Situating evaluativism in psychiatry: on the axiological dimension of phenomenological psychopathology and Fulford’s value-based practice

ABSTRACT

Evaluativists hold that psychiatric disorders have a factual and evaluative dimension and recognize that psychiatric patients have an active role in shaping their symptoms, influencing the development of their disorders, and the outcome of psychiatric therapy. This is reflected in person-centered approaches that explicitly consider the role of values in psychiatric conceptualization, classification, and decision-making. In this respect, in light of the recent partnership between Fulford’s value-based practice (VBP), and Stanghellini’s phenomenological-hermeneutic-dynamical (P.H.D) psychotherapy method, this paper presents a comparative analysis of two person-centered approaches to psychiatric care currently discussed within the literature. I claim that while these approaches share some core ideas, they also present important divergences concerning their axiological underpinnings, which could potentially compromise their partnership. In particular, by exploring their theoretical, practical, and ethical dimensions, I show that these models have different conceptions of what values are, which, in turn, affect their understanding of how values relate to the person and how clinicians can identify them. Finally, I argue that although Fulford’s and Stanghellini’s approaches are prima facie compatible and complementary, developing a “combined analytic-plus-phenomenological form of values-based practice” should address fundamental conceptual issues if it is to become a consistent and coherent method for psychiatric care.

KEYWORDS:

• Evaluativism
• phenomenological psychopathology
• Fulford’s value-based practice
• axiology
• personal values
• person-centered care

1. Introduction

In their conceptual taxonomy, Zachar and Kendler (2007) argue that one of the “critical dimensions of psychiatric classification” is represented by the opposition between objectivism and evaluativism.¹ Indeed, a major issue in the philosophy of psychiatry is whether the attribution of mental disorders is a “simple factual matter”, namely, it is based on discoverable facts about psycho-physical states and processes, or a “value-laden judgment”, depending on socio-cultural and legal norms as well as personal values (2007, p. 558).² Broadly, the evaluativist critique of the objectivist model of psychiatric phenomena does not concern only the ontological problem of whether mental disorders can be identified with empirically discoverable entities. It also aims at uncovering what de facto drives, influences, or motivates psychiatric theory and clinical practice. The general philosophical question then is not just whether values should figure in psychiatry nosology but what role they play and how we individuate them.

Arguably, this marginal or generally ancillary place of consideration of values in health care can be explained by two main factors: 1) the positivist paradigm dominating medical science that has traditionally neglected the roles of non-empirical principles or norms in favor of the idea of impartial observation, quantitative measurement, and causal determination (cf. Canguilhem & Fawcett, 1943/1991; Ingleby, 1981); 2) the rising bureaucratization of medical practices connected to the development of national health systems and the origin of medical associations that set general recommendations and professional codes reflecting socio-cultural and political ideals (cf. Fulford, 1993; Sadler, 1997, pp. 541–542). Against this background, evaluativism in psychiatry broadly developed by uncovering value assumptions of widespread psychiatric classifications and research programs (cf. Sadler, 2005, 2013) and investigating the role of values in psychiatric reasoning and decision-making, with specific attention to the diagnostic, therapeutic, and monitoring phases of the clinical encounter (cf. Fulford, 2004; Fulford et al., 2012).

While the first group of studies focuses on the conceptual assumptions of psychiatric classification, the other is more concerned with psychiatric practice. These two interrelated strands of research share a similar intention: to “augment the evaluative rigor of classification efforts in psychiatry.”³ (Biddle, 2013; Douglas, 2000; Sadler, 2002, p. 5) Arguably, by disclosing hidden value agendas in mental health care, evaluativists’ main intention is not to abolish psychiatric classifications or undermine psychiatric validity. On the contrary, they aim to make explicit those non-factual principles or norms that ultimately contribute to the construction of psychiatric knowledge raising the awareness of those implicit principles that guide diagnostic and therapeutic decisions. From this perspective, evaluativism sets an epistemic and ethical task altogether, because, by understanding how psychiatric evidence is built, it aims at identifying those socio-political and cultural interests that influence psychiatric theory and practices, favoring the identification of possible discriminatory ideologies.

Broadly, the spectrum of evaluativist positions can be conceptualized by speculating on how the relationship between factual descriptions of neuro-bio-psychological states or processes and consideration of socio-cultural or personal values can be conceived.⁴ Since under the label of “evaluativism” we find a plurality of diverse approaches, expressing different assumptions, methodologies, and research questions, one main problem regards, for instance, to what extent or in what sense these accounts are equivalent, compatible or complementary (cf. Amoretti & Lalumera, 2021).⁵ For this reason, in this paper I investigate the axiological standpoints of two prominent approaches to psychiatric practice by focusing on how they conceptualize their core notions. This issue is particularly relevant in light of the recent partnership between distinct research traditions such as linguistic or analytic evaluativism, paradigmatically expressed by Fulford’s value-based practice (VBP), and phenomenologically oriented approaches, represented in this paper mainly by Stanghellini’s phenomenological-hermeneutic-dynamical (P.H.D) model of psychotherapy (cf. Messas & Fulford, 2021; Messas et al., 2023; Fulford & Stanghellini, 2019, 2020, cf.; Stoyanov et al., 2021).⁶

Although phenomenologically oriented psychiatry is not traditionally regarded as a form of evaluativism, it resonates with some of its fundamental tenets. For instance, Stanghellini shares with Fulford the idea that the concept of mental disorder is relatively value-laden compared to the notion of bodily disorder because: 1) psychiatric classification and diagnosis entails also moral considerations, as in the case of forensic psychiatry and involuntary psychiatric treatment, and 2) because current DSM criteria include evaluative concerns, such as whether one’s behavior is socially dysfunctional (cf. Fulford etal., 2005, p. 78). In addition, they also share the ideas that 3) values are action-guiding in the sense that our decisions are driven not only by considerations based on facts but also on our principles, norms, ideals; 4) personal values contribute to shaping psychopathological symptoms and therefore are crucial for formulating an effective diagnosis and articulating ad-hoc therapeutic intervention; 5) clinical decision-making should be informed by clinicians and patients’ values and should not be driven by a priori moral codes reflecting socio-cultural or political standards (cf. Fulford & Stanghellini, 2019, 2020; Stanghellini & Aragona, 2016).

Against this background, Fulford and Stanghellini, considering a potential partnership between their approaches, acknowledge that “the connections between the phenomenology of values and values-based practice remain potential” while emphasizing that “there is no barrier of principle to such connections being made” (2019, p. 364). Therefore, they claim that “a combined model” can “build on the many methodological and other points of contact between these two traditionally opposed disciplines” (2020, pp. 172–173). However, as this paper will argue, significant differences exist between Stanghellini’s phenomenological and Fulford’s analytic-linguistic approaches. Within the context of psychiatric evaluativism, this paper contributes to understanding the relationship between the phenomenology of values and values-based practice by providing a detailed analysis of the similarities and differences between Fulford’s and Stanghellini’s approaches, investigating their philosophical presuppositions.

Specifically, I claim that although Fulford’s analytic-linguistic and Stanghellini’s phenomenological model are prima facie compatible and indeed complementary in the appropriate contexts of application, a “combined analytic-plus-phenomenological form of values-based practice” (Fulford & Stanghellini, 2020, p. 169) should address fundamental conceptual issues if it is to become a consistent and coherent method for psychiatric care.

This is because, as I argue, there exist differences concerning the definition of what values are in the first place, how they relate to the person, and how clinicians can identify them, as well as the idea that there exist universal values fundamental for human flourishing. Therefore, despite the potential for compatibility, it is worth considering whether the conceptual differences on the matter of values could have implications for clinical practice and ethical considerations, especially for the identification of patients’ individual values and the process of clinical decision-making. To achieve the objective of clarifying the potential implications these conceptual differences hold for the practical and ethical aspects of patient care, I focus on three main dimensions for comparing Fulford’s and Stanghellini’s approaches.⁷

The first dimension regards the status of psychiatric knowledge. In particular, in the first section, I explore Fulford’s evaluativist critique of the assumption that psychiatric diagnoses can be entirely objective and that psycho-physical states can be objectively deemed “dysfunctional”. In this respect, I show that Fulford’s critique is compatible with the phenomenological psychopathological critique of psychiatric objectivism. For Fulford, as for the phenomenological approach, the attribution of mental disorders cannot be independent of social or cultural considerations. However, exploring Fulford’s critique of psychiatric objectivism provides an opportunity to uncover his philosophical stance regarding values. In this sense, I show that Fulford’s non-cognitivist perspective is at odds with the phenomenological understanding of values. Despite important variations, phenomenological approaches generally reject the idea that values are simply subjective prescriptions to be investigated “psychologically”. Within phenomenology, values are conceived as intentional achievements of our affective interaction within the life-world that have determinate conditions of self-evidence connected to their mode of givenness (cf. J. Drummond, 2014, 2021, 2018; Ferran, 2022).

Consequently, in the second section, I further expand on the impact of these two different conceptions of values by focusing on the clinical dimension, in particular, on the problem of identifying patients’ individual values, for improving the quality of diagnostic assessments and the effectiveness of the therapeutic intervention. Specifically, I claim that the conceptual limitations of Fulford’s analytic-linguistic approach become evident when value-based practice is applied to particular clinical cases, for instance, to “medical conditions that shift or erode values” (Wieten, 2015, p. 2). Therefore, I show in what sense Stanghellini’s P.H.D. method reveals to be particularly suitable by providing a “depth dimension of affective and conative understanding of values” (Fulford & Stanghellini, 2020, p. 172). Broadly, I claim that phenomenological psychopathology can make sense of general dispositions and characterological attitudes associated with psychopathological conditions that transcend individual value-commitments because it possesses the conceptual resources for identifying disorder-specific value-systems. In this sense, I show in what sense Fulford’s and Stanghellini’s approaches are complementary. However, in this respect, I identify some challenges for the phenomenological approach.

