Challenging ideas in mental health
Challenging ideas in mental health

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Challenging ideas in mental health

2.2 What is risk?

‘Risk’ is a word which is used frequently and in many different contexts. On the face of it, it can seem as though the word has a clear meaning, but when you start to examine the different ways it is used it seems less straightforward. This is because ‘risk’ is not a real thing in the world, it is a concept, which simply means it is an idea expressed in words. In fact, the more you explore it, the more you realise risk is a problematic concept: it has been defined in a number of ways and so means different things in different contexts and to different people. There has been a lot of debate about the meaning of risk in recent times because it is seen as increasingly central to modern life. This section explores the meaning of risk and looks at the different explanations offered for its increased prominence. Examining how people use the word in everyday life may help to unpack its meaning, and so this is the focus of the next activity.

Activity 5: Exploring the meaning of risk

0 hours 15 minutes

Take a few minutes to think about how you would define the word risk and make a note of your ideas. If you get the opportunity, ask other people what they think the word means, and make a note of what they say too. Look out for two important ideas: that risk involves the chance, likelihood, or probability (or similar words) of something happening, and it often involves the chance of something ‘bad’ happening or something ‘good’ happening, or perhaps both.

Discussion

The following are some examples that course testers came up with when they did this activity:

  • Risk only exists when there is something to lose.

  • Risk involves an assessment of the likelihood of any particular outcome occurring.

  • Risk can lead to failure.

  • Risk is sometimes defined by you, sometimes by others about you.

  • Risk is the probability of a predicted outcome occurring.

Although your definitions of risk may be different, they are likely to involve the two ingredients of the chance of something happening and the nature of the outcome, which might be good, bad or both.

The likelihood of something happening can be assessed in two ways: in mathematical or in more qualitative terms. The mathematical approach involves measuring the probability of an event occurring and giving a figure that summarises the risk. For example, before consenting to an operation a patient might be given a figure that describes the likelihood of the procedure being successful, such as ‘a 1 in 100’ chance of success. This would mean for every 100 patients who had undergone the same operation, it had been a success for one of them. Of course, this means it had been a failure for the other 99. This would clearly not be as good as being told there is ‘a 1 in 2’ chance of success, which would mean the operation had been a success for one out of every two patients. Qualitative approaches use words instead of figures, by saying the likelihood of an outcome is, for instance, ‘quite likely’, ‘very likely’ or ‘very unlikely’. In both mathematical and qualitative approaches, some assessment of the likelihood is being made.

In the context of mental health, a similar distinction is drawn between two kinds of risk assessment: ‘actuarial’ and ‘clinical’ (Parsloe, 1999). Actuarial risk assessments use statistical information about populations to help make decisions about who may be ‘at risk’, depending on whether or not they belong to a high-risk group. For example, in suicide risk assessment it is known that higher-risk groups are people who are older, male, separated, divorced or widowed, live alone, are unemployed or retired, are in poor health, have a mental illness, or abuse substances (Alberg et al., 1996). Clinical risk assessment is when professionals use their informed judgement to assess the level of risk. This judgement may be based on experience as much as statistical knowledge about risk factors. Most risk assessment involves some combination of these two approaches.

Closely linked to the likelihood of an outcome occurring is the second important aspect of defining risk, which is the nature of the outcome. To continue the example of a medical procedure, a patient might be making a decision about a relatively minor operation which involves only local anaesthesia. The possible outcomes associated with such minor surgery are normally far less serious than those involved in an operation under general anaesthetic, because the general anaesthetic itself carries some degree of risk. So, decisions about risk often involve consideration not only of how likely an event is to happen, but also what the consequences might be if things go wrong: whether it is ‘high consequence’ or ‘low consequence’.

Some definitions of risk incorporate the possibility of good outcomes as well as bad. For example, if you buy a lottery ticket, you might say that you are taking a ‘risk’ because there is a chance of a bad outcome (you might lose your money) or a good outcome (you might win some money back). In fact, this association between risk and gambling goes back a very long way, at least to the seventeenth century. An argument has been proposed in the mental health literature that we need to return to this way of thinking about risk. This would mean seeing risk assessment as a way of balancing the possibility of good outcomes against the possibility of bad ones (Davis, 1996).

