Beyond the Risk Paradigm in Mental Health Policy and Practice

Sonya Stanford, Elaine Sharland, Nina Rovinelli Heller, Joanne Warner

• Publisher: Bloomsbury Academic
• Year: 2017
• ISBN:
  9781350313071
• Edition: 1
• Topic: Psychology
• Subtopic: Movements in Psychology
• Index: Psychology

Modern society is increasingly preoccupied with fears for the future and the idea of preventing 'the worst'. The result is a focus on attempting to calculate the probabilities of adverse events occurring – in other words, on measuring risk. Since the 1990s, the idea of risk has come to dominate policy and practice in mental health across the USA, Australasia and Europe. In this timely new text, a group of international experts examines the ways in which the narrow focus on specific kinds of risk, such as violence towards others, perpetuates the social disadvantages experienced by mental health service users whilst, at the same time, ignoring the vast array of risks experienced by the service users themselves. Benefitting from the authors' extensive practice experience, the book considers how the dominance of the risk paradigm generates dilemmas for mental health organizations, as well as within leadership and direct practice roles, and offers practical resolutions to these dilemmas that both satisfy professional ethics and improve the experience of the service user. Combining examination of key theories and concepts with insights from front line practice, this latest addition to Palgrave's Beyond the Risk Paradigm series provides an important new dimension to debates on mental health provision.

1

THE HISTORICAL CONTEXT OF THE RISK PARADIGM IN MENTAL HEALTH POLICY AND PRACTICE: HOW DID WE GET HERE?

Joanne Warner, Nina Rovinelli Heller, Elaine Sharland and Sonya Stanford

Introduction

The chapter begins by briefly setting the ‘rise of risk’ in mental health policy and practice in its wider context. It demonstrates that the idea of risk not only dominates mental health policy, practice and experience; it is also the major organizing paradigm in health and welfare services more widely. Of even greater significance is the fact that risk dominates public, political and cultural life in general. The language of risk is everywhere: in debates about health, childcare, pensions planning, banking, child protection, crime, what we eat, how we use our leisure time, what we buy. The idea of risk also characterizes organizational cultures and institutional life, where concern for the ‘reputation risk’ of those that occupy positions of power plays a particularly significant – and problematic – role (Power, 2004).

While the use of the term ‘risk’ has become increasingly widespread, it has been defined in a number of different ways. In the broadest sense, risk can be understood as either ‘real’ or ‘constructed’. On the one hand, risk is treated as an objectively measurable and controllable entity, where, with the right expertise and tools, risks can be predicted, managed or even eradicated altogether. On the other hand, risk is ‘constructed’, in so far as the risks we identify as important – the way we perceive and respond to them – are all determined by social and cultural values. This distinction is an important one for this book. The starting point for our exploration of how we can ‘move beyond the risk paradigm’ is that we take it to be a paradigm: a mode of thinking and acting that is political, social and moral. We are not proposing that we move beyond (eradicate or stop caring about) objective dangers or harm, but that we find ways of thinking and acting with them in different ways when working for human rights and social justice in mental health. It is in this sense that we often use the term ‘risk’ as shorthand for the idea of risk.

The chapter considers the key theoretical accounts of risk, including Beck’s ‘Risk Society’, that help us to understand the processes that have been at work and the growing significance of neoliberal agendas in welfare policy. The chapter then charts the rise of risk’s ‘peculiar’ expression in mental health (Pilgrim & Rogers, 1999) through critical analysis of the trends in mental health policies towards ‘deinstitutionalization’. These policies essentially signalled the replacement of asylum-based confinement with ‘care in the community’. The discussion considers the problematic and contested nature of both community and care. It argues that community care policies, while progressive in important respects, were both symptomatic of, and also the cause of deep cultural anxieties about, ‘madness’ linked to the apparently increased visibility of people experiencing mental distress. The chapter highlights the disproportionate attention that was given by the media and policymakers to certain risks, in particular to the perceived increase in the risk of violence by people with mental health needs living in the community. This disproportionate focus on one particular kind of risk has simultaneously served to obscure from view the range of other risks to which mental health service users are exposed and that they live with each day.

The discussion then moves on to explore risk in mental health practice by tracing the relationship between risk and the much older concept of dangerousness in psychiatry. The targeting of services for individuals judged to be ‘high risk’ (especially to others) has meant that significant areas of professional practice revolve around processes of assessment based on calculating probabilities and risk factors. Being deemed ‘high risk’ can result in risk management practices, such as preventive detention, that have important implications for social justice and human rights. But the designation ‘low risk’ can mean exclusion from any form of support at all, with equally significant implications for human rights and justice.