Finally, in the third section, I move to consider the ethical dimension connected with the problem of justifying the values driving clinical decision-making. Notably, I analyze the question of what ethical principles guide psychiatrists in making diagnostic and therapeutic decisions. In this regard, I show that while Fulford’s value-based practice (VBP) seems neutral for what concerns any ideal of health and well-being, Stanghellini’s approach implies an idea of human flourishing rooted in Ricœur’s ontology of the self (1992, 2005, 2010). In this sense, I claim that the concept of “the good life”, as based on a “teleology of recognition” has normative implications for the concept of recovery. While this may have an impact on clinical decision-making and therapeutic processes, I argue that insofar as Fulford’s approach remains “electively unclear” on what values are, it is prima facie compatible with this concept of recovery.

As I further contend in the paper’s conclusion, the partnership between linguistic-analytic value-based practice and phenomenological psychopathology presents conceptual challenges. Indeed, as Fulford and Stanghellini (2019, 2020) acknowledge, these two approaches to psychiatry are grounded on apparently opposing philosophical traditions such as phenomenology and the Oxford School of ordinary language philosophy. Indeed, as I show in the paper, Fulford’s concept of value, as it is based on Hare’s understanding, does not seem compatible with a phenomenological interpretation. Yet, while these differences exist, they shouldn’t prevent the development of a model that integrates both analytic and phenomenological methods in value-based care. Rather, these divergences call for an explicit clarification of the core notions of value that can be shared between these two distinct approaches, especially considering that these two philosophical traditions are not totally extraneous to each other (cf. Leeten, 2022).

2. The evaluative dimension of psychiatry knowledge: the problem of conceptualization and classification

Broadly conceived, psychiatry objectivism holds that mental disorders are best studied through an empirical, third-person perspective (epistemological thesis) and often implies a physicalist argument according to which mental disorders can be reduced to a neuro-biological dimension (ontological thesis) (cf. Berrios, 2014; Parnas & Sass, 2008). Arguably, for the objectivist, the progress of psychiatric knowledge would be measured against the exclusion of any kind of non-factual evaluation, which would represent only a contextual factor for the development of psychiatric science. On the contrary, for the evaluativist, the attribution of psychiatric disorders implies value judgments, at least that “something is wrong with a person” (Nielsen, 2020, p. 55). In this view, mental disorders cannot be just about neuro- or bio-psychological states or processes – as a strong objectivist position may claim – since they also entail some kinds of evaluations.⁸

In this section, I discuss Fulford’s critique of psychiatric objectivism, and I compare it with the phenomenological perspective. As I show, both approaches challenge the objectivist ideas that a) mental disorders can be reduced to somatic disorders or disorders within the body and b) considerations of value are marginal or even detrimental to psychiatry knowledge. Sharing this common objective, they present a similar understanding of the reason why psychiatric knowledge cannot be free of values. However, by reconstructing Fulford’s critique, I also illustrate how his understanding of value diverges from that discussed within phenomenology, especially as it is based on Husserl’s phenomenological axiology.

2.1. The priority of illness over disease and the phenomenal origin of psychiatric knowledge

In his seminal work, Moral Theory and Medical Practice (1989), Fulford criticizes the priority assigned to the notion of physiological dysfunction by the disease model of medicine. In particular, Fulford argues that the concept of illness, which denotes “the patient’s direct experience of something wrong, […] normally precedes a clinical diagnosis of what is wrong in terms of particular diseases, so, in the logic of medicine it is illness which comes first.”⁹ (1989, pp. 262–263) This is reflected in the fact that, in the assessment of a medical condition, pathophysiological and etiological considerations are derivative of symptomatologic and phenomenological observations. The priority granted to the experience of mental disorder as illness over its conceptualization as a disease certainly echoes the phenomenological perspective on psychiatric knowledge. In this regard, as Fulford contends, the notion of illness, contrary to that of disease, is an overtly evaluative concept because of its reference to subjectivity through the patient’s lived experience of disease. Phenomenologically oriented psychiatry has a long history dating back to Jaspers’ Introduction to General Psychopathology originally published in 1913. However, in the phenomenological tradition of psychopathology, we do not find a specific focus on the evaluative understanding of psychiatric conceptualization. At least, not in the manner found in Fulford or Sadler.¹⁰

Yet, the phenomenological approaches to the conceptualization of mental disorders share with Fulford’s critique the idea that the evaluative component of psychiatric knowledge lies in the interpretation of the experience of illness, namely, in the meaning of patients’ suffering. According to the phenomenological approach, in psychiatry, the phenomenal dimension has an epistemological priority because is the locus or the “phenotypical level” of the originary manifestation of mental disorders (Parnas et al., 2013, p. 270). From this perspective, psychiatric knowledge is built through a descriptive work that translates the patient’s psychopathological experience and expressions, recounted through a first-person perspective, into impersonal categories from which psychiatric knowledge derives his “objective” status. Making sense of the patient’s symptoms and manifestations for psychiatric diagnosis and treatment, clinicians are confronted with the singularity or uniqueness of human beings as persons, with their existence and life-word. Therefore, for the phenomenological approach, mental disorders first consist of abnormal lived experiences associated with the patient’s expressions and therefore it is meaningless to talk of mental disorders as a mind-independent notion.

In this respect, it is worth mentioning that phenomenology does not share with objectivism the same notion of “description” and “reality”. Broadly, metaphysical objectivism adheres to the idea of an independent, objective reality that exists wholly separate from the mind (cf. Sober, 1982). Its concept of description aims to capture this reality accurately and neutrally, devoid of individual interpretations or subjective experiences. Phenomenology, in contrast, takes a radically different perspective, since it views “reality” via the sense-giving acts of our lived experience, placing the individual’s subjective consciousness at the foundation (cf. Zahavi, 2010b). As Husserl writes, “Every sort of existent itself, real or ideal, becomes understandable as a ‘product’ of transcendental subjectivity, a product constituted in just that performance”¹¹ (Husserl & Cairns, 1960, p. 85) Therefore, for the phenomenological approach, the concept of objectivity as entailing the existence of a mind-independent reality presupposes “to engage in a kind of cancellation of one’s own subjectivity” (Moran, 2013, p. 105).

Limitedly to the critique of psychiatric objectivism, Fulford share the phenomenological perspective since he pinpoints an irreducible “subjective” element intrinsic to the notion of bodily dysfunction. Notably, Fulford argues that if mental diseases are conceived as bodily dysfunctions, which are defined, in turn, against the “normal function” of an organism through the reference to some assumed “goals”, then psychiatry objectivism remains the victim of an implicit teleology, because “a goal is something which (in itself) it is good to hit and bad to miss” (2001, p. 83). In this sense, for Fulford, objectivists like Boorse (1975) cannot provide a value-free account of mental disorders because any medical account of health and disease would necessarily include evaluative considerations. In this respect, the legacy of phenomenological psychiatry traditionally contested the positivistic ideals of a value-free science of mental disorders. For Jaspers, contrary to somatic medicine, in psychiatry establishing what is healthy on the basis of the statistical average is highly controversial because of the “multiplicity of ‘psychic standards’” that implies “much greater fluctuations in what should be styled as ‘psychically sick’” (1963, p. 783). Jasper argues that, by lacking precise norms, psychiatrists tend to use their “instinctive attitudes and personal intuitions” to assess the pathogenicity of a condition. Consequently, the working notion of health in psychiatry hides specific value standards that do not derive from empirically discoverable norms but result from an implicit teleology of life (1963, pp. 782–783).

Therefore, for Jaspers, while psychiatry, as science, aspires to be essentially typifying and normalizing, because it aims to “know, recognize, describe and analyze general principles rather than particular individuals” (1963, p. 1), as clinical practice, it remains value-laden for epistemological reasons. Indeed, Jaspers believes that “the separation of observation and value-judgment” or the “pure appreciation of the facts” should remain the heuristic principle of any scientific endeavor.¹² Similarly, for Fulford, “medicine is more than science” because medical notions, such as illness and disease, inherently carry evaluative implications. In this sense, to him, values constitute the “non-scientific aspects of medicine” (Fulford, 1989, p. 52). However, there is a significant difference in how Fulford and phenomenology frame the concept of values. While both acknowledge that values cannot be entirely separated from the concept of mental health, Fulford adopts a non-cognitivist and anti-realist stance, which is generally rejected within phenomenological philosophy (cf. J. J. Drummond, 2021; Rinofner-Kreidl, 2016). To understand Fulford’s idea of values, let’s focus on his critique of the naturalization of the concept of mental disorder.

