Risk is an idea that seems to hover over mental health like a dark blanket of cloud. Public discourse around mental health is suffused with it. It runs through every discussion of how mental health services might be better delivered.
One of the most radical (and contested) suggestions emerging from Big Society ideas is that people are better placed to decide what they should do than the state. Rather than the state services coming up with solutions on their behalf, the Big Society idea believes that people can come up with their own answers and find their own ways of doing things.
This questions the idea that it is the role of decision makers to decide courses action to the people upon whose behalf they make decisions. This is why Big Society is often described as a ‘bottom up’ movement.
The model is that people work out what they want to do and it is the job of the state to help them do it.
If the Big Society is to have a legacy in mental health, it is this bottom up empowerment that will be its lasting legacy.
Perception of risk and creation of extensive structures and processes to manage it are generally regarded as a major impediment to innovation in the public sector in a general sense. So much so that it often seems that the burdensome effects of risk management can be negative as the potential dangers that they have been introduced to mitigate against. But perceived risk is a particularly significant issue in mental health, even when compared to the public sector as a whole.
Why would the issue of risk be of more concern in mental health than in other fields of activity?
Knowing that someone experiences mental health difficulties often brings into play a highly developed set of concerns about risk that would not be present if that person’s mental health difficulties had not been disclosed.
The NHS tends to see its role as a ‘looking after’ people with mental health difficulties, which can lead to a paternalistic concentration on preventing the possibility of harm to either themselves or others.
Local authorities tend to see its role as risk managing potential events, reducing the possibility of hazardous outcomes.
Both of these can come into direct conflict with the wishes and aspirations of people with mental health difficulties to do and decide things for themselves.
Rather than preventing things that we know have a good chance of occurring otherwise, risk management can often slide into preventing things that may happen or may not happen.
This partly has its roots in the historical role of mental health services, which were often literally conceived as mechanisms to prevent harm to self and others, partly to an honourable intention to safeguard individuals and staff from harm and partly as a response to wider political and media narratives about the ‘responsibility’ of mental health services for the conduct and actions of people within their care.
This focus on risk and safety, while often welcome where deployed in the right situations, can lie like a stifling blanket over the possibilities for people with mental health difficulties to do what they choose to do with their lives and with their time and energy.
It can also have a toxic effect when combined with existing stigmas and prejudices about people with mental health difficulties where controlling risk becomes more important than enabling possibility.
It creates a situation where the question is not ‘how can we make the best of this situation or services? But ‘how can we make sure that nothing bad happens for which we’ll be held responsible?’.
EXAMPLE: An NHS trust instigated the setting up of an innovative co-produced and peer led training and education project. The project was to be led by as many people with direct experience of mental health difficulty as possible and would use people with mental health difficulties to train both peers and professionals.
Some debate was had amongst clinical staff involved in the project that the physical setting and furnishings in the place that the project would take place were insufficiently ‘safe’ and could pose a risk should someone attending or employed wish to undertake violent or threatening behaviour.
In essence, the idea that people with mental health difficulties would use the space was taken as an indication that all risks should be controlled to the highest level.
In this case, these concerns were not upheld as suggested changes would have confounded what the project as a whole was trying to achieve.
In the context of personalisation, the same wish to control risk is at work but in a less obvious fashion. The tension for many is between stepping back to let people make their own decisions and intervening when those decisions do not seem to be in their best interests.
As noted elsewhere in this piece, the growing understanding of mental health difficulty and the growing range of aspirations that people with mental health difficulties hold have led to the extension of mental health services into areas where they are ill-suited.
One effect of this is to medicalise all aspects of an individual’s life once they have received a mental health diagnosis. All actions are then seen through the prism of their mental health.
The idea of personal recovery requires that someone find themselves an identity outside of a mental health diagnosis. Personalisation seeks to free people to use funds allotted to them in the ways that they see fit to support their own recovery.
Carrying over the mindset of risk has the possibility of stifling both of these processes.
Services have to let go of ideas of people who use them as passive recipients of services and work with them to develop their independence. They cannot do that in circumstances where the individual, because of their mental health difficulties, is always considered to remain a patient for which the service has an ultimate paternal responsibility.
To enable this to happen it makes sense to divide treatment, which is medical, and support which may be underpinned by medical principles but is not, in itself, medical. In treatment settings it makes sense to treat patients as patients. In everything else, people are people and should have the same expectations of agency as anyone else.
Recovery and personalisation should always enable people to make good choices, but the true measure of whether the shift in mindset has been made is whether services can allow individuals to also make what might be considered bad choices.
Services must let go of their attempts to control risk where it conflicts with people’s wishes to develop, grow and recover. To do so will mean, at least initially, stepping back and and enabling change to happen rather than stepping in to intervene to minimise the effect of change.
The prevention of risk must stop being used as a way to prevent uncertainty. If people are to make the decisions about what their recovery means and what their choices should be to get there, they must be able to supported and advised to the highest standard but free to take decisions themselves.
The same is true of organisations and groups formed by people with mental health difficulties. Paternalistic views of the needs and potential weaknesses of organisations run and staffed by people with mental health difficulties have led to an over-focusing on the risks of working with such organisations rather than a recognition of how much additional value they can add to service delivery. It is as if even as professionals, people with mental health difficulties cannot leave behind the idea that risks involving them or caused by them cannot be left behind.
Risk management can be a way of saying ‘we don’t think people like you should do things like that.’ Often people do not know what risk they are trying to minimise except for ‘the risk that people with mental health difficulties pose’
EXAMPLE: I have a mental health difficulty. In my professional role I regularly meet with leading healthcare professionals in a variety of settings.
When I receives treatment, I am treated very differently. As a patient I must step away from the desk, not demand to speak to someone, must sit down and wait to be called.
I am not different, but in the category of patient rather than professional I am considered to pose more of a risk.
(This blog post originated as part of a think piece Social Spider CIC is carrying out exploring how Big Society ideas interact with mental health. The full piece will be published in late March.)
Mark Brown is the editor of One in Four magazine.
Typical of the paternalistic attitude of Mental Health services is the fact that, in my area at least, there is no opportunity to use the ‘Choose & Book’ service when referred from one’s GP to a consultant, unlike every other speciality I’ve come across.
We need to realise that all of us face risks in mental health services. Sometimes the service user creates risk by violent or exploitative behaviour but that is not always the case. Sometimes a staff member may pose a risk to service users. Some can be violent or exploitative. Some carers can also pose risks.
For that reason I would like to eliminate language which implies that all acts of staff violence are legitimate. To me violence is violence. Sometimes it can be justified in self-defence. Other times a violent act may be an inexcusable act of aggression. But if staff automatically call certain types of violence acts of “restraint” you make it harder for people who do suffer real violence at the hands of staff.
That’s why I want an end to such terminology as “restraint”. Make everyone justify acts of violence each and every time. It should not matter whether you are staff or service user. We should be judged equally when it comes to risk.