Abstract
Beyond the Risk Paradigm in Mental Health Policy and Practice argues that risk is the major organising principle of contemporary mental health policy and practice in the Western World. The book adopts a partnership approach to ‘speak back’ to the dominant risk paradigm in mental health, integrating theoretical, practice and lived experience knowledge (p. 174). Reflecting this, the 12 chapters are by Australian, British, Irish and North American authors with academic, practice and lived experience of mental health issues.
The opening chapter by the editors sets the mental health risk paradigm within the wider context of the ‘Risk Society’ (Beck, 1992) and the ‘othering’ of marginalised groups within neo-liberalism. They argue convincingly that mental health policy and practice has been dominated by a conceptualisation of risk as measurable, predictable and focused on ‘danger’ to others posed by people with mental health problems. Perceived dangerousness is used to justify coercive legislation (for example Community Treatment Orders, introduced by the 2007 amendments to the 1983 Mental Health Act in England and Wales). The paradigm minimises attention to other elements of risk, such as the iatrogenic harm caused by mental health services’ interventions and the disproportionate detention of black people in psychiatric hospitals in the UK (Health and Social Care Information Centre, 2016).
The range of authors’ backgrounds is reflected in the eclectic subjects of the chapters, which include analysis of mental health legislation, the experience of managing mental health services, suicide prevention, and the mental health of asylum seekers and refugees. Nevertheless, some common themes animate the book. Central is the recognition of the ‘social suffering’ experienced by people with mental health problems. This is obscured and magnified by the risk paradigm’s focus on dangerousness and on ‘compliance’ with treatment and services. In their chapter, Gerry Bennison and Dawn Talbot discuss their lived experience of mental health problems and the dehumanising experience of being seen as ‘a risk’ rather than ‘at risk’.
How do we challenge the risk paradigm? Throughout the book, authors promote a human rights based approach to mental health policy and practice centred on choice, participation and fairness. Given the dominance of the risk paradigm in policy and practice, this creates potential conflicts for workers and users of services. Anne-Maree Sawyer’s chapter draws on her research with Australian mental health practitioners on the experience of using a human rights based approach. She found many workers struggled to balance the procedural risk management required by their agencies with positive risk taking and relationship building.
Across the book, authors suggest critical reflection as a first step to challenging the hegemony of the risk paradigm. This is most strikingly outlined in the chapter by Catherine Hartley, Chris Lee and Jim Campbell on their experience as mental health managers within the UK’s National Health Service. They identify the impact of the risk paradigm in the performance management dominated culture of their workplace. Workers felt personally accountable for the management of risk, despite the impact of cuts to services and the difficulty of accurately predicting adverse events. As managers, they encouraged workers to write reflective logs and used art images to prompt team discussions. Memorably, the workers were divided over their interpretation of de Goya’s The Third of May 1808, unclear whether they were the firing squad because of their coercive interventions with users of services or the victim given the impact of managerialist demands on them.
The eclecticism of the authors and subjects of the chapters does lead to some unevenness and inconsistency across the book: for example, in the use of mental health terminology. Perhaps the main weakness is the limited number of authors who acknowledge lived experience of mental health problems: hearing more diverse perspectives on what it feels like to be on the receiving end of the risk paradigm would have been helpful. However, these weaknesses are acknowledged by the editors in the excellent final chapter. What I particularly liked was the tone of critical reflection and respectful uncertainty in this chapter. They suggest that confronting the risk paradigm, with its ‘tidy understandings of mental health and risk categories’ (p. 188), exposes us to complexity and uncertainty. Given the dominance of the risk paradigm, with many of us having internalised its tenets through training and socialisation, challenging the paradigm is a long-term process. This book is a helpful contribution to that process. The editors’ state this is the first of a series of three books: I look forward to reading the next two.