In the concluding section of the chapter we emphasize that the dominant focus on risk has had major implications for social justice and for the human rights of people who experience mental distress. We briefly consider where challenges to the dominance of the risk paradigm have come from and where they may come from in the future. Specifically, we highlight the importance of refocusing attention on social suffering and the forms of power that influence responses to mental distress. When human rights and social justice are compromised by the policies and practices of the risk paradigm, the impact is felt directly by service users through experiences such as stigma, shame and the loss of dignity. Social suffering ‘results from what political, economic, and institutional power does to people and, reciprocally, from how these forms of power themselves influence responses to social problems’ (Kleinman et al., 1997, p. ix). The chapter ends with a brief summary of the chapters that are to follow and the contribution they each make to ‘moving beyond the paradigm of risk’.

Risk society, the ‘other’ and neoliberalism

We have been described as living in ‘an age of anxiety’ (Dunant & Porter, 1997) where, since the 1990s, ‘safety has become the fundamental value’ (Furedi, 1997). One of the most influential works on risk from a sociological perspective is Beck’s (1992) Risk Society, where the issue of risk is elevated to the status of a new political theory. According to Beck, society is no longer structured as it was in the past, in terms of the distribution of ‘goods’. It is instead organized according to a preoccupation with fears for the future and the distribution of ‘bads’ in the form of potential harm. The potential harms Beck has in mind are those that arise from industrialization and modernization; they are global in their impact – such as nuclear accidents and climate change – and they are incalculable in terms of their consequences. In Beck’s account, the risk society is one that is concerned with safety and preventing ‘the worst’ and so it is motivated by a ‘commonality of anxiety’ about the future rather than a ‘commonality of need’ as in the past (1992, p. 49). In this preoccupation with the future, the focus falls on increasingly sophisticated attempts to calculate the probabilities of adverse events occurring. Through risk calculations, a lack of certainty about the future becomes quantifiable (Rose, 1998, p. 181) and this gives a measure of confidence about how to act in the here and now, even if that confidence is misplaced. Beck’s (1992, p. 21) definition of risk is centred on the way modern risks are dealt with: ‘Risk may be defined as a systematic way of dealing with hazards and insecurities induced and introduced by modernisation itself.’

Beck’s argument is underpinned by the view that Western civilization is indeed faced with the threat of self-annihilation. For Beck and also for Giddens (1990, 1991, 1998), it is greater knowledge about risk that has fuelled anxieties about modernization – particularly technological developments – and made us morbidly aware of the risks we may face in the future. As Wilkinson (2001, p. 103) puts it:

For both of these theorists the significance of public knowledge of risk lies in the extent to which it makes us more uncertain about the future. Where our minds are filled with thoughts of risk, then we are understood to acquire an amplified sense of doubt with regard to our personal ability to live in safety.

As Hollway and Jefferson (1997, p. 258) suggest, the importance of Beck’s argument lies in the fact that ‘risk is understood as pervasive in late modernity’, and they emphasize the importance of addressing risk issues in terms of the political context for their recognition and management.

The risk society argument suggests that the focus on risk in mental health needs to be understood as part of a much wider development in which heightened levels of anxiety are endemic in modern society in general. However, as well as fuelling anxiety in the way that Beck and others suggest, knowledge about risk is understood by cultural theorists such as Mary Douglas as being part of the antidote to anxiety (Wilkinson, 2001). For cultural theorists, it is important to note historical changes in the meaning of risk in order to grasp the socially constructed nature of the concept and its modern-day use in relation to blame. Douglas (1992) traces the concept of risk back to the seventeenth century, where the probabilities and magnitude of both gains and losses in gambling were calculated mathematically. From this, the concept of risk subsequently evolved to become the basis for decision making in scientific environments. Douglas argues that this historical association with scientific calculation and the credibility that comes with it partly explains the modern use of the term ‘risk’. Risk is now only associated with the possibility of negative outcomes and its political use is as a forensic resource in working out accountability for abuses of power:

Risk is invoked for a modern-style riposte against abuse of power. The charge of causing risk is a stick to beat authority, to make lazy bureaucrats sit up, to exact restitution for victims …. (Douglas, 1992, p. 24)