2.2. Prescriptivism and phenomenological axiology

Fulford develops his philosophical ideas about values through his critique of psychiatric objectivism. This is achieved by arguing against the naturalization of value judgments and value predicates implicit in psychiatric diagnosis, for instance, when a psycho-physical state is deemed as an “undesirable” state by some descriptive standards. Fulford’s main strategy entails questioning “whether any expression of value (including ‘ought’) may ever be defined purely descriptively (in terms of ‘is’)” (Fulford, 1989, p. 36). Briefly, Fulford argues that attributing positive or negative values to purely factual descriptions of an organism’s state constitutes a logical fallacy because value predicates do not refer to real or natural properties but are expressions of persons’ choices. Notably, Fulford’s critique is based on an argument originally developed in analytic metaethics by Moore and differently reinstated by Hare. For Moore moral or evaluative property in general are, ultimately, “simple, unanalysable, indefinable” non-natural properties (ibidem, p. 89), that cannot be reduced to factual properties.¹³ By reworking Moore’s ideas, Hare develops the idea that language can have a descriptive and evaluative function. With descriptions, we convey factual information about states of affairs or objects, and descriptive meaning is defined by its relation to truth conditions. In the case of evaluations, we commend, as in the case of “X is good” or prescribe, as in the case of “it is right to do X” (Hare, 1952, pp. 127, 129).

For Hare, evaluations are not meant to inform but to teach value standards that guide our choices and that of others (1965, p. 194). In his prescriptivist view then, descriptions and evaluations mean different things, standing as different functions of language.¹⁴ Therefore, while Hare recognizes that evaluations are logically dependent on descriptions because evaluative properties supervene on descriptive properties (cf. Hare, 1984),¹⁵ he denies any logical relationship of “entailment or identity of meaning” between a set of descriptions and value words (1952, p. 145). On this background, Fulford uses similar arguments in favor of the distinction between facts and values and proposes an anti-descriptivist understanding of the concept of mental disorder. By drawing on Hare, Fulford argues that we attach descriptive meaning to value words by adoption so that if our value judgments include descriptive criteria, these criteria are ultimately an expression of subjective choice (1989, pp. 49, 50, 54). Against this backdrop, objectivists encounter a hurdle when attempting to reduce value-laden conditions like disability to mere neuro- or bio-psychological states or processes. This challenge arises because value-laden terms are ultimately about subjective preferences that express specific value standards rather than stating natural facts. For Fulford, following Hare, evaluations are inherently relative to individuals’ unique positions, and understanding them necessitates addressing a “psychological question” (Fulford, 1989, p. 55). This is the reason why, for Fulford, any evaluative assessment of a psychiatric condition cannot be deemed “objective” in the sense of being satisfied by definite descriptions.

However, the value-fact dichotomy as it is reinstated by Fulford via Hare and Moore, has been criticized in phenomenology (cf. Rinofner-Kreidl, 2016). The idea that we cannot derive an “ought” from an “is”, namely “Hume’s law” (Hume et al., 1975, 1978), as a paradigmatic antecedent of Moore’s critique to the “naturalistic fallacy”, had been challenged since Husserl’s early lectures in ethics (cf. Husserl, 1989; Husserl, 1988).¹⁶ In this sense, I briefly expand on the concept of value as it is discussed in phenomenology to show how this differs from that used by Fulford. Within Husserl’s perspective, values, or what is generally deemed to be worthy or unworthy, are to be conceived as achievements of intentional activity and cannot be reduced to needs or desires. Before being expressed in linguistic forms, values are experienced through intentional feelings, as in the “delighting devotion” of a feeling attitude, that is “that feeling in which the Ego lives with the consciousness of being in the presence of the Object ‘itself’ in the manner of feelings” (Husserl et al., 1989; p. 11; cf. Ferran, 2022). However, what is important is that by acknowledging “normative differences” („normativen Unterschiede“) in relation to the acts of feeling (Gefühlsakten) (Husserl, 2004, p. 220; cf. Montagova, 2012), in phenomenology there is the idea that value judgments can be true or the false, correct or incorrect.

Indeed, what is central to this phenomenological conception is that, as Husserl observes, there is an intrinsic lawfulness (Gesetzmässigkeit) in our feelings and emotions. Our emotional experience is not chaotic since emotions and feelings have their intentionality and are not compatible with arbitrary objects. Therefore, for phenomenology, value judgments can be justified on the basis of the evidence of the feelings which show that values “belong” to the objects of our experience (Cf. J. Drummond, 2014, 2021, 2018; Guardascione, 2022).¹⁷ This philosophical position does not seem compatible with Fulford’s account, since for him value judgments are not truth-apt. Fulford, by drawing mainly on Hare, denies that value judgments can be true or false, and, in so doing, takes evaluations as subjective expressions. In other words, for him, values do not belong to the world of facts. Instead, at least in Husserl’s phenomenological approach, there is the idea that value judgments have truth conditions that must be searched, ultimately, in our affective engagement with reality, and precisely, in the normativity of emotions. Furthermore, differently from Fulford, for a phenomenological approach to value, the understanding of individual evaluative judgments or position-takings cannot be reduced to a psychological problem, to an explanation of psychic events. Rather, it entails an intentional analysis directed toward the structure of experience as constituting one’s life-world.¹⁸ While I cannot develop this point further, it is worth pointing out that phenomenological philosophy presents a rich account of evaluative intentionality, that is, the acts of consciousness involved in value-taking (Wertnehemen) (cf. J. Drummond et al., 2021, 2018).

Some ideas of phenomenological axiology have been taken up and reworked by contemporary authors ascribed to the legacy of phenomenological psychopathology, such as Stanghellini (cf. 2016; Fulford & Stanghellini, 2019, 2020; Stanghellini & Ballerini, 2007). For instance, by drawing mainly on Ricœur’s hermeneutic phenomenology, for the latter, values, understood as personal evaluative position-takings, “form a structure that is rooted in the person’s ontological constitution: they form a rather coherent order and as such they suffuse and organize the person’s emotions” (Stanghellini & Ballerini, 2007, p. 132). In this respect, Stanghellini acknowledges the normative aspects of emotions, as providing “information about the world and about me as a person” (Stanghellini & Rosfort, 2013, p. 172). Consequently, it can be understood why phenomenological psychopathology is more resourceful when it comes to understanding and making sense of patients’ value commitments. This is because it presents an account of affective and evaluative intentionality that cannot be found in Fulford’s analytic-linguistic value-based practice. As I show in the next section, the difference between Fulford’s and Stanghellini’s views on values, rooted in their respective philosophical traditions, is echoed in the way they access and interpret patients’ experiences, especially in deciphering what matters most to them.

3. On the identification of individual value-commitments and general value-orientations in psychiatric patients

Evaluativists believe that diagnosing mental disorders involves value judgments about harm and desirability. They advocate for a person-centered approach to mental health care, taking patients’ values and goals into account in treatment. On this background, a fundamental task of evaluativist accounts is to identify patients’ inner cares and concerns and increase psychiatrists’ awareness about their individual values, which provide, together with the analysis of the patients’ symptoms and signs, the basis for grounding clinical decisions. However, while both Fulford’s analytic-linguistic and phenomenological evaluativist positions recognize the active role of psychiatric patients in shaping their symptoms and orienting therapy, they differ in the identification of patients’ individual values. As I show in this section, this is due to conceptual differences concerning their underlying value theories. In this sense, their approaches differ not only in the definition of the notion of value but also in the epistemic access to patients’ individual values. In particular, I discuss some limitations of Fulford’s model that can be overcome by integrating phenomenological considerations. In this sense, I show in what sense Fulford’s analytic-linguistic approach can be complemented by Stanghellini’s P.H.D. method. Notably, differently from linguistic-analytic value-based practice, Stanghellini’s approach can make sense of conditions that “shift or erode values” because can provide a model for understanding patients’ psychopathological transformation of lived experience and deciphering, in this sense, disorder-specific value-systems. However, I further consider some challenges linked to the phenomenological approach to patients’ values.

3.1. Understanding what matters by the means of language

Fulford’s Value-Based Practice (VBP) is a skill-based approach that aims to detect and identify explicit or implicit value commitments on the side of service users, providers, and other potential stakeholders, to support clinical decision-making. Specifically, Fulford’s value-based practice (VBP) focuses on identifying the clinical skills that may favor a process of value-informed decision-making. These skills include fostering “the awareness of where what, and how values come into healthcare” (Fulford, 2004, p. 67), through particular attention to the language used in the clinical encounter; the capability of discerning values “bearing, or likely to bear, on a given decision in a given context” (ibidem, p. 70); ethical reasoning and communication skills^.⁠ Since Fulford’s value theory is based on the linguistic analysis of ordinary language, his understanding of individual values, whether of patients or clinicians, is restricted to a verbal dimension centered on the identification of value terms, judgments, or expressions. In this respect, Fulford takes personal values as what patients and clinicians simply consider as such, so to include needs, desires, wishes, and preferences (Fulford et al., 2012, pp. xiii, 5–7).

Fulford’s philosophical value theory may seem to have a prima facie pragmatic advantage in capturing individual values. Indeed, it stems from a linguistically driven empirical investigation that directly engages with patients and clinicians involved in psychiatric practice leaving aside theoretical considerations about what values are. The attribution of value terms to objects, states, or persons, by patients and clinicians through ad-hoc exercises and discussions is then sufficient for having the conversation started. As a result, value judgments or -terms emerging from the dialogic engagement between psychiatrists and patients would provide some ground to inform clinical decision-making. Yet, this method is theoretically problematic. As Brecher (2011, p. 996) has objected, focusing on the use rather than defining the concept of values makes it difficult to distinguish between values and needs. There is a reason why cognitive or conative objects, whether appetitive or volitive cannot be simply equated to individual values. For instance, I may need something that I utterly disvalue or that I have never considered in the perspective of a value worth pursuing. Eating or sleeping as biological needs do not constitute personal values per se unless they are recognized as such. Therefore, either we consider all needs as kinds of values, or we must use a discriminating criterion to differentiate those needs, desires, wishes, or preferences that acquire a determinate value for an individual.

