice is one of a number of resources for working more effectively with the plurality of values in health care.15 Other tools in the ‘values toolkit’ include, for example, ethics, law, health economics, and regulation. Values-based practice complements these in providing a process that supports balanced decision-making within frameworks of shared values according to the circumstances presented by the decision in question.

The process of values-based practice is shown diagrammatically in Figure 2. Learnable clinical skills (such as raised awareness of values, as in our ‘three words’ exercise, above), strong links with evidence-based practice, and partnership in decision-making, are important. So too are teamwork and person-centred care. Building on Colombo’s work (see note 5, above), the extended multi-disciplinary team of values-based practice includes (or extends to) team values as well as knowledge and skills; and the range of team values contributes to the person-values-centred care of values-based practice.

Values-based practice is currently being developed across a variety of areas of health and social care through a new Collaborating Centre in Oxford.16 The approach has been successfully applied to a training programme in values-based surgical care, for example. An early programme in mental health, developed by the UK’s Department of Health, was on values-based diagnostic assessment.17 The ‘3 Keys’, as the programme was called, were three shared (p.151) values that emerged from a wide-ranging consultation among stakeholders. Everyone agreed that assessment should be: person-centred, multidisciplinary, and strengths-based.

Depressions PluralPathology and the Challenge of Values

Figure 2 The process of values-based practice

No surprises there, you might think. In the consultation, many excellent examples of each of the three keys being operationalized under challenging circumstances were given (these examples made up over 80% of the final report). Locally implemented, the ‘3 Keys’ have correspondingly been well received. However, the ‘3 Keys’ have turned out to be remarkably difficult to scale up across mental health practice as a whole.

One response to such failures of scaling is to turn to the resources of medical law. This would be consistent with the toolkit approach noted above. But does it work? In the next section we illustrate the strengths but also some of the limitations of medical law in areas such as depression, where a plurality of values is in play.

Values, Law, and Depression

A key area of overlap between law and clinical practice relevant to depression is involuntary psychiatric treatment. The relevant law in most of the UK (Scotland has its own legislation) is the Mental Health Act 2007. Like other similar legislation around the world, the Mental Health Act covers the use of involuntary hospitalization and treatment for mental disorders where, in refusing treatment, the person concerned is putting themselves or others at risk.

In this section we give examples of uses and abuses of involuntary treatment, outline research pointing to the role of diagnostic values in differentiating between them, and describe experience of combining values-based practice with law in the way the Mental Health Act 2007 was conceived and implemented. Although initially successful, this combined approach faced similar challenges of scaling as the (p.152) ‘3 Keys’ programme. We suggest possible reasons for these challenges of scaling in our concluding section.

Uses and abuses of involuntary treatment

The story of Mr AB given in the Box illustrates the use of the Mental Health Act 2007 in depression.

Mr AB satisfied the conditions for use of the Mental Health Act. He was refusing treatment for a mental disorder (major depressive disorder) that in general, and in his particular case, carried a clear risk of harm (suicide, or, in very rare but tragic cases, homicide). There were checks and balances to apply (a second opinion for example). Nonetheless, here at least, most would agree, the use of involuntary treatment was justified. The outcome too in this case was good: Mr AB recovered over a period of a few weeks on antidepressant medication.

Notwithstanding stories such as Mr AB’s, involuntary treatment is highly contentious. The problem in essence is that involuntary treatment risks being abused as a means of social control. Social control as such is not the problem: this is after all why we have police and other public guardians. The problem is with a medical intervention being used as a means of social control.

Some have argued that involuntary treatment is always and by definition social control. The psychiatrist and human rights campaigner Thomas Szasz took this (p.153) extreme position.18 That his concerns were not without foundation is evidenced by high profile abuses of involuntary treatment in the former Soviet Union and elsewhere. Such abuses have tended to turn on diagnoses of psychotic disorders such as schizophrenia, rather than depression. However, the issues they raise are generic.

