Mental health practice: a risky business?

Citation

Felton, A. and Wright, N. (2018), "Mental health practice: a risky business?", The Journal of Mental Health Training, Education and Practice, Vol. 13 No. 1, pp. 1-2. https://doi.org/10.1108/JMHTEP-11-2017-0061

Mental health practice: a risky business?

Risk is a core aspect of mental health practice that remains high on the agenda for mental health services and professionals. However, the growth of the recovery philosophy in mental care has raised new questions about the impact of risk assessment and management approaches, creating the need for a critical debate surrounding risk. This special edition draws on a wide range of expertise to examine theoretical, professional and service user perspectives on risk and mental health. It aims to promote recovery-orientated practice through critique and the exploration of new ways of working with risk.

Until recently, the majority of literature on risk and mental health focussed on the evidence base of risk calculation with debates centred on the validity of clinical judgements and risk assessment tools. More recently, a small but growing voice has demanded the need to recognise the limitations of these approaches to understanding risk. There has been increased recognition of the damaging impact the process of risk assessment and the consequences, often in terms of restrictive practices can have on service users. The publication of Boardmen and Roberts (2014) “Risk, safety and recovery” paper for Implementing Recovery Through Organisational Change set out the key challenges for mental health services to adopt ways of working with risk that promote rather than undermine the principles of recovery. A shift in practice involves acknowledging the expertise of lived experience and the importance of people with mental health problems having access to opportunities through positive risk taking and collaborative approaches to safety planning. Risk can dominate service users’ identity and adopting these approaches has the potential to challenge the influence of risk in peoples’ lives (Felton, 2015). However, professionals remain under pressure to provide accurate predictions of future events and satisfy organisational demands.

The special edition draws together international work of practitioners, academics and service users to first offer a critical examination of risk in the context of mental health services before considering the role of recovery and the adoption of more person-centred approaches to promoting safety and managing risk.

The edition begins with two papers which examine the current risk assessment and management practices with a particular focus on the areas of violence and aggression. These issues have often presented the biggest challenge to policy makers, the media and the public and have been influential in both practice and the literature on risk. Callaghan and Grundy present a narrative review of risk assessment of violence and mental health from both an evidence and conceptual perspective. The paper highlights that risk assessments aspire to reduce harm yet have little impact on this area whilst actually perpetuating stigma against people with mental health problems. The paper sets out a powerful starting position to question contemporary practice of risk assessment.

The second article offers in-depth insight into the viewpoint of practicing Psychiatrist Giles Newton-Howes. Echoing the previous paper’s recognition of the limitations of risk assessment, this article explores the societal and legal influences on risk-orientated practice for mental health professionals. The stimulating discussion concludes with the need to move away from the practices focussed on prediction of risk to collaborative recovery-orientated relationships with service users and their families to facilitate not only safety but high-quality care.

The remaining four papers consider risk and recovery, incorporating an exploration of professionals’ perspectives, older peoples’ views and theoretical inquiry. Crowe and Deane offer an empirical analysis of implementing positive risk taking which involved investigating the relationship between professionals’ commitment to recovery practice and their risk aversion. Their research examined the perspectives of both clinicians and managers, providing a comparison between the two. This paper offers a unique and in some respects surprising insight into attitudes to risk and recovery across the hierarchy of an organisation.

Picking up on the central role of professionals’ values in influencing risk practices, Morrissey, Doyle and Higgins focus on the experiences of individuals who self-harm, offering an appraisal of the discourses that shape the responses of mental health professionals to people who may self-hurt. The authors position self-harm as an action that is often misunderstood and can attract stigmatising and unhelpful attitudes amongst staff. The article explores how a recovery-orientated approach to safety planning could offer a personalised and compassionate means to support individuals who self-harm, traditionally defined as “risky”.

Extending the focus on the experiences of individuals in relation to risk, Clarke, Titterton, Wilcockson, Reed, Moyle; Klein, Marais and Cook’s research provides a fascinating and rare perspective on well-being in older people. The multi-national research study using focus groups and interviews with people over the age of 65 draws out how risk perceptions are temporally linked but also how risk can be a feature of ageist attitudes. These mask the resilience and strategies for coping with life challenges employed by older people.

The final paper brings together the emphasis on both the limitations of risk assessments and the desire for greater recovery working presented in the special edition. Felton and Stickley propose that the narrative provides a powerful and important framework that facilitates a co-produced understanding of safety and risk, which centralises the individuals’ subjective experiences. Narrative facilitates a nuanced and personalised assessment of areas which may threaten a person’s safety but also strengths, coping and resilience. The authors employ a narrative theory to argue for the benefits of this approach to risk and recovery.

Being a guest editor for this edition has been a privileged opportunity to work alongside researchers, innovators, academics practitioners and service users in the journey towards moving beyond the tensions between risk and recovery. Open and honest discussions about the risk assessment processes and the opportunities offered by co-produced safety plans creates the possibility to progress from a situation in which service users are treated as the source of risk towards one in which the person is supported in taking more control.