One may object that there is a risk of generating ambiguities or contradictions that can be misleading to clinical practice because it is unclear, for instance, what practitioners should understand as constituting patient-specific value-commitments. Indeed, it is far from evident how and what interpretative tools are used to decipher hidden or non-intentional (unconscious) values (cf. Lesser, 2014, p. 123) resulting from personal inclinations (cf. Fulford, 2014a, p. 161). Another epistemological problem may concern the truthfulness of patients’ narratives. On what basis they can be trusted? In addition, as for any dialogical or narrative approach, non-compliant patients would represent a difficulty as patients with low linguistic competence. While de iure, everything can potentially constitute a value for an individual, it is reasonable to ask whether there must be an evaluation that bestows to objects of experience their worthiness or unworthiness. In this respect, Fulford’s value-based practice does not seem to have the conceptual resources to individuate how individual values are constituted in the first place. In this regard, it is dubious whether the “three words” exercise would suit the task (Fulford, 2014b, pp. 14–15;, pp. 4; Fulford et al., 2012, pp. 4, 193).

For Fulford indeed asking the patients and trainees to write a list of what the term “value” means for them would produce the “(locally) minimal characterization” of the meaning of value in value-based practice (Fulford, 2014a, p. 162). However, whatever evidence is produced by this exercise, is unconvincing. Even if the exercise is propaedeutic for a group discussion, it is not clear how it would deliver knowledge on individual values, since patients or trainees may not be aware of what they actually value. If the threat of self-deception may be weakened by improving the design of this exercise, without properly addressing the nature of evaluative experience analytic-linguistic approaches remain unsatisfactory. Moreover, in Fulford’s model, there are no theoretical grounds for assessing whether clinical interviews or group discussions are successful or not, namely, whether would capture individual values. Indeed, the most important consequence of a linguistic understanding of individual values is that it provides “insufficient information about how to proceed in the face of medical conditions that shift or erode values” (Wieten, 2015, p. 2).

In this respect, Fernandez and Wieten (2015) show that value-based practice (VBP) may be exposed to “the failure of addressing the shifting nature of values or diminished ability to have values at all that occur in disorders such as depression in several ways.” (ibidem, p. 512) They argue that mental disorders can transform individuals’ value-systems or hierarchies and even individual capacity to make or hold their value-commitments. If the person as a valuer is compromised, how do we consider her choices and preferences? In other words, if the person is not accountable for the values she seems to endorse, how is taken into consideration in the clinical decision-making process? These kinds of questions remain unanswered in the value-based practice (VBP) approach or, at least, represent a marginal concern.

This is due to the fact that Fulford’s value-based practice (VBP) remains “electively unclear” not just on what values are but on the conception of evaluative experience in general. In this respect, Fulford admits an explicit self-limitation of his approach which is expressed by his intention to “eschew claims to final or complete or definitive views and the cramping orthodoxies such claims seek to justify” (Fulford, 2014b, p. 15). Yet, one may wonder whether his concern refers more to the ethical problem of whether there exist universal values that ought to be pursued rather than the axiological question of what values are and how we come to know them. An ambiguity remains in this respect since this does not seem to be articulated in the literature. However, as I demonstrate in the following subsection and Section 3, arguably, it is because of this ambiguity – specifically, Fulford’s deliberate decision to keep his value-based practice (VBP) “electively unclear” – that it can be complemented by other methodologies providing a more structured understanding of values, such as that found in Stanghellini’s psychotherapy model.

3.2. The phenomenological exploration of patient’s lived experience

Contrary to Fulford’s approach, which seems to eschew the conceptual problems implied in a theory of value, providing no clear definition of this core notion, in the phenomenological tradition Stanghellini relies on a structured value theory for understanding and framing patients’ values. Stanghellini’s conception of value is mainly grounded on an interpretation of Ricœur’s theory of subjectivity (Stanghellini & Rosfort, 2013, p. 5; cf. Stanghellini, 2016). According to Ricœur, personal identity is the precarious product of the continuous dialectic between selfhood (or the voluntary/activity) and otherness (or the involuntary/passivity) (cf. Ricœur & Blamey, 1992, pp. 1–25, 297–356). On his account, the human being is characterized by an originary disproportion between the mind, expressing spiritual values and desires, such as that for “well-being” or “good life” (cf. Ricœur & Blamey, 1992, pp. 171–202), and the body understood as the source of biological values and desires, such as those associated with for “self-preservation” (Stanghellini & Rosfort, 2013, p. 89; cf. Ricœur & Savage, 1970, pp. 124, 127, 283, 290, 308–09).

The voluntary and involuntary dimensions of the human being are linked with “two fundamental affective projects” (Ricœur & Kelbley, 1986, p. 132). Whereas biological values and consequently vital desires, which instruct and motivate our “will to live”, are directed toward an “instantaneous perfection of pleasure”, spiritual values and desires tend toward “perfection of happiness”. (Ibidem) Beyond organic values, represented, for instance, by the person’s sexual preferences, we also find two other kinds of values belonging to the involuntary dimension of the human being and specifically linked with the person’s history and his or her place in the social world. In this respect, both historical values, such as family values, and social values, or the principles regulating society including social roles, are stratified in the person’s experience through habits (Stanghellini & Mancini, 2017; pp. 33-34; cf. Husserl et al., 1989, pp. 118–119, 189–191, 324; 1973, pp. 52, 121–124, 275–284). Since we are exposed to heterogeneous values that are the product of both voluntary and involuntary factors which do not always result from our active choices or deliberations, for Stanghellini “human values” are ultimately characterized by a “kind of non-transparency” (Stanghellini & Rosfort, 2013, p. 201).

From this general axiology, Stanghellini’s phenomenological – hermeneutical – dynamical (P.H.D.) approach to psychotherapy identifies patients’ existential orientation and personal values through a process of progressive “self-objectification” (Stanghellini & Mancini, 2017, p. 174). Briefly, the therapeutic interview starts with an exploration of the patients’ “style of experience and action” achieved through open-ended questions about what their abnormal experiences feel like aiming at understanding the “personal meaning” they attribute to these states (ibidem, p. 190). Through the phenomenological unfolding (P) clinicians reconstruct the “basic structures or existential dimensions” of patient’s psychopathological life-worlds by focusing on their experience of lived space, time, body, self, and others (Stanghellini, 2019, p. 5; Stanghellini & Mancini, 2017, pp. 139–146). The second stage consists of a hermeneutic analysis (H) of patients’ position-takings with respect to their distressing experiences and is meant to capture their world-views or general attitudes toward life (Stanghellini, 2019, p. 6; Stanghellini & Mancini, 2017, pp. 147–154). Finally, in the psycho-dynamic analysis (P), clinicians proceed to contextualize patients’ psychopathological life-world and their world-view within their personal life-history by making use of patients’ self-narratives (Stanghellini, 2019, pp. 6–7; Stanghellini & Mancini, 2017, pp. 180–183).

The precondition for Stanghellini’s therapeutic model is the affective attunement with patients that entails an “entanglement between persons based on a silent mode of dialogue, a non-propositional flow of communication between persons embedded in a given atmosphere” (Stanghellini, 2019, p. 9). In this respect, clinicians attempt to individuate patients’ felt concerns or values not just through their narration or expressions but by searching an access to their affective experience. This represents the main difference with Fulford’s approach, which does not present a thematization of the non-linguistic forms of relatedness that can be found in the clinical encounter. Indeed, from a phenomenological perspective, even though we can articulate what we value through words, originally cares and concerns are pre-reflectively felt through our emotional life. In this sense, the access to patients’ intimacy can be opened by the “aesthetic properties of the clinical encounter” such as the affective atmospheres that inhabit the interpersonal relationship between clinicians and patients (cf. Stanghellini, 2016, p. 184).

For this reason, unlike the analytic-linguistic model, Stanghellini’s approach can be also applied to those clinical cases in which patients’ narrative ability is disturbed. By attending to the emotions and “feeling-tones and how they arise in particular forms of relatedness” (Stanghellini, 2016, p. 186), psychotherapists can establish a form of conversation with their patients through the use of metaphorical thinking and by relying more on the form of language rather than on its content. For instance, by observing and responding to patients’ facial expressions, saccadic movements, gestures and bodily micromovements, tone of voice, et cetera, clinicians may enter into a form of joint intentionality with their patients. Evidently, this introduces a further element of complexity to the task of grasping patients’ personal condition. Since the access to patients’ lived experiences passes through empathic resonance, shared emotions, and intercorporeality in general, there may be epistemological and ethical problems related to the elusiveness of other’s experiences. Notably, clinicians risk projecting their experience onto the patients or assimilating patients’ experience to their understanding, leading to forms of epistemic injustice of patient’s experience, which generally denote “a wrong done to someone specifically in their capacity as a knower” (Fricker, 2007; cf. Kidd et al., 2023).

