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About this book

Modern society is increasingly preoccupied with fears for the future and the idea of preventing ‘the worst’. The result is a focus on attempting to calculate the probabilities of adverse events occurring – in other words, on measuring risk. Since the 1990s, the idea of risk has come to dominate policy and practice in mental health across the USA, Australasia and Europe.

In this timely new text, a group of international experts examines the ways in which the narrow focus on specific kinds of risk, such as violence towards others, perpetuates the social disadvantages experienced by mental health service users whilst, at the same time, ignoring the vast array of risks experienced by the service users themselves. Benefitting from the authors’ extensive practice experience, the book considers how the dominance of the risk paradigm generates dilemmas for mental health organizations, as well as within leadership and direct practice roles, and offers practical resolutions to these dilemmas that both satisfy professional ethics and improve the experience of the service user.

Combining examination of key theories and concepts with insights from front line practice, this latest addition to Palgrave’s Beyond the Risk Paradigm series provides an important new dimension to debates on mental health provision.

Table of Contents

1. THE HISTORICAL CONTEXT OF THE RISK PARADIGM IN MENTAL HEALTH POLICY AND PRACTICE: HOW DID WE GET HERE?

Abstract
The chapter begins by briefly setting the ‘rise of risk’ in mental health policy and practice in its wider context. It demonstrates that the idea of risk not only dominates mental health policy, practice and experience; it is also the major organizing paradigm in health and welfare services more widely. Of even greater significance is the fact that risk dominates public, political and cultural life in general. The language of risk is everywhere: in debates about health, childcare, pensions planning, banking, child protection, crime, what we eat, how we use our leisure time, what we buy. The idea of risk also characterizes organizational cultures and institutional life, where concern for the ‘reputation risk’ of those that occupy positions of power plays a particularly significant – and problematic – role (Power, 2004).
Sonya Stanford, Nina Rovinelli Heller, Elaine Sharland, Joanne Warner

2. UNDERSTANDING RISK AND COERCION IN THE USE OF COMMUNITY-BASED MENTAL HEALTH LAWS

Abstract
We use this chapter to explore the contested risk paradigms that can be used to understand the organization and delivery of mental health services, with a particular focus on the use of mandated legal powers. These debates have influenced our ideas as former Approved Social Workers in Northern Ireland, and now academics who have worked in the UK, Ireland and Northern Ireland. Our experiences have coincided with fundamental changes to the way in which politicians, professionals and the wider public view risk and coercion in community settings.
Sonya Stanford, Nina Rovinelli Heller, Elaine Sharland, Joanne Warner, Jim Campbel, Gavin Davidson

3. RISK THINKING AND THE PRIORITIES OF MENTAL HEALTH SOCIAL WORK ORGANIZATIONS

Abstract
Beck (1998) and Giddens (1994), in their analyses of contemporary ‘risk society’, see risk as having a democratizing effect, given our shared vulnerability to, and anxiety about, risk in the late modern era. However, governmentality theorists argue that meanings about risk are constructed and practised as an art of neoliberal government (Barry et al., 1996) and, as Dean (1999) points out, the heterogeneity of risk has allowed forms of neoliberal governance to colonize diverse and discrete spaces and practices.
Sonya Stanford, Nina Rovinelli Heller, Elaine Sharland, Joanne Warner, Chris Lee, Catherine Hartley, Elaine Sharland

