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Challenging ideas in mental health
Challenging ideas in mental health

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2.2 Community care, fear and the ‘high-risk’ service user

This is a photograph with a sign saying ‘Crime scene do not cross’.
Figure 7 Mental distress and the risk of violence have been falsely conflated.

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.

A major change in mental health policy, which occurred over a number of years, was the shift from asylum-based treatment to care in the community. There has been a great deal of debate about whether this policy has been a success or not. However, one thing is clear: the media portrayal of people experiencing mental health problems in general continues to be negative.

The debate about the supposed link between mental distress and the risk of violence to other people is also 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. Furthermore, Ross and colleagues’ (2019) work has noted that the media can potentially exacerbate or exploit this weak link. For example, after systematically reviewing all research studies that explored the impact of the media on stigmatising attitudes towards those with ‘severe mental illness’ they documented some notable trends. In particular that reporting in the news media often focussed on the negative aspects of mental illness, and that there was an over-representation of negative portrayals of people with a mental illness, where dangerousness to others and violence were the most common negative depictions.

The media continues to 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. However, since 2009, the number of homicides committed by people diagnosed with a mental illness has actually decreased (Appleby et al., 2018). Moreover, when a detailed analysis of ‘patient homicides’ in the UK (from 1997 onwards) was conducted, certain key features were identified. Specifically, substance misuse was usually a factor, around half of the ‘patients’ were not receiving the mental health care intended for them and the ‘patients’ were also at high risk of being a victim of homicide (Appleby et al., 2018). Tellingly, the issues are not new, as in 2001 the National Confidential Inquiry into Homicide and Suicide by People with Mental Illness (DH, 2001) stated:

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 was argued that community care policies in the 1990s (and beyond) 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 hospital discharge planning tends to emphasise the importance of someone’s preparedness for discharge from an in-patient mental health unit. 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. 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 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 having 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 extremely 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.

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.