The vulnerability of psychiatric patients to epistemic injustice (Crichton et al., 2017), can be the result of negative stereotyping and the practices of epistemic privileging (Scrutton, 2017) among other factors. Since it is not always possible to empathize with psychotic behaviors, Stanghellini proposes a “second-order empathy” that is not based on the analogical principle of common forms of empathy but adopts a heterological principle.¹⁹ In this respect, the intelligibility of another’s psychic life should pass through the acknowledgment of an “existential difference” between one’s life-world and that of others that involves self-reflection and the suspension of one’s everyday beliefs (Stanghellini, 2016, pp. 128–130, 139). Yet, this is problematic. Indeed, Spencer and Broom argue that relying solely on “empathic understanding” may exaggerate one’s capacity to fully comprehend patients’ experience, potentially leading to “(1) error due to transformative experience (leading to misdiagnosis, mistreatment and an overall misunderstanding of the condition at hand) and (2) epistemic injustice, through co-opting the patient’s experience and intellectual arrogance (epistemic co-opting) and epistemic objectification” (Spencer & Broome, 2023, p. 16).

Finally, the phenomenological approach to mental health care distinguishes patients’ individual value-commitments from disorder-specific value-orientations, consisting of attitudes motivating determinate beliefs and actions associated with mental disorders. Different authors indeed suggest that mental disorders entail particular characterological traits and evaluative attitudes transcending the singularity of patients’ projects of life (cf. Pienkos & Sass, 2017; Stanghellini & Ballerini, 2007). This distinction, absent in Fulford’s value-based practice, helps to make sense of the “pragmatic motive” and the “system of relevance” that permeates and regulates patients’ general “style of experience and action”, contributing to explaining apparently incomprehensible behaviors or beliefs (Stanghellini, 2016, pp. 170–171).

However, the results of these studies based on clinical phenomenology are still controversial for a number of reasons. These studies are poorly supported by empirical evidence because of the small sample of patients and are difficult to replicate, since no structured interview for capturing general value orientations is available in the phenomenological literature. Also, another problem is represented by a potential selection bias. Since patients’ value-orientations are mainly built on the basis of “sentences spoken by patients and faithfully reported in the clinical files” (Stanghellini & Ballerini, 2007, p. 134), or through an “interactive conversation style” (Stanghellini & Mancini, 2020, p. 50), patients with a high linguistic competence may be overrepresented while non-compliant patients as well as patients in severe conditions may be scarcely represented.

4. On clinical decision-making: values as heuristic principles for psychiatric practice

As I have shown, evaluativism broadly holds that the property of being “mentally disordered” is attributed not only on the basis of definite descriptions of a psychiatric category but also entails a normative evaluation of the patient’s symptoms and signs. Consequently, the focus of the evaluativist agenda shifts from the theoretical problem of whether mental disorder is a value-laden concept to what functions values have in psychiatric practice. Yet, a part speculating on the diagnostic and therapeutic implications of patients’ needs and preferences, a further problem for the evaluativist positions concerns the status of the general principles orienting clinical decision-making. In this section, I show that Fulford’s deflationary understanding of value is conceptually problematic especially in the context of mental health care because it is not clear whether and in what sense contributes to clinical decision-making. On the contrary, I argue that by drawing on an idea of human flourishing, Stanghellini’s approach can provide a normative basis to ground a positive account of recovery. Yet, this can be compatible with Fulford’s value-based practice (VBP) only if the formalism of the latter can allow for an idea of the good life. Before focusing on whether a “combined analytic-plus-phenomenological form of values-based practice” can be a consistent and coherent method of psychiatric practice, let’s then first understand Fulford’s idea of value-informed clinical decision-making.

4.1. Fulford’s value-based practice and the challenge of balancing conflicting values

Contrary to established bioethical paradigms of healthcare, evaluativists, such as Fulford, seem to reject the idea of universally valid principles to settle difficult decisions in medical practice. According to the “space of values” principle, Fulford’s value-based practice employs ethical reasoning to “explore differences of values, [but] not, as in quasi-legal bioethics, to determine ‘what is right’” (Fulford, 2004, pp. 70–71). This is apparently motivated by an ethical motive. The rejection of universal therapeutic goals and ideals of health and well-being is justified by Fulford on the basis that he wants to avoid any authoritarian drift that may lead to medical abuses.

However, there is also an epistemological reason why Fulford cannot ascribe to determinate values a universal function. Let’s remember that, in Fulford’s analytic-linguistic evaluativism, fluctuations across individual value-commitments, namely, variations across persons’ preferences, are explained as psychological differences (Fulford, 1989, p. 55). Therefore, for his value theory, any individual value-commitment holds the same degree of legitimacy. On this account, no value can be justified as supra-personal or general principle of conduct properly because evaluations are understood first and foremost as prescriptions not bearing any logical relationship with facts or objects. These are the reasons why Fulford argues that clinical decisions should be taken not by following supposedly universal principles but by adopting “processes designed to support a balance of legitimately different perspectives” (Fulford, 2004, p. 63). Indeed, Fulford is not interested in defining ideal clinical outcomes since it is more concerned with how clinical decisions should be taken. The subsequent problem is therefore how or in what sense it is possible to settle conflicts of values or perspective in clinical practice without recurring to general principles.

In Fulford’s view, there is the idea that “’right outcomes’ should be defined by “good process” where “good” means that the process in question links the required outcomes to the values of those concerned” (Fulford, 2013, p. 539). In other words, de iure, for Fulford, the evaluation of any clinical decision must be measured against patients’ specific values so that the criterion for assessing psychiatric practice comes to depend on the individual.²⁰ In this regard, some authors object that value-based practice embraces a sort of value-subjectivism (Cassidy, 2013; Loughlin & Miles, 2014), at risk of an inappropriate relativization of the idea of well-being. For Fulford, the reason why value-based practice does not lead to “anything goes” or laissez-faire, which is typical of radical forms of liberalism, is the conviction that there are “limits to the values that are value-based practice-able” (Fulford, 2013, p. 539). Clinical decisions cannot be informed by whatever patients consider important because there are limits to what can be a legitimate preference or value. For instance, racism is discarded as such, “it never gets into the process at all” because it is “incompatible with respect for differences” (Fulford, 2004, p. 230; 2013, p. 539). Therefore, Fulford argues that value-based practice is based on the premise of “mutual respect” for differences in values. Mutual respect is considered the “analytic premise” or the “meta-value” of his approach and consists of taking patients’ individual preferences and orientations seriously without discrimination (Fulford, 2004, p. 67).

However, some authors like Kingma and Banner (2014) argue that Fulford’s conception of “mutual respect” is problematic since it leaves unanswered the question of what values are compatible with value-based practice “meta-value”. As they ask, what about homophobia, sexism, and religious or cultural practices? Who decides what values are excluded? In this respect, Kingma and Banner signal that value-based practice may be prescriptive in deciding ex-ante what values can be taken into consideration for clinical decisions and what cannot. This point is further developed by Hutchinson and Read (2014) who argue that value-based practice adopts a liberalist principle expressed by mutual respect “master-value” that by making all value claims of equal status retains a subtle authoritarian orientation.

Hutchinson and Read make the point that in value-based practice personal values can be taken “more than mere expression of preference, opinion, or interest” and then, “formally recognized as politically significant” only if they have been “legitimized by having passed through institutionalized procedures as prescribed by the theory” (2014, p. 78). They argue that value-based practice’s apparent “value-neutral” position is ultimately committed to three main philosophical claims: 1) there is nothing, in reality, to settle value-conflicts so that conflicting values in clinical decisions can be at maximum recognized (ontological claim); 2) we cannot know what values are correct or right (epistemological claim) so that we cannot justify what the best clinical solution is for patients on the basis of an idea of “right outcome”; 3) we must be indifferent to “which views, if any, are, or can be shown to be, correct/true” (2014, p. 78) (moral claim) so that clinicians are not allowed to take clinical decisions for other persons on the basis of their preferences and values.

Against these objections, Fulford argues that value-based practice is not purely procedural because it is based on “frameworks of values shared by the relevant stakeholder group” as the National Institute for Mental Health (NIMHE) Values Framework. However, one may still counterargue that there is nothing in Fulford’s value theory to justify the adoption of those values apart from the fact that without those values “VBP would be impossible” (Thornton, 2014, p. 57). Indeed, Thornton and other authors remain critical of Fulford’s idea that “Disagreements over values are resolved primarily by processes which seek to balance legitimately different value perspectives” (“multi-perspective” principle) (Fulford, 2004, pp. 63–65). It is unclear how value-based practice would balance different value perspectives when making clinical decisions. In this regard, Thornton notes that since value-based practice is not interested in checking whether the values held by the patients are justified or legitimate, it may consist of “nothing further than competing views having been heard” (Thornton, 2011, p. 991, 2014).

Arguably, the crux of the matter is captured by Loughlin and Miles (2014). On their account, Fulford’s extremely cautionary attempts to avoid authoritarianism may result in rejecting value realism, namely, the idea that moral judgments and value claims, in general, have truth conditions and are then amenable to being true or false. They argue that Fulford can blame and condemn authoritarianism and the danger of medical abuses on the basis of a moral disapprobation, which is not just considered as an expression of personal antipathies but aspires to be universal: “We can only have a rational basis for condemning totalitarianism if value-subjectivism is false, so any argument moving from the evident wickedness of totalitarianism to a rejection of value-realism looks at risk of pulling the inferential rug from under itself” (Loughlin & Miles, 2014, p. 221).