In addition to risk’s appeal as a concept that can be used to invoke blame, cultural theorists have also highlighted its power in relation to cultural processes such as ‘othering’. The concept of the ‘other’ can be defined as ‘that which is conceptualized as different from the self’ (Lupton, 1999, p. 124). Otherness is rooted in observations of strangeness and danger in ‘them’, in binary opposition to the safety and familiarity associated with ‘us’. The concept has been used to explain how and why different social groups become the focus of anxieties about particular kinds of risk so that they come to be seen as ‘the marginalised and stigmatised risky other’ (Lupton, 1999, p. 124). As we see in a later chapter, an equivalent process is defined in psychoanalytic terms, where othering involves splitting as a defence against anxiety and guilt. Regulation of the other has been identified as a central feature of the ‘history of madness’. Otherness associated with mental disorder has been identified as a particularly potent force when combined with otherness associated with ‘race’. To be black and to have been diagnosed with a mental illness is to experience two forms of otherness that are mutually reinforcing (Scott, 1998; Wilkinson, 1998). The significant over-representation of young black men in the most dehumanizing and coercive parts of the mental health system testifies to the social suffering that results from the social construction of the ‘black other’ (Frost & Hoggett, 2008). Through discourses of risk, the ‘welfare other’ is designated ‘at risk’ of dependency or ‘a risk’ to others, with the supposed moral deficits of ‘Non-white Others in welfare policy’ a sustained focus (Stanford & Taylor, 2013, p. 488).

Risk has also been linked closely with economic policies of neoliberalism. The meaning of the term ‘neoliberalism’ has shifted over time, but in its contemporary form it is mainly associated with the assumption that markets are inherently superior. Neoliberalism is underpinned by values of extreme individualism and self-interest with the expectation that citizens have agency actively to fulfil certain duties responsibly (Stanford & Taylor, 2013). Where citizens fail in their duty to look after themselves and, specifically, fail to plan for and guard against future risks, then they become blameworthy. Under neoliberalism, state welfare systems are viewed as burdensome, especially because they are seen to generate dependency among welfare recipients. Key to understanding the relationship between risk and neoliberalism is the idea that the neoliberal project has benefited from the ‘fear of the future’ generated by a climate of a particular kind of individualized risk (Culpitt, 1999). The role of the state is no longer to own risk, but to attribute it to, and to regulate and blame, others. In this way risk has come to dominate all forms of human services as well as welfare provision (Stanford & Taylor, 2013). As part of wider sociocultural and political shifts that have taken place in Western industrialized societies, risk has supplanted care in terms of becoming the main focus of professional activity (Turner & Colombo, 2008). Psychiatrists, social workers, mental health nurses and support workers are all engaged to some extent in procedures and policies relating to risk assessment and risk management.

One of the difficulties with defining risk is that it is closely associated with a number of different processes, including perception, assessment, management and communication. In mental health, risk has found a particular expression, which has been described as ‘peculiar’ (Pilgrim & Rogers, 1999, p. xiv). This is partly because the concept of risk in mental health policy and practice has increasingly been identified with one dimension more than any other: the risks posed to others by people with a mental health problem as opposed to the risks they overwhelmingly face. The preoccupation with the risk of harm to others is in contrast with other fields of social welfare, such as learning disability and older people, where the vulnerability of people ‘at risk’ is a more prominent feature. The question of how far this is new or simply a reworking of old fears about ‘madness’ and dangerousness has been the subject of some debate. When we ask how the particular and ‘peculiar’ expression of risk in mental health can be understood, part of the answer is linked to the major changes in ideas about care and in particular the shift away from asylum to ‘community care’. From the 1960s large-scale institutions in the form of asylums, which had been a feature of the landscape across Europe and the US throughout the nineteenth century, began to lose their credibility in the minds of policymakers. The pace at which change took place was variable, but as Pilgrim and Rogers (1999) have argued, the overall trend towards deinstitutionalization was broadly the same.

Community care and the ‘shift to risk’

One important reason for particular constructions of risk in mental health links to the policies of deinstitutionalization in mental health systems that have been implemented across Europe, North America and Australasia – that is, the shift from asylum to community in terms of the location of formal service provision. While this movement can be understood as progressive, it can also be understood as a further reflection of neoliberal ideology and the push towards marketization of welfare that has featured more widely across Western democratic states. ‘Care in the community’ may have its roots in an ethical stance about mental health service users as citizens, but there is also an argument that the driving force behind policies has been economic. One of the most plausible explanations is the ‘fiscal crisis’ thesis proposed by commentators in social policy, such as Lewis et al. (1995), where it is argued that limited resources demanded a focus on those deemed most ‘in need/high risk’. As Pearson (1999, p. 164) has pointed out, however, the implications of this development for mental health compared with most other policy areas have been quite distinctive:

Where the mental health field is concerned, however, this fiscal squeeze has come to be associated not with the ‘invisible welfare state’ of family obligations, but with the newly demonised vision of unchecked madness rampaging the streets.

At this point in our discussion we should note that community care, or, more specifically, the twin concepts of ‘community’ and ‘care’, are contested and themselves subject to intense debate. Both community and care have received detailed attention in social policy and social welfare literature (Bornat et al., 1993; Bytheway et al., 2002; Symonds & Kelly, 1998). Although there is insufficient space here to explore these areas in depth, one of the most helpful insights for present purposes is the distinction that can be drawn between community care a...