The construction of people with mental health problems as risk objects: Findings of a case study inquiry

Abstract

Accessible summary What is known on the subject? Risk assessment and management in mental health services are contested and perceived as problematic by both professionals and service users. There is substantial emphasis on risk as a core component of professional practice. However, recovery for people with mental health problems emphasizes self‐determination which seems to conflict with risk management. A critique is emerging of risk assessment and management. However, there is a lack of empirical evidence which seeks to explore how professionals manage the conflicts between recovery orientated practice and risk management. What the paper adds to existing knowledge? The paper reports on qualitative research which highlights people with mental health problems are objectified and frequently associated with the potential for harm. Risk dominates the work of mental health professionals and undermines individualized care. Service users are subject to increased surveillance and medication as a result. What are the implications for practice? Service users’ subjective experiences need to be prioritized in mental health care by renewed focus on the relationship between professionals and service users. Mental health professionals should question the centrality of risk to their practice. Abstract IntroductionThe emergence of recovery, alongside significant focus on risk management, creates potential for conflicting influences in mental health care. Although evidence has critiqued risk assessment, there is a lack of research that seeks to explore how professionals make decisions within these apparently incompatible agendas. AimTo explore how practitioners, experience potential tensions arising from delivering recovery‐orientated care and enforcing containment. MethodThis paper reports on a case study inquiry, using interviews with mental health professionals and observations in an acute ward and an assertive outreach team. ResultsRisk governed the practice of mental health professionals to such an extent it defined how service users were understood and treated. Service users were constructed as objects of risk, first by being objectified and secondly by creating a link between that object and harm. DiscussionHilgartner's (1992, Organizations, uncertainties and risk (pp. 39–53). Boulder, CO: Westview Press) theory of risk explains how risk dominates the identity of people with mental health problems at the cost of recovery. This results in increased monitoring, surveillance and medication to enact control. Implications for practiceTo undermine the dominance of risk, professionals should reconnect with the subjective experiences of people with mental health problems and challenge the acceptance of risk as central to their role.

Patient perspectives of helpful risk management practices within mental health services. A mixed studies systematic review of primary research

“…Studies have acknowledged that tensions involving risks can lead clinicians to avoid patients, as a way of circumventing risk anxieties and concerns about culpability (Felton et al, ). However, what this review adds is that when clinicians acknowledge these tensions and offer space to negotiate, a valuable shared understanding can emerge.…”

“…A potential discrepancy was a lack of detail in how interpretations were verified by participants. Given that literature criticizes absence of patient involvement in risk management (Felton et al, ), it follows, at least ethically, that patient participation is more considered when their views are utilized in research. Hence, while acknowledging the aforementioned limitations, it is recommended that future studies consider member checking as characterized by Birt et al, ().…”

The governance of sexuality in a Recovery‐oriented mental health service: Psychosis, consumers and clinical approaches

“…Another explanation for this is not so much that sexuality enables this resistance because of identification per se but because sexuality allows for a more proximal relationship between clinician and consumer as it is not so rigidly defined by the nosology of psychiatry. This explanation draws on Felton's PhD work (Felton et al, ). The findings of her study indicate that a proximal relationship where the clinician feels some connection with the consumer's distress, makes it more difficult to construct the consumer as an object.…”

Factors influencing decisions of mental health professionals to release service users from seclusion: A qualitative study

“…Service users appeared to have little involvement or choice in decisions regarding their release. This suggests seclusion practices remain paternalistic (Goulet & Larue, ) and, if patients do not feel their opinion is valued (Soininen et al, ), it will reinforce tensions regarding the management of restraint (Felton, Repper, & Avis, ) and counter principles of shared decision‐making central to the recovery movement (Slade, ). Furthermore, as decisions to use seclusion are not therapeutic interventions, it seems professionals find the ideal of equality and service user involvement at this stage of their journey unrealistic.…”