While Fulford’s value-based practice is not “value-neutral”, it is certainly true that he is committed to some forms of skepticism about whether value judgments can be true or false. This skepticism can certainly foster a critical attitude to spot fallacies and idiosyncratic distortions in clinical decision-making. Ultimately, Fulford defends his skepticism by appealing to “the undecided (hence still open) status of the ‘is-ought’ debate as a whole” (Fulford, 2014a, p. 166). Yet, this skepticism can be problematic since, for instance, it would offer no guide to clinical decisions taken in the absence of explicit individual preferences or values as shown by Fernandez and Wieten (2015). In this respect, it is particularly interesting to confront Fulford’s position with Stanghellini’s model of care. While both argue that clinical practice should be informed by value pluralism, because, ultimately, people have reasons to live differently, Stanghellini’s account also defends an account of human flourishing that informs his approach to psychotherapy. As I show, this it is grounded on Ricœur’s notion of “the good life” (cf. Ricœur & Blamey, 1992, p. 314). The problem is then to see whether this normative theory which also “helps to deal with the vexed distinction between normality and pathology” (Stanghellini & Rosfort, 2013, p. 34) can be compatible with Fulford’s idea of value-based practice.

4.2. From mutual recognition to care: normativity in Stanghellini’s P.H.D. model

Not unlike Fulford, for Stanghellini psychiatric practice must be grounded on “mutual” or “reciprocal recognition” (2016, p. 65; cf. Gilardi & Stanghellini, 2021; Stanghellini & Rosfort, 2013). Yet, because of his underlying philosophical commitments, Stanghellini justifies the necessity of mutual recognition as the value presupposed by any psychiatric intervention dissimilarly from Fulford. Mutual recognition is a “complex emotional and intellectual readiness to acknowledge the reasons of the other person” that cannot be identified with simple understanding or approval (Stanghellini, 2016, p. 50). As Stanghellini claims, psychiatric patients show values that “depart from common-sense” so clinical decision-making should start by recognizing and acknowledging the peculiarity of their individual character to avoid forms of epistemic injustice (Fricker, 2007; Kidd et al., 2023) and stigma. As Stanghellini writes, “The neglect of the value system of persons suffering from psychopathological conditions contributes to seeing them merely as people who bear pathological experiences, beliefs, and abnormal personality traits” (Stanghellini & Mancini, 2017, p. 62). In particular, in Stanghellini’s approach, the recognition of forms of axiological rationality in mental disorders is already a means for making sense of the apparently meaningless and incompressible actions and beliefs of psychiatric patients to reduce stigmatization.

In this sense, unlike Fulford, Stanghellini’s approach is more attentive to the fact that psychopathological transformations of subjectivity impact how patients make sense of their existence, influencing their personal identity, and choice. Stanghellini talks of “value-recognition”, as reflecting an “ideal of modus vivendi” that “aims to find terms in which different forms of life can coexist” (2016, p. 65). In this, Stanghellini is close to Fulford (1999), as the practice of value-acknowledgment that derives from value-recognition “rather than merely focusing on symptom assessment and reduction” aims at improving “insight, understanding, resilience, and development of self-management abilities” of persons affected by psychiatric conditions (2016, pp. 172–173). Mutual recognition is not a spontaneous activity, but it can be achieved by establishing an emotional attunement with the patients while acknowledging their autonomy or “existential difference” (ibidem, p. 53). In this sense, reciprocal recognition is a transformative process that permeates the patient-clinician relationship constituting the very ground of the therapeutic dialogue.

However, differently from Fulford, what is central to Stanghellini’s idea of mutual recognition is that, as he argues on the basis of Ricœur’s ontology of the self (Ricœur & Blamey, 1992), mutual recognition is an essential step for the development of a healthy subjectivity. This is because, in his account, otherness, to indicate the eminently intersubjective dimension of our existence, is a fundamental condition for the constitution of personhood. As he writes: “Our existence is inescapably You-oriented and as such is conditioned by the spiritual value of recognition, […] We desire to be recognized by the Other to such a degree that our being-so is acknowledged by the Other as a value in itself.” (2016, p. 3) This value of recognition is rooted in intersubjectivity, which comprises a “primary system of motivation that organizes human behavior towards valued goals felt as need and desire by human beings.” (2016, pp. 17–19)

Indeed, according to Ricœur, there is a fundamental “mutuality” implied in the development of human capacities. Ricœur has in mind a “double necessity”, linked to “interpersonal and the institutional otherness” (Ricœur & Pellauer, 2000, p. 5) functioning as a condition of possibility for the actualization of human capabilities (cf. Honneth, 1995, p. 175; Ricœur & Pellauer, 2005, 2010).²¹ Therefore, unlike Fulford’s notion of mutual respect, which seems more a semantic rather than an ethical notion, because it is simply grounded on the observation that people attach values differently (Fulford, 2014b, p. 15), Stanghellini’s conception of mutual recognition also retains an ontological meaning, because entails a teleological conception of human person that stems from his understanding of Ricœur’s theory of subjectivity. This can be appreciated by the fact that in Stanghellini, mutual recognition is connected to the idea of “the good life”.

Notably, mutual recognition constitutes a basic condition of the good life since “the other person is fundamental to my identity in the world, since the world is a common world whose meaning is derived from the coexistence of different persons” (Stanghellini & Rosfort, 2013, p. 91). Yet it is important to clarify that this idea of the good life does not consist of a set of pre-established values to be pursued in one’s life. As Stanghellini and Rosfort acknowledge, the notion of “the good life”, as “a qualification of the existence of the self conceived as a singular totality […] seems impossible to clarify, let alone explain.” (ibidem, p. 90) Yet, even though the “specific idea of the good life may change in the course of our lives”, it remains the fact that, as a global idea, it nonetheless continues to inform or orient our decisions and projects. Indeed, as Stanghellini and Rosfort write, “the basic value of living is always counterbalanced by the more complex value of living well.” (ibidem, p. 89) It is worth then understanding whether the normative aspect of the concept of the good life may represent an obstacle to a “combined analytic-plus-phenomenological form of values-based practice” (Fulford & Stanghellini, 2020, p. 169). The point of friction between the analytic-linguistic and the phenomenological approaches might lie in the way they conceptualize recovery.

In this regard, it must be acknowledged that Stanghellini and Fulford share a value-based idea of “recovery” that is not defined by pre-determined values set by some external metrics, “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.” (2023, p. 1) However, differently from Fulford, by appealing to a normative notion of the good life, Stanghellini, and phenomenological psychopathology in general, can potentially provide a much more structured idea of recovery as grounded on a “teleology of recognition” (Stanghellini & Rosfort, 2013, p. 196), on the ontological and intersubjective conditions for the development of human capacities as developed by Ricœur’s hermeneutic phenomenology (cf. Ricœur, 2010; Ricœur & Blamey, 1992; Ricœur & Pellauer, 2005; Ricœur & Savage, 1970).

In this respect, phenomenological psychopathology could contribute to building an evidence-based notion of recovery based altogether on “experts-by-experience” and “expert-by-training”. Yet, as Messas et al. (2023) acknowledge, this is a challenging and risky task. It does not only presuppose that operational concepts like that of “quality of life” could be interpreted phenomenologically, from a first-person perspective, by drawing from “patients and carers as experts-by-experience” (ibidem, p. 13). In addition, it necessarily requires an understanding of the normativity that pervades our existence, studying the structural conditions of possibility that make life a good life, without resorting to universalizing prescriptions that might undermine the very idea of mutual respect and recognition.²² This is to avoid, as Fulford (2004) warns, any form of paternalism or authoritarian drift.

Conclusions

In this paper, I have argued that psychiatric evaluativism is a multifaceted position comprising diverse but interrelated problems. I have outlined a theoretical, practical, and ethical dimension to map some relevant issues of the contemporary debate in the philosophy of psychiatry. While the first dimension concerns the problems of psychiatric conceptualization, the second regards a question of practical importance for evaluativist accounts, namely that of the identification of patients’ values, commonly called “needs”, on the basis of which diagnostic and therapeutic decisions are justified. Finally, the third dimension is about bioethical issues implied in clinical decision-making. Against this background, I have compared two contemporary forms of evaluativism by looking at the focus of their orientation, namely, the analytic-linguistic and phenomenological perspectives. In particular, I have shown that Fulford’s value-based practice (VBP) and Stanghellini’s phenomenological-hermeneutic-dynamical approach to psychotherapy (P.H.D.) do not share the same underlying conception of value. This can be appreciated by looking at their different philosophical commitments. In addition, I have discussed how this conceptual difference affects their understanding of clinical practice. Specifically, I have focused on the problem of identifying a patient’s unique values and determining the values that ultimately guide clinical decisions.

Fulford’s value-based approach in psychiatry is useful when it comes to empowering shared decision-making in the clinical practice, by considering the patient’s values alongside clinical evidence, fostering a more patient-centered practice. However, I have shown that Fulford’s analytic-linguistic approach mainly frames the concept of value cognitively since it focuses on the analysis of ordinary and technical language. The main attention is dedicated to understanding the meaning of value words and value judgments looking at their use in everyday discourses. By drawing on Hare, Fulford’s analytic-linguistic approach to psychiatry focuses on values as represented in everyday language. This emphasis could be interpreted as leading to a somewhat propositional understanding of how values are experienced. Yet, this is also the reason why the analytic-linguistic approach is best suited for investigating psychiatric classifications. Indeed, as Sadler claims, it can be applied, for instance, to deciphering the implicit values of written texts as psychiatric diagnostic manuals (1997, p. 542).