In the Soviet Union, as a number of authors have documented,19 political dissidents were regularly diagnosed with a form of subclinical psychosis (‘sluggish schizophrenia’) on the basis of ‘delusions of reformism’ and as a result incarcerated, very much against their wishes, in asylums. In contrast to Mr AB’s story, this was prima facie an abusive use of involuntary treatment. Comparing the two situations side-by-side, however, shows that exactly where the critical difference between them comes is far from obvious. It is true that the diagnosis in the Soviet case was of a form of schizophrenia (‘sluggish schizophrenia’) rather than depression. However, the Mental Health Act covers any form of mental disorder. Another difference is that Mr AB was deemed a danger to himself (he was at risk of suicide), whereas those involved in the Soviet cases were deemed a danger to others (as subversives). Again, however, the Mental Health Act covers risk to others as well as to the person concerned.

A further difference is in the content of the respective delusions: Mr AB had hypochondriacal delusions (of brain cancer), whereas the ‘delusions of reconstruction’ in the Soviet case were political in content. But delusions with political content are well recognized in Western psychiatry too. Delusions of reconstruction, it is true, are evaluative in form (that the state could be better organized), while Mr AB’s were factual (that he had a brain tumour). However, evaluative delusions are commonplace in Western psychiatry and as such carry the same implications for treatment as their factual counterparts.20 Delusions of guilt, for example, are common in depression: and whether factual or evaluative in form they serve equally to justify involuntary treatment.

So where does the difference come? Why is involuntary treatment in Mr AB’s story appropriate while in the Soviet case it is not? The answer, it might seem, is obviously a matter of diagnosis: Mr AB really did have a mental disorder, while the political dissidents of Soviet psychiatry did not. Psychiatric diagnostic concepts themselves it is important to emphasize are highly contested: witness concerns ranging from the now classic social science fieldwork of David Rosenhan,21 through conceptual and philosophical challenges22 to contemporary neuroscientific critiques.23 But even granted the validity of psychiatric diagnostic concepts, (p.154) pointing to diagnosis only pushes the ‘why?’ question back a stage. For it begs the question in exactly what respect Soviet diagnoses were wrong.

The assumption among Western psychiatrists when these cases first came to light (in the 1960s and 1970s) was that Soviet psychiatric science was at fault. Clearly, this assumption went, Soviet diagnostic concepts lack the scientific rigour of their Western counterparts. However, a study of Soviet psychiatric literature from the period suggests that this assumption was mistaken.

Diagnostic values and the uses and abuses of involuntary treatment

The study in question took the form of a retrospective analysis of Soviet psychiatric literature from the period when abusive uses of psychiatry had become widespread.24 The guiding theory was broadly that of the ‘Oxford School’ of ordinary language philosophy. The nub of this approach is that, rather than merely theorizing about concepts, we should look at how the concepts in question are actually used.25

The opportunity to carry out the study arose with the visit to Oxford of a Russian psychiatrist, Alex Smirnoff. Working with one of us (KWMF), and with a Russian-speaking social worker, Elena Snow, Alex translated a representative sample of Soviet psychiatric literature on schizophrenia from the relevant period. Comparing this literature with corresponding literature from Britain and the United States thus allowed us to compare Soviet diagnostic concepts directly with their Western counterparts.

What we found was a surprise. The two sets of concepts, so far at least as schizophrenia was concerned, ran almost exactly parallel. Western psychiatry, like Soviet psychiatry, recognized a subclinical form of schizophrenia (albeit called ‘latent’ rather than ‘sluggish’ schizophrenia). The diagnostic criteria for both subclinical forms of schizophrenia were closely similar, and they were both attributed to underlying brain pathology (the model for which in the Soviet case was derived from the work of a pathologist, I V Davidovsky).

Our conclusion from this work, therefore, was that while other factors (such as lack of professional training) might have been involved in abuses of involuntary psychiatric treatment becoming widespread in the Soviet Union, the essential vulnerability of psychiatry to such abuses could not be attributed to the lack of a robust scientific model of the kind available at the time in Western psychiatry. To the contrary: that such a model was actually in place in the Soviet Union showed that contrary to Western assumptions of the day, Western-recognized models were no barrier to involuntary treatment being abused as a means of social control.

