2.3 Community care, fear and the ‘high-risk’ service user
So far in this course you have seen how the concept of risk has come to suggest danger. This section explores in greater depth how the changes that have led to this situation have impacted on mental health policies and practice. The next activity involves reading an article to help you consider risk in the context of mental health services.
Activity 7: Risk and mental health policies
Click on Reading 3 by Hazel Kemshall below. As you read, make a note of your answers to the following questions:
How are risk reduction and risk taking defined?
According to Kemshall, which of the two is the more dominant in mental health policy?
What are the main reasons for this emphasis?
Click to view Reading 3.
The article describes risk reduction as a basically defensive response to the perceived failure of community care policies. Rather than focusing on the needs of all service users/survivors and providing services accordingly, risk reduction strategies encourage the focus to fall on small groups of ‘high-risk’ people. Kemshall argues this is currently the dominant approach in policy.
This article emphasises that risk taking has its roots in service user/survivor empowerment and involvement and is seen as a necessary part of life. It is underpinned by a focus on the radical values of empowerment and structural change. It challenges risk reduction strategies by reducing stigma, dependence and over-protection.
Risk taking is about professionals and service users/survivors working together to ensure that decisions about risk take account of their possible benefits as well as the possibility of bad outcomes.
The major change in mental health policy in recent years has been the shift from asylum care to care in the community. There has been a great deal of debate about whether this policy has been a success or not. The government has stated that community care has failed, and community care policies have also been presented in a negative light in the media. However, one thing is clear: the media portrayal of people experiencing mental health problems in general is overwhelmingly negative. In particular, community care has been linked with an increase in violent attacks by people experiencing mental distress. Community care has been ‘socially structured’ so that it is now equated with violence committed by people experiencing a mental health problem.
The debate about the supposed link between mental distress and the risk of violence to other people is fraught with difficulty, and you have already examined some of the issues. Consider for a moment the question of how ‘violence’ itself should be defined. In some studies, violence has included relatively minor acts which have been excluded from other studies. In other words, different studies have been measuring different things. However, studies do consistently show that the vast majority of people who act violently in our society are not experiencing mental distress. The main risk factors for violence are being male, young, less well-off and under the influence of alcohol. Equally, the vast majority of people who do experience mental distress, or have a history of it, never behave violently. To this extent, the link between mental distress and violence is very weak. However, some studies have shown that a small number of people may be at increased risk of becoming violent towards other people, but only when they are actively unwell (Hodgins, 1993; Monahan and Steadman, 1994). It is important to emphasise that this is not the same as saying that rates of violence have increased.
In order to make sense of this issue, it can be helpful to focus on understanding the nature of some of the symptoms of some forms of mental distress, particularly paranoia. When someone is behaving in ways that others view as ‘irrational’, the behaviour still makes perfect sense to that person. For example, if I believed that my postman was in the CIA and was plotting to assassinate me and my family, but there was no evidence that this was true, it could be safely assumed that my belief was ‘irrational’. However, within this irrationality, any efforts I made to defend myself, such as barricading my front door or threatening the postman when he delivered the post, would make sense because they would be a ‘rational’ response to a perceived threat that I was convinced was real. If, at the same time, I was hearing voices that were directing me to attack the postman before being attacked myself, it is not difficult to understand how threats or even violence might be one possible outcome. This scenario illustrates that there is ‘rationality-within-irrationality’ (Link and Stueve, 1994), particularly with intense feelings of paranoia. When some people are very paranoid and terrified that they might be attacked themselves, a violent or threatening response ‘in self-defence’ can result. Such behaviour is often completely out of character for those people.
The media present a picture which increasingly links mental distress with violent behaviour. The focus on the rare event of homicides in the community by people experiencing mental distress has resulted in the perception that the number of such events has increased under community care. A number of studies have demonstrated this is not the case (for example, Taylor and Gunn, 1999). Most tellingly, the five-year report of the National Confidential Inquiry into Homicide and Suicide by People with Mental Illness (DH, 2001) included the following statement under the heading of ‘Stigma’:
One of the most distressing problems facing people with mental illness is the prejudice and discrimination they face from society at large. In particular, the assumption that they are likely to be violent is painful and destructive. The Department of Health, the Royal College of Psychiatrists and others have attempted to tackle these public perceptions and pejorative press reporting through campaigns that aim to give the facts about the risks presented by the mentally ill. Key findings in this report should be used in this way. For example, the killing of strangers by people with mental illness is rare; most stranger homicides are committed by young men without mental illness who are under the influence of alcohol or drugs. The public may fear the mentally ill but they are more at risk from heavy drinkers.
(DH, 2001, p. 152)
The idea that mental distress can be very frightening, for both those who experience it and those close to them, is hardly new. Many people who have written about how mental health services have developed have emphasised the importance of social fears and anxieties as determining factors in the way mental health care is organised. The asylums of earlier centuries, for example, are often portrayed as institutions designed to ‘protect’ society as much as, if not more than, the people who were detained in them.