The main goal of my critique of Fulford’s account has been to show that Fulford does not seem interested in providing a definition of value that goes beyond the reality of linguistic practices and he tends to conceive with skepticism any value theory with substantial ontological claims. As a matter of fact, for Fulford, so-called “conceptual value theories” are exposed to the danger of “grammatical illusions” and the risk of presenting a totalitarian conception of human values (cf. Fulford, 2013, pp. 540, 545). Yet, for the same reason, his analytic-linguistic approach comes short in justifying those values guiding psychiatric practice. This is the case of “mutual respect” that, as the “analytic premise” of Fulford’s value-based account, retains a semantic rather than an ethical meaning, because it is limited to acknowledging the empirical fact that people have different values so that it has been accused of embracing a sort of value-subjectivism.

Arguing that people attach and hold on to different values because of their psychological constitution does not provide a reason to justify “mutual respect” as that “meta-value” orienting psychiatrists in their clinical decisions. As signaled by several commentators, by appealing to the idea that values only have a local type of legitimization, because they are linked to the community committed to them, Fulford’s analytic-linguist approach runs the risk of relativism. This approach also has some problems in relation to the individuation of patients’ values in the clinical interview. Broadly, it is unclear how it can capture “unconscious” values, or simply, values that go unnoticed in patients’ everyday life, either because they can be barely communicable based on their linguistic capacities or because are deeply hidden in their identity.

Whereas the analytic-linguistic form of evaluativism elaborated by Fulford perceives differences in persons’ values as a matter of their psychological makeup, phenomenological-oriented approaches precisely search for the conditions of possibility of differences across persons’ individual values, for instance, investigating the affective basis and cognitive processes underlying value judgments and commitments. While recognizing that values can be expressed in language, these accounts, represented in the paper by Stanghellini’s phenomenological-hermeneutic-dynamical approach to psychotherapy, focus on how values are constituted from within one’s experience by looking at the function of emotions, feelings, and moods so to make sense of psychopathological life-worlds. In this regard, I have indicated how Stanghellini’s model can complement Fulford’s value-based practice by providing a more comprehensive understanding of what constitutes values. This is especially helpful for clinical cases in which patients hold incomprehensible values, or when the capacity of the person as a valuer is compromised, such as in depression.

According to Stanghellini, attaching values, or valuing, entails affection, so individual values belong to a per-reflexive level of subjectivity that can be made intelligible through narration. Even though values are below or beyond language, insofar as we make the experience of what we care about through affective phenomena, their epistemic access is made possible through “synthesizing schemes of comprehensions” or “narrative configurations”, that articulate often obscure and unclear feelings and emotions. However, what kinds of evidence may be produced in this regard and how the phenomenological approach can account for personal values is yet to be investigated. Phenomenological accounts like that of Stanghellini’s also provide value taxonomies according to which classify human values because they rely on an underlying theory of subjectivity, something that is missing in the analytic-linguistic approaches. It is worth noting that in Stanghellini there is the idea of a fundamental epistemic uncertainty in regard to the identification of personal values since personhood is seen as a task of becoming that is permeated by ambivalence and doubt.

Finally, I have argued that since Fulford’s value-based practice (VBP) is “electively unclear”, then it can be reasonably claimed that, as it currently stands, Fulford’s model is prima facie compatible with Stanghellini’s method. As also Stanghellini and Fulford acknowledge, these approaches are complementary since whereas linguistic-analytic value-based practice “is required for engagement first with the values challenges of the patients’ “presenting symptoms”, phenomenology “provides a depth dimension of affective and conative understanding of values” (2020, p. 172). And yet, developing a “combined analytic-plus-phenomenological form of values-based practice” necessarily implies addressing fundamental conceptual issues related to value theory since, as I have shown, Fulford’s non-cognitivist and anti-realist position does not seem compatible with the main tenets and methods of phenomenological axiology, which includes normative claims on our affective and evaluative life.

Therefore, on a conceptual level, the partnership between phenomenology and linguistic-analytic value-based seems problematic since, as even Fulford and Stanghellini seem to acknowledge, these are apparently “two traditionally opposed disciplines” (2020, p. 173). The relationship between the linguistic-analytic with the phenomenological approaches is further complicated by the fact that, as Fulford and Van Staden (2013, p. 386) argue, “ordinary language philosophy is not a well-defined discipline” and beyond Hare, on which Fulford bases his critique to psychiatric objectivism, in the conceptual resources of this tradition one must include other philosophers belonging to the Oxford School of philosophy, such as J. L. Austin, Gilbert Ryle, Philippa Foot, R. M. Hare, Geoffrey Warnock, which present contrasting conceptions of value. However, the same can be said for the phenomenological tradition, as, for instance, Sartre’s voluntarism does not sit well with Husserl’s weak value realism (cf. Caminada, 2022a; J. Drummond et al., 2021, 2018). For this reason, building a consistent and coherent method for psychiatric care based on values requires a clarification of the underlying philosophical presuppositions, in particular concerning the notion of value.

In this regard, I have contended that a potential point of disagreement between these two approaches may arise in the justification of those ethical values orienting clinical decision-making such as mutual respect or recognition. Even if Stanghellini shares with Fulford the idea that mutual respect should ground psychiatric practice, there is a difference in how they defend or argue for this fundamental principle at the base of psychiatric practice. Indeed, while mutual respect remains the “analytic premise” of Fulford’s value-based practice (VBP), Stanghellini’s idea of mutual or reciprocal recognition results from a teleological conception of the human being, which follows from his reading of Ricœur’s theory of subjectivity. Unlike Fulford, in Stanghellini, via Ricœur, there is the idea that whatever persons might aspire for their realization, human flourishing is the product of an intersubjective process of mutual recognition. In this sense, phenomenological approaches seem to endorse a determinate conception of what constitutes a non-instrumental or ultimate good for a person, absent in Fulford’s account.

This conception of the good life is then eminently normative and can be problematic for analytic-linguistic approaches like that of Fulford. Indeed, for him, any account that would offer such consideration on the “good life” or well-being would be subjected, ultimately, to Moore’s “open question argument”. In this regard, Fulford’s concept of mutual respect risks being reduced to “nothing further than competing views having been heard” mainly because he lacks a conception of well-being or a normative theory that can transcend individual situations and preferences (cf. Thornton, 2011, p. 991). I have argued that this conceptual difference may have a practical impact in the clinical setting, especially when it comes to understanding the notion of recovery. In Stanghellini, mutual recognition is conceived more as an open-ended process operative in the clinical encounter grounded on the emotional attunement between clinician and patient. In this respect, mutual recognition does not only designate a process of value-acknowledgment between the patients and the carers as in Fulford’s model. Rather, in Stanghellini’s approach mutual recognition has also a therapeutic meaning since is associated with the basic conditions of autonomous selfhood, and consequently, it is necessarily associated with the idea of recovery.

For this reason, future research should be dedicated to clarifying whether and how a phenomenologically informed model of recovery might be reconciled or integrated with Fulford’s idea of value-based practice. It remains unclear in the literature how the normative and ontological dimensions inherent in a phenomenologically based approach, such as that of Stanghellini, could be compatible with Fulford’s “analytic” model (cf. Loughlin, 2014, p. xii), as Fulford seems to reject any conceptual value theory that makes significant claims about the nature of reality. According to Fulford, this rejection is justified because any conceptual value theory may potentially promote, for instance, a restrictive, harmful view of what constitutes universal human values (cf. Fulford, 2013, pp. 540, 545).

Acknowledgements

I want to thank the anonymous reviewer for their helpful comments and constructive feedback, which really helped improve this article.

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No potential conflict of interest was reported by the author(s).

Additional information

Funding

The work was supported by the Irish Research Council [GOIPG/2021/606].

Notes

1. I prefer the term “evaluativism” to “normativism” for distinguishing an axiological from a deontic connotation of those values or principles influencing or orienting psychiatry theory and practice. Furthermore, as Kostko also argues, the reference to norms is ambiguous because objectivist accounts also use the term to refer to biological norms (2014, p. 11n).

2. In this respect, contemporary evaluativist approaches to psychiatry emerged not only as a reaction against the bio-statistical model developed by Boorse (1975), and differently, by Kendell (1975), but also against anti-realist views, such as that of T. S. Szasz (1974). While the firsts claimed that mental illnesses essentially consist of deviations from general biological norms, anti-realist positions were essentially deflationary. In their view, mental disorders are not diseases but normative social constructs, because their attribution is not dependent on “detectable alteration of bodily structure” (T. S. Szasz, 1974, p. 12) but on “cultural, ethical, religious, and legal” norms (T. Szasz, 2006, p. 332).

3. Contrary to objectivists and anti-realist positions, for evaluativists, recognizing that psychiatry is value-laden does not invalidate its scientific aspiration. Evaluativists claim that scientific methods and practices are necessarily driven by and teleologically directed to a plurality of epistemic and non-epistemic values. In contemporary epistemology and philosophy of science, the ideal of value-free science or the “ideal of epistemic purity” is believed to be inadequate to represent actual scientific research for there are ineliminable contextual factors that influence scientific reasoning (cf. Biddle, 2013; Douglas, 2000).