However, a number of commentators have argued that risk is not really thought of in terms of balancing good and bad outcomes any more. They argue that in Western societies risk now generally refers only to the possibility of a bad outcome and there are important reasons why it has taken on this meaning. Mary Douglas (1992) is one of the most influential thinkers in this area and she argues that risk in modern Western societies now equals danger: ‘the word risk now means danger; high risk means a lot of danger’ (Douglas, 1992, p. 24).

Danger is clearly a word associated with negative outcomes. For Douglas, one of the reasons the word risk is more prominent is that it implies a rational, scientific capacity to measure danger accurately. It is therefore well-suited to modern industrialised societies where there is rapid technological change. This is because, as you have already seen, risk is associated with words like ‘probability’, where an estimate can be given for the chances of something occurring in mathematical terms. The appeal of risk is that it gives us the sense of dangers being measurable scientifically and therefore manageable.

Douglas has also argued that risk has become a central concept in modern life because it has a ‘forensic’ function. Blame is primarily centred on the failure of someone to assess risk accurately and then to take the steps necessary to prevent a tragic incident. So the concept of risk enables people to look back at tragic events and attribute blame for them to someone else. The media play a key role in shaping how we all think about risk and the process of attributing blame. The next activity focuses on risk-related stories in the newspapers to explore how risk issues are presented in the media. This may help clarify further some of the complex issues to do with risk you have considered so far.

Activity 6: Exploring risk in the media

0 hours 30 minutes

Look at two newspapers that are clearly aimed at different sectors of the population (such as the Independent and the Sun, or the Guardian and the Daily Mail) from the past few days. Scan the headlines for stories that are concerned with risk in some way. Some may actually have the word ‘risk’ in the headline, but most will not. You may find risk-related words such as danger, hazard or warning instead. Read through the articles you find and start to analyse the way risk is being presented. Look out for the dimensions of risk you have already considered in this section as follows:

  • the likelihood of something happening (which might be expressed mathematically, i.e. using statistics, or qualitatively);

  • a focus on bad outcomes as opposed to good ones;

  • the seriousness of the outcome;

  • whether anyone is being blamed.

Make a note of what you find under a separate heading for each newspaper.

Discussion

In analysing the articles you may well have noticed references to likelihood in some form. These may have been in the shape of quantitative risk estimates, including references to probability such as ‘twice as likely’ or ‘three times more likely’. You may also have noted more qualitative statements, such as ‘very likely’ or ‘higher risk’. In terms of the nature of the outcomes, the focus in press reports tends to be on bad outcomes rather than good. You may have noticed that some newspapers tend to go into greater depth in their reports, and often make an attempt to analyse findings in a more sophisticated way. They tend to use more complex language and discuss the implications of reports more thoroughly, although this is not always the case.

Course testers who did this activity commented that headlines about risk in ‘tabloid’ newspapers tended to be more sensationalist. For example, one headline simply said, ‘We Will Die’! In contrast, other newspapers seemed to try to give more factual accounts of potential outcomes.

This activity suggests another important dimension of risk, which is that risk is political. The way risks are presented in different parts of the media and elsewhere vary according to the perspective of the groups or individuals concerned. These different perspectives often come into conflict with one another. Some groups may seek to ‘play down’ a risk, while others may seek to magnify it. Some kinds of risks are given greater weight than others because of what they mean, culturally or politically, and so the amount of attention different risks receive is not always proportionate to the actual likelihood of an event occurring. One of the best examples of this is in relation to child mortality. The biggest single risk facing school-age children is road accidents. However, this kind of risk receives far less attention in the media than child abduction and murder by a stranger, which is presented as an increasing problem, despite the evidence to the contrary:

Many parents simply do not believe that, over the years, the number of children murdered by strangers has remained fairly static. On average it has been five per year. A few highly publicised child murders have helped shape the impression that such tragedies ‘could happen to every child’.

(Furedi, 1998, p. 24)

Another good example of disproportionate attention given to low probability events in the media is the focus on homicide by someone experiencing mental health problems. It is argued that this has been one of the most significant contributions to the ‘fear factor’ about mental health since community care policies were introduced. It has been noted that modern images of people experiencing mental illness as a danger or threat have been linked to ‘violent masculinity’ (Pearson, 1999, p. 166). In mental health terms, the reporting of negative images of mental disorder, particularly stories that relate to violence and especially those that include elements of racist stereotypes of black men, are very powerful (Keating et al., 2002; Sayce, 1995). The next section further explores the central position of risk as a concept in connection with mental health and distress.

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