One response to this conclusion is to look to a scientific model of a different kind. Some have argued, for instance, that psychopathology, as the basic science (p.155) of psychiatry,26 should develop diagnostic concepts that are less prone to abuse. Phenomenological psychopathology in particular has challenged the practice of diagnosing ‘delusion’ on the basis of ‘abnormal’ contents (such as false beliefs) and developed alternatives based on the formal aspects of delusion (essentially, the way a given content comes to the mind27) and on the global transformation of the field of experience of the person concerned.28

A second response, complementary to the first, is to turn from the diagnostic facts to the relevant diagnostic values. There are a number of indicators of the importance of values in this respect. First, the risk (to others) in issue in the Soviet case (subversion) cut directly against the prevailing (totalitarian) social values. Soviet values were furthermore reflected in the content of the key symptom—delusions of reconstruction—on which in the Soviet case the diagnosis of subclinical schizophrenia was made. As we have indicated, delusions with political content are commonplace in psychiatry. However, judged against Soviet values of the time it is easy to understand why these particular political beliefs—of reconstruction—were judged irrational: ‘he must be mad’, we can imagine those espousing Soviet social values exclaiming; or, perhaps, drawing on the language of DSM’s criteria of clinical significance, he shows clear ‘[i]‌mpairment in … social functioning’.

There is clearly more to be said here. However, if the vulnerability of psychiatry to abuse is at least in part values-based, then at the very least we need to look more critically at the way values come into involuntary treatment in other contexts, including contemporary Western psychiatry. The particular values differentiating uses from abuses of involuntary treatment may be different in different contexts. But values as well as science might be critical nonetheless. It was this possibility that led to the values-plus-law approach of the Mental Health Act 2007.

Combining values-based practice with law

The development programme for the Mental Health Act 2007 got off to a bad (values) start.29 There had been at the time a high profile tragic episode of a person with a mental disorder killing an innocent bystander. The minister responsible (Jack Straw) correspondingly launched the programme on a public safety ticket: public (p.156) safety, he said, ‘is paramount’. Understandably, this greatly reinforced concerns among the mental health community that the proposed new legislation would be used for the control of dangerousness (a social purpose), rather than for the treatment of mental disorder.

The result was that the original six months allowed for the programme became bogged down in a deeply contested five-year public consultation. The consultation, however, established a number of points on which everyone agreed. These points thus amounted to a set of shared values that became the basis for the values-based approach to involuntary treatment adopted in the legislation. This worked at three levels: in the legislation itself the agreed points were flagged as matters to be defined in the accompanying Code of Practice; the Code of Practice then spelled them out as five Guiding Principles to which in using the Act those concerned must ‘have regard’; and the Guiding Principles in turn became a ‘Framework of Shared Values’ for a suite of values-based training materials developed by the Department of Health to support implementation.30

The model guiding this values-based approach to implementation is summarized in Figure 3. Consistently with the approach described above, the skills and other process elements of values-based practice supported balanced decision-making within the Guiding Principles according to the circumstances of an individual case. This approach had a degree of legal force in that it reflected the requirement for decision-makers to ‘have regard’ to the Guiding Principles. It was well received in a road show of training workshops run in various parts of the UK shortly after the Act became law. Like the 3 Keys programme, however, there have been problems when it comes to scaling up the approach. What we find now, just a few years on, is that most practitioners are not even aware that there are Guiding Principles to which they should have regard. Far from balanced decision-making, use of the Act is being driven mainly by values of aversive risk management.31

Conclusions

At the start of this chapter we used the ‘3 words’ exercise to raise awareness of the plurality of personal values. It is this same plurality of values that runs through (p.157) our three main sections. The first section showed with examples the many contributions of plurality of values to the heterogeneity of depression: the ‘depressions plural’ of our title turn out to be in large part a matter of ‘values plural’. The next section then gave a brief introduction to values-based practice as a skills-based approach to working with plurality of values in health care: this approach we noted had worked well up to a point but faced problems when it came to scaling up across mental health services as a whole. Problems of scaling have become apparent too with the combined values-and-law approach adopted in the UK’s Mental Health Act 2007 described in the final section. This approach provided for balanced judgments within the Act’s ‘Guiding Principles’. The need for such balanced judgments arises directly from the plurality of personal values. However, despite being initially well received, the Act as we have indicated is being used in practice mainly as a risk management tool.