It is argued that community care policies have resulted in many of these fears being revisited with a special force because they may reflect deep-rooted cultural fears of mental distress (Pearson, 1999). Presenting the media with ‘the facts’ is likely to have little impact on such deep-rooted fears and this may explain why this strategy has so far failed to prevent negative media reporting. These fears are about what it means to be ‘mentally distressed’ in a society which is undergoing rapid change, one consequence of which, it is argued, is that ‘rationality’ and social order are valued particularly highly.
You have seen that there has been a focus in policy and the media on what individuals may experience or do to other people. However, there is good evidence in the relevant literature of important risks posed by organisations and services to service users/survivors. In other words, sometimes services are organised in a way that means service users/survivors are exposed to risks they otherwise might not encounter. A good example is the way discharge planning tends to emphasise the importance of someone's preparedness for discharge. Decisions about this are often based on relatively narrow measures of someone's fitness, relating to the treatment for whatever is identified as their primary mental health issue. People may be discharged with insufficient support networks in place because of this emphasis on risk rather than on their needs (Parton, 2001). Organisations tend to focus on preventing bad outcomes for which they are likely to be penalised financially. In particular, the culture of risk assessment has its origins in the increasingly litigious culture of the NHS in general. Organisations are afraid of being sued, and individual professionals are afraid of being publicly vilified.
Different groups of service users/survivors are affected in different ways by the culture of risk and defensive practices in mental health services. One particular group that is adversely affected, and about whom a culture of fear has developed, is young men diagnosed as experiencing schizophrenia. Within this group, black men are particularly ‘at risk’ of being regarded with fear and mistrust. Research has shown that people from particular ethnic groups are over-represented in some psychiatric diagnostic categories compared with other ethnic groups. One of the most hotly debated issues relates to the over-representation of African-Caribbean men with a diagnosis of schizophrenia.
There is also an over-representation of African-Caribbean men in terms of the kinds of services they are likely to receive. They are more likely to experience coercive forms of intervention, such as compulsory admission to hospital or detention via the police. In terms of explaining this over-representation, one very powerful argument presented in some studies is that black people are less likely to voluntarily seek support from services than their white counterparts. This is because of the poor experiences many black people have had of mainstream services. Therefore they are less likely to benefit from support, from their GP for example, during the early stages of their experience of mental distress. When they do eventually come into contact with services, they are thus more likely to do so because they have become very distressed.
The relationship between ethnicity and violence is another good example of how the media have contributed to distorted images of particular issues. In a general sense, media reporting of crime contributes to an association between black people – especially young black men – and certain types of crime (particularly muggings and other forms of violence). This means that young black men are at risk of becoming the victims of a particularly powerful cocktail of distorted images. This is an issue which has been actively addressed by some services in order to adequately meet the needs of particular groups of service users/survivors.
Fanon Care is an organisation based in south-west London which provides specialist mental health services for African and Caribbean people living in the area (Southside Partnership, n.d.). In particular, it stresses the importance of early intervention in order to avoid crises. It is a good example of an approach to services which emphasises people's needs rather than risks. The organisation's vision statement says:
Fanon Care's vision is of:
A society that puts people first and provides them with a choice of the highest quality services aimed at promoting mental well-being, delivered by people who want to make a difference.
A society where black people in mental distress are valued and included as equal citizens in the communities in which they live.
A society where there is much greater public understanding of the issues they face, and where diversity is valued.
A society that recognises the oppressive nature of racism and its effects on mental well-being.
It is clear that a disproportionate amount of attention is given to the risk of violence by people experiencing mental distress compared with other risks affecting them. This adversely affects some groups more than others. There is a perceived link between mental distress and violence, and this perception itself gives rise to a number of risks for service users. At least six have been identified by Alberg et al. (1996), although you may be able to think of more:
The priority given to risk of violence may mean that other types of risk – such as the risk of self-harm – are not addressed.
Professionals appear to relate differently to someone who is identified as a risk for violence: for instance, they may be afraid or critical.
The label ‘violent’ is highly stigmatising and tends to stick, even when a person is no longer at risk of becoming violent.
People can be blamed for their violent actions even though it may be a symptom of their illness rather than behavioural.
People who have become violent in the past are often placed in secure conditions where there is a high risk of violence to them from other patients.
Someone who has become violent in the past is more likely to be detained compulsorarily and therefore have less say in their treatment and care options.
So, the narrow focus on the risk of violence has serious implications for service users/survivors and their everyday experiences of services and professionals. As well as perpetuating a negative image of mental health service users/survivors, it also means that other risks that are just as real and pressing tend to be neglected. In part, this problem can be addressed by professionals in their practice by paying closer attention to service users'/survivors' perspectives on risk.