4. On this basis, a strong form of evaluativism would consist in taking value-judgments as a necessary component of the attribution of psychiatric disorders. In this view, facts about bodily conditions cannot be separated from evaluative considerations, such as, for instance, whether a disturbance is harmful or undesirable. On the contrary, weak evaluativism would only acknowledge the existence of normative factors in diagnostic assessment without for this reason claiming that values play a major role in establishing the boundary between “problems in living” and mental disorders. As Varga writes, for these positions “Value-dependent evaluations are not important to settle the issue whether something is dysfunctional” (2011, p. 9).

5. See Amoretti and Lalumera (2021) for a review of some traditional and contemporary normativist positions in the debate about the concept of health and disease. By drawing on Kingma (2014), they argue that while strong normativism consider the concept of disease “constitutively ‘value-requiring’”, weak accounts only claim that “evaluative component may play a role in the operationalization of some elements of the definition of the concept of disease” (Amoretti & Lalumera, 2021, p. 57). Cf. also Boorse (1975), Skene (2002). In this sense, they conceive non-epistemic values in medicine as interest- or context-dependent.

6. With analytic-linguistic approaches, I indicate those accounts that variously use the philosophical methodology originally developed in the ordinary language philosophy, and usually associated with the Oxford School, but also include other seminal figures like Wittgenstein and other authors ascribed to the analytic philosophy like Moore and Russell. In particular, I focus on Fulford’s works that paradigmatically express this analytic-linguistic approach. Broadly, these authors share the idea that philosophical problems should be solved through the analysis of language as it is used in everyday life situations. When applied to the philosophy of psychiatry, as I will show, this means that the conceptual problems will be addressed by an investigation of the definitional strategies of psychiatric theories. With phenomenological approaches, I refer to those models that differently draw on the phenomenological method and concepts originally developed by Husserl. Despite being highly heterogenic, all the authors ascribed to this tradition share the basic idea that psychiatry must focus on deciphering human existence by passing through the study of abnormal experiences. Phenomenological psychopathology originated in Jaspers, differently developed through other authors such as Binswanger and Blankenburg, and sometimes assumes more pronounced anthropological and hermeneutical connotations.

7. These dimensions are not always spelled out in the relevant literature, so it is difficult to understand some of the debates. In addition, there is no unified terminology. Consequently, the meaning of different expressions such as “value-commitments” or “value-orientations” and “value-system”, “value-structure” or “value-hierarchy” may result ambiguous because unclear.

8. Yet an objectivist counterargument may consist in showing that that value-judgments in psychiatric diagnosis are simply incidental because, on their account, the pathological assessment should be made solely on the basis of identifiable malfunctioning within the body. Another option may be claiming that if mental disorders result from detectable dysfunctions in the body, then they bear an intrinsic negative value for the person affected by the condition. In particular, this latter option implies some form of value reductionism, namely, the idea that values can be reduced to natural properties. In this case, a psycho-physiological state “X” would be identified as “malignant” and therefore “undesirable” by definition, so that the value judgment about the disordered condition would be reduced to a factual description. These are both options that are addressed by Fulford in his Moral Theory and Medical Practice (1989).

9. In particular, for Fulford, the concept of illness derives its meaning from “the experience of failure of ‘ordinary’ doing in the perceived absence of obstruction and/or opposition” (1989, p. 263), whether this failure is understood physically or mentally (cf. Boyd, 2000; Nordenfelt, 2007; Twaddle, 1968).

10. Probably, this is because in phenomenology the quarrel on the fact/value distinction as a philosophical problem did not have the impact it had in the analytic or English-speaking philosophy since Moore’s “open question” argument in metaethics.

11. As Husserl writes, “objectivism, as the genuine accomplishment of an investigator oriented toward true norms, presupposes precisely those norms and that objectivism thus is not meant to be based on facts, since facts are thereby already meant as truths rather than mere opinion” (1970, p. 296).

12. Yet, he also claims that the separation between facts and value would have not been resolved in the relinquishment of “all human values” but on the contrary, would have resulted in “truer, clearer and profounder values the more we observe before we judge.” (1963, p. 17) For Jasper indeed, impartiality in psychiatric knowledge cannot be the exclusive prerogative of the psychiatrist’s scientific attitude, aimed at suspending all value judgments in his search for objective facts in support of his causal model. Impartiality is also the epistemic value orienting psychiatrist’s empathic efforts to understand the patient’s psychopathological condition, especially when this type of understanding “is fair, many-sided, open and critically conscious of its limitations” (Jaspers et al., 1963, p. 310).

13. According to the famous “open question” argument, Moore claims that it is fallacious to define moral properties such as “good” in terms of natural properties because “whatever definition [of good] be offered, it may be always asked, with significance, of the complex so defined, whether it is itself good” (Moore, 1903/1993, pp. 67, my italics).

14. For Hare, since moral prescriptions are not logically connected to factual contents, “there is no statement of fact that a moral prescription, taken singly, can be inconsistent with” (1965, p. 194).

15. Phenomenology, as represented by Husserl and Scheler, does not explain the relationship between value-attributes and non-axiological properties through the notion of non-reductive supervenience, as Hare, namely, by appealing to an asymmetric ontological dependence (cf. Caminada, 2022b). Specifically, the relationship between values or value attributes and objects, describes “a bilateral ontological dependence between a containing whole and its contents or ‘parts,’ such that the whole can be preserved independently of its particular contents, although not independently of some contents of that kind” (De Monticelli, 2022, p. 229). This relation of dependence is understood through the mereological notion of unitary foundation (Einheitliche Fundierung), developed by Husserl in the Logical Investigations (cf. Husserl, 1984, pp. 235–236). In this sense, from a phenomenological perspective, value attributes are “neither separate from nor reduced to the non-axiological properties on which they are founded” (J. Drummond, 2014, p. 185).

16. Husserl’s reception of Hume’s philosophy was deeply influenced by Brentano (cf. Janoušek & Zahavi, 2020; Melle, 1991). Following Brentano, Husserl praises Hume for his critique of ethical rationalism while blaming his ethical skepticism, derived from the thesis that if feelings are essential for ethical judgments, ethics cannot be a science insofar as depends on empirical considerations. In this respect, Husserl opposes Hume’s idea that no moral laws can be derived from facts by claiming that as we can build a formal logic on the basis of a priori considerations, then we can also build formal ethics and axiology. As Donnici notes, the main thread of Husserlian ethical research after 1902, the year of the lecture course on the Grundprobleme der Ethik, seems to coincide with Human problems: “the whole problematic concerning the Wertkonstitution is nothing but an examination of the way in which from perception and representation one passes to evaluation, once it has been established, with Hume, that it is not possible to make this passage perceptually.” (1982, p. 467, my translation).

17. For Husserl, our feelings and emotions show a kind of “Konvenienze” with the objects of experience, insofar as value-exhibiting feelings are grounded on the perception of the objects and state of affairs (cf. Husserl, 2020, pp. 284–285).

18. While it is true that Husserl distinguishes a transcendental from a psychological phenomenology (Husserl & Scanlon, 1977), it remains the fact that the latter must be distinguished from empirical psychology, as it is concerned with the study of the intentional directness of conscious experience (cf. Zahavi, 2010a). For the debate on the status of applied phenomenology, cf. Zahavi (2021).

19. With nonconative empathy, Stanghellini intends a “spontaneous and pre-reflective attunement between embodied selves” (Stanghellini, 2016, p. 126), while conative empathy is conceived as a reflective form based on the active search for experiences that may resonate with the other person. (ibidem, pp. 127–128) Both types of empathy suffer from important limitations. While nonconative empathy cannot be achieved in the case of the radical otherness of psychotic patients, the conative form functions through analogical reasoning. Consequently, the epistemological risk of the latter is that of projecting the clinician’s personal experience and common sense onto the patient.

20. Yet, it must be noted that in Fulford’s value-based practice, rules and regulations still find a place in clinical decisions but have a marginal role because they only function as a “framework for practice defined by values shared within a given community […] [which] set benchmark outcomes against which decision taken within the relevant community can be measured” (Fulford, 2004, p. 66).

21. Ricœur’s account resonates with Honneth’s own “conception of ethical life” (Honneth, 1995, p. 175), the positive, individual self-realization, namely one’s “good life” (Honneth, 1995, p. 171), is grounded on a three-stages processual model of mutual recognition consisting in self-confidence, self-respect, and self-esteem. Broadly, Ricœur and Pellauer (2000, 2010) distinguishes at least four basic human capabilities. From the institution of language, represented by the rules of grammar shared by the speakers and corresponding to the capability to speak, to the legal institutions of contracts, based on a “structure of trust” correlated to the capability to be accountable for one’s actions, Ricœur show, for each of the four capabilities, the insufficiency of relying only on an intersubjective explanation of social interaction. As he contends, from an agential perspective, human beings are bound not only to others but also to “different orders of social systems” or, following Jean-Marc Ferry, “orders of recognition”, namely “large-scale organizations that structure interaction” (Ricœur & Pellauer, 2000, p. 6). This has implications for psychiatry insofar as, for instance, psychiatric institutions play a crucial role in mediating recognition processes.

22. As Stanghellini and Rosfort (2013, p. 37) write: “Our existence in the world is pervaded by normativity. Our biological constitution promotes certain immediate and pre-reflective values such as eating, drinking, sleeping, reproduction, self-preservation, and many others, but our being human persons coexisting with other persons elicits complex values as well such as courtesy, forbearance, self-esteem, love, friendship, envy, respect, hatred, and recognition. These complex and heterogeneous values condition and shape human existence, and to understand human selfhood we have to understand how the self orientates itself and acts by means of these values.”