Depressions PluralPathology and the Challenge of Values

Figure 3 The Guiding Principles as a framework of shared values

We are not the first to run up against problems of scaling with values pluralism. The political philosopher Isaiah Berlin, writing in the late 1950s, noted that our default setting as human beings is not values pluralism but monism.32 We seek the security of a ‘right answer’. Small wonder, then, that we should run into problems of scaling with the essentially pluralistic values-based practice. It is much easier to (p.158) adopt the monism of a diagnostic label than the pluralism of the ‘3 Keys’ for mental health assessment. It is much easier to adopt the monism of risk aversion than the pluralism of the ‘Guiding Principles’ for involuntary treatment. Yet, given the plurality of personal values, meeting Berlin’s challenge is essential to contemporary person-centred care.

Although focusing here on depression, equivalent challenges of values pluralism are evident in other disorders, mental and indeed physical (recall the programme in values-based surgical care noted above). Nor are these challenges confined to the Mental Health Act: a recent House of Lords Select Committee expressed concern that use of the Mental Capacity Act 2005 (like that of the Mental Health Act 2007) is being driven largely by values of risk aversion.33 Values-based practice, just in raising awareness of the plurality of values, takes us an important first step towards meeting the challenge of pluralism in health care. Medical law adds further resources. But there is clearly much still to be done if person-centred care is to move beyond aspiration to reality.

Notes:

(1) See eg K W M (Bill) Fulford, Edward Peile, and Heidi Carroll, Essential Values-based Practice: Clinical Stories Linking Science with People (CUP 2012) ch 14. The three-words exercise was introduced by Kim Woodbridge-Dodd as lead author of the first training manual in values-based practice, Kim Woodbridge and Bill Fulford, Whose Values? A Workbook for Values-based Practice in Mental Health Care (The Sainsbury Centre for Mental Health 2005).

(3) Besides criteria of clinical significance values occur throughout the DSM. See J Z Sadler, Values and Psychiatric Diagnosis (OUP 2004) and, though more implicitly, in the International Classification of Diseases (ICD) (World Health Organization, The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines (World Health Organization 1992)). See also K W M Fulford, ‘Closet Logics: Hidden Conceptual Elements in the DSM and ICD Classifications of Mental Disorders’ in John Z Sadler, Osborne P Wiggins, and Michael A Schwartz (eds), Philosophical Perspectives on Psychiatric Diagnostic Classification (Johns Hopkins University Press 1994).

(4) See American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (5th edn, American Psychiatric Association 2013) 161.

(5) Anthony Colombo and others, ‘Evaluating the Influence of Implicit Models of Mental Disorder on Processes of Shared Decision-making within Community-based Multidisciplinary Teams’ (2003) 56 Social Science and Medicine 1557. The values aspects of the study are described in K W M Fulford and Anthony Colombo, ‘Six Models of Mental Disorder: A Study Combining Linguistic-Analytic and Empirical Methods’ (2004) 11(2) Philosophy, Psychiatry, & Psychology 129.

(6) An account for non-clinicians of the main diagnostic concepts of depression is given in K W M Fulford, Tim Thornton, and George Graham, ‘Experiences Good and Bad: An Introduction to Psychopathology, Classification and Diagnosis for Philosophers’ in K W M Fulford, Tim Thornton, and George Graham (eds), The Oxford Textbook of Philosophy and Psychiatry (Oxford University Press 2006) ch 3. This includes a number of brief clinical examples of the main clinical concepts of depression (34 ff).

(7) Matthew Ratcliffe, Experiences of Depression: A Study in Phenomenology (Oxford University Press 2015) 265.

(8) Giovanni Stanghellini and Marco Bertelli. ‘Assessing the Social Behavior of Unipolar Depressives: The Criteria for Typus Melancholicus’ (2006) 39 Psychopathology 179.

(9) Andrew Moore, Tony Hope, and K W M Fulford, ‘Mild Mania and Well-being’ (1994) 1(3) Philosophy, Psychiatry, & Psychology 165.

(10) William Styron, Darkness Visible (Jonathan Cape 1991).

(11) Gerald G May, The Dark Night of the Soul: A Psychiatrist Explores the Connection Between Darkness and Spiritual Growth (Harper Collins 2004).

