Narrative Understanding, Value, and Diagnosis: A Particularist Account of Clinical Formulations and Shared Decision-making in Mental Health

Abstract

In this article, I deploy the notions of narrative and discernment as complementary support tools in understanding the moral significance of the first-person perspective in mental health. My aim is to develop and extend moral particularism’s emphasis on the significance of context and the general problem of relevance in understanding the dynamics of practical judgement and shared decision-making as applied to comprehensive diagnosis and integrated treatment. I argue that it is a mistake to think of the values embedded in responsible integrated care and patient involvement as either determined by the individual patient’s autobiographical narrative or as determined by the ‘top-down’ conception of health as presented in the biomedical model. What is missing in accounting for the idea of clinical decision-making as a shared enterprise is a relational account of the person and the wider diagnostic treatment context in understanding the process of perspective-taking. Such reorientation of focus makes available a distinctive conception of clinical knowledge, in which claims to objective meaning in patient narratives are criticised not as false per se, but as failing to yield the insight into the problem it was the point of those claims to provide