www.crossingdialogues.com/journal.htm DIALOGUES Crossing Dialogues Association 21 Cross-Cultural Relevance of the Third Revolution in Psychiatry MOHAMMED ABOUELLEIL RASHED Department of Mental Health Sciences Division of Population Health University College London Email: m.rashed@ucl.ac.uk DIAL PHIL MENT NEURO SCI 2010; 3(1): 21-22 Fulford's and Stanghellini's (2008) concise and rich article is a mission-statement of an infl uential direction in what they call the "third revolution" in late twentieth-century psychiatry. Values-based practice fi nds its intellectual mooring in phenomenology and analytic philosophy and is geared to handle the "complex and confl icting values" that are part of clinical decision-making. The authors present values-based practice as a complement to the neurosciences (concerned with establishing diagnostic facts), and patient-guided, multidisciplinary organised practice (a reminder of just who philosophy and science are in service to: patients). The essence of clinical practice thus conceived seems a world away from the rule-of-experts characteristic of pre-revolution psychiatry in the United Kingdom, for example, and current psychiatric practice in many parts of the world. In this dialogue I will be referring to Egypt. This new vision of clinical practice undermines the power previously reserved to the experts, by whom I mean the clinicians who held within their practice all the available facts, all the relevant values, and who worked with objective and non-negotiable frameworks and systems. Now this power has been seriously diluted by valuesbased practice and tempered by patient-guided practice and multidisciplinary teams. Values-based practice endorses democratic values and a pluralistic orientation, both suited to multicultural societies where the proliferation of identities and values precludes assumptions of basic values and core identities, regardless of political rhetoric. It requires a degree of moral relativism and a temporary suspension of assumptions and judgements. There are two related implications of values-based practice that I would like to raise: (1) an essential ambiguity seems to arise: in place of unquestionable diagnostic certainty we fi nd dialogue, communication, and a quest for agreement; prerequisites for delivery of acceptable health-care. (2) Rule-ofexperts is undermined. The value of this in a pluralist, multicultural society is obvious. Here I want to ask: are these changes necessarily positive in cultural contexts where different orientations to authority and knowledge exist? Rule-of-experts is very much a reality in medical practice in Egypt. The question is not how we could change that but whether it is advisable. Changing it will have implications on the very meaning of "treatment", "consultation" and the very idea of seeing a doctor. Medical authority in Egypt is absolute and medical knowledge, owing primarily to illiteracy and absence of interest, continues to seem esoteric. In this context I note, and this is evidence drawn from my own work and research in Egypt, that patients rarely appreciate the chance to be involved in health-care decisions; they are not willing to tolerate ambiguity. They tend to see this as a sign that the doctor perhaps is not an expert, after all why would a good doctor ask his patient what her view of her predicament is (why is this relevant?) and what treatment she wants (shouldn't the doctor know better?). Confl icts of values are not visible, since the values brought to the fore by the expert are the only relevant ones, and this is frequently the patient's view. Psychiatric assessments take on an extreme medical form, with symptom checklists followed by an extensive prescription. It is quite common for a patient to be brought to the psychiatrist by a family member who reports a few symptoms on their behalf, keen to be handed a Dialogues in Philosophy, Mental and Neuro Sciences DIAL PHIL MENT NEURO SCI 2010; 3(1): 21-22 Rashed prescription and get on their way. In my experience patients found it strange that I wanted to spend an hour with them, asking them about their views and their family's. This of course points to a different conception of psychiatry and mental illness, and different power hierarchies within the family, but the main point holds: rule-of-experts is the norm in healthcare, and patients seem to be adapted to this, in fact recognise this as a sign of a "good doctor" and a decent consultation. To conclude I would tentatively like to raise the idea that values-based practice is a philosophically inspired methodological approach to clinical assessment that suits particular societies but not necessarily others. I must admit here that I personally and as a clinician believe that to set the clinical encounter on the right foot valuesbased practice is of utmost importance. However, as I learnt from exposure to different cultural contexts, what constitutes the "right foot" varies widely. 22 REFERENCES Fulford KWM, Stanghellini G. The Third Revolution: Philosophy into Practice in Twenty-fi rst Century Psychiatry. Dial Phil Ment Neuro Sci 2008;1:5-14.