(12) Lauren Alloy and Lyn Abramson, ‘Judgment of Contingency in Depressed and Nondepressed Students: Sadder but Wiser?’ (1979) 108 Journal of Experimental Psychology 441. For a helpful discussion of the contested concept of ‘depressive realism’ see Ratcliffe (n 7) 273 ff.

(13) Kay Redfield Jamison, Touched With Fire: Manic Depressive Illness and the Artistic Temperament (Free Press Paperbacks, a division of Simon and Schuster 1994).

(14) Piers Allott, Linda Loganathan, and Bill Fulford, ‘Discovering Hope for Recovery’ (2002) 21 Canadian Journal of Community Mental Health 13.

(15) See Fulford, Peile, and Carroll (n 1).

(16) See valuesbasedpractice.org (last accessed 2 March 2017).

(18) Thomas S Szasz, Law, Liberty and Psychiatry: An Enquiry into the Social Uses of Mental Health Practices (MacMillan 1963).

(19) Among the first to document these abuses were Sidney Bloch and Peter Reddaway, Russia’s Political Hospitals: The Abuse of Psychiatry in the Soviet Union (The Camelot Press 1977).

(20) K W M Fulford, ‘Evaluative Delusions: Their Significance for Philosophy and Psychiatry’ (1991) 159 British Journal of Psychiatry 108.

(21) David Rosenhan, ‘On Being Sane in Insane Places’ (1973) 179 Science 250.

(22) K W M Fulford, Lisa Bortolotti, and Matthew Broome, ‘Taking the Long View: An Emerging Framework for Translational Psychiatric Science’ (2014) 13 World Psychiatry 108.

(23) Thomas Insel, ‘Transforming Diagnosis’ www.nimh.nih.gov (last accessed 3 March 2017).

(24) K W M Fulford, Alex Smirnov, and Elena Snow, ‘Concepts of Disease and the Abuse of Psychiatry in the USSR’ (1993) 162 British Journal of Psychiatry 801.

(25) For a clear account of the strengths and limitations of this approach see ch 1 in Geoffrey Warnock, J L Austin (Routledge 1989).

(26) G Stanghellini and M R Broome, ‘Psychopathology as the Basic Science of Psychiatry’ (2014) 205 British Journal of Psychiatry 169.

(27) Kurt Schneider, Clinical Psychopathology (5th edn, Grune & Stratton 1959). See also A Kraus, ‘Schizo-affective Psychoses from a Phenomenological-anthropological Point of View’ (1983) 16 Psychiatria Clinica 265.

(28) Josef Parnas and Louis Sass, ‘Self, Solipsism, and Schizophrenic Delusions’ (2001) 8 Philosophy, Psychiatry, & Psychology 101. See also Giovanni Stanghellini and Andrea Raballo, ‘Differential Typology of Delusions in Major Depression and Schizophrenia. A Critique to the Unitary Concept of “Psychosis” ’ (2015) 171C Journal of Affective Disorders 171.

(29) K W M Fulford, Sarah Dewey, and Malcolm King, ‘Values-based Involuntary Seclusion and Treatment: Value Pluralism and the UK’s Mental Health Act 2007’ in John Z Sadler, Werdie van Staden, and Bill Fulford (eds), The Oxford Handbook of Psychiatric Ethics (Oxford University Press 2015).

(31) The problems created by overly risk averse use of the Mental Health Act 2007 have been highlighted in a series of publications: see eg Royal College of Psychiatrists, Rethinking Risk to Others in Mental Health Services: Final Report of a Scoping Group. College Report CR150 (Royal College of Psychiatrists 2008); NESTA, The Challenge of Co-production: How Equal Partnerships between Professionals and the Public Are Crucial to Improving Public Services (NESTA 2009); and Care Quality Commission, Monitoring the Mental Health Act in 2010/11: The Care Quality Commission’s Annual Report on the Exercise of Its Functions in Keeping Under Review the Operation of the Mental Health Act 1983 (Care Quality Commission 2011).

(32) Isaiah Berlin, Two Concepts of Liberty (Clarendon Press 1958).

(33) House of Lords Select Committee on the Mental Capacity Act 2005, Report: Mental Capacity Act 2005: Post-legislative Scrutiny (House of Lords 2014).