4. MOVING BEYOND NEOLIBERAL RATIONALITIES OF RISK IN MENTAL HEALTH POLICY AND PRACTICE

Abstract
In this chapter we, the editors, explain why it is important and what it means to adopt a critically reflective approach to the mentality of risk (Culpitt, 1999; Rose, 1996) that informs current neoliberal welfare approaches to the organization, management and resourcing of services that respond to mental health problems. In keeping with a key theme of this book, we position mental illness as a human rights and social justice issue. That is, we locate the lived experience of mental illness, and its associated risks, as structured. In this way we connect the subjective experience of mental health problems with social inequality, which requires critical reflection of the ‘social misery’ (Frost & Hoggett, 2008, p. 438) that both gives rise to and that arises from living with mental illness. As Harrison and Melville (2010) note, globalization and neoliberal economic policies have introduced a new range of risk inequalities that impact people’s mental health worldwide. Our beginning point in the chapter is to explicate how neoliberal risk rationalities reinforce prevailing inequalities that are associated with mental ill health, limiting and in some cases precluding social justice. Next, we clarify the mutability of rationalities of risk, even though they are institutionalized in law, policy and practice. By understanding that risk forms a part of the rhetorical apparatus that supports the politic of neoliberalism, we are challenged to envisage how we might ‘speak back’ to its logic at macro (structural), meso (policy and organizational) and micro (interpersonal) levels. Sonya’s story above illustrates the importance of using a critically reflective approach to reconnect with and advance mental health policy that is human rights focused and aims to achieve social justice. We therefore present our model for critically reflecting on neoliberal rationalities of risk and how they operate in mental health settings, and we consider the implications such critical analysis has for moving beyond the risk paradigm in mental health policy and practice.
Sonya Stanford, Nina Rovinelli Heller, Elaine Sharland, Joanne Warner

5. DIRECTIONS FOR POLICY AND PRACTICE FROM THE LIVED EXPERIENCE OF MENTAL HEALTH PROBLEMS

Abstract
The chapter begins with Dawn’s reflections on an incident that occurred on one occasion when she was being admitted to hospital. Through this small and seemingly insignificant event, Dawn illustrates some key features about how the medical model of mental distress and risk thinking combine so that they dominate everyday experience and dehumanize normal interaction
Sonya Stanford, Nina Rovinelli Heller, Elaine Sharland, Joanne Warner, Gerry Bennison, Dawn Talbot

6. THE LIMITS AND POSSIBILITIES OF RISK ASSESSMENT: LESSONS FROM SUICIDE PREVENTION

Abstract
The management of the individual risk of suicide is arguably one of the most challenging practice dilemmas for mental health professionals and it is not an uncommon experience. Jacobson et al. (2004) and Heller and Parks (unpublished data), in studies of social workers in the United States, found that one in three had experienced the death of a client by suicide, and the overwhelming majority had worked with clients who were actively suicidal. While suicidality is a relatively rare, albeit increasing, event population-wide, it is not particularly rare in clinical practice. One of the core mandates for social workers is the enhancement of individual wellbeing, and work with the suicidal person tests our ability to fulfil that mandate. This work requires advanced clinical assessment skills, knowledge of the emerging suicide knowledge base and certainty about who is at risk, at what particular point, and under what conditions. Paradoxically, the worker must also be able to tolerate the ambiguities and uncertainties of suicide risk assessment and prediction, all while maintaining a crucial connection with the humanity and complexity of the individual at risk. At the same time, in the context of a dominant risk paradigm, the public, funding agencies and government regulators, managers and supervisors, and indeed we ourselves, demand certainty in our assessment and prevention efforts. Work with suicidal clients is not for the faint of heart.
Sonya Stanford, Nina Rovinelli Heller, Elaine Sharland, Joanne Warner, Nina Rovinelli Heller

7. WORKING WITH PEOPLE WHO HAVE PSYCHOTIC ILLNESS: BALANCING RISK AND RECOVERY

Abstract
For people impacted by the experience of psychotic illness, risks do appear to be everywhere. People who have low-prevalence psychotic illnesses, such as schizophrenia, bipolar disorder and depressive psychosis, are profoundly affected by the power of risk-focused approaches in mental health services. A risk-focused approach in mental health emphasizes the individual’s risk of self-harm or of harming others. Accordingly, clinical practice is often oriented towards managing these risks. As people with psychotic illnesses are more likely to be seen as a threat to themselves or others than people who experience more high-prevalence disorders, such as depression, anxiety and substance abuse disorders, they are likely to be subject to the provisions of involuntary treatment (Kallert & Schutzwohl, 2008). There are consequently social and legal risks to people’s human rights in this context; there are risks to people’s liberty and their autonomy
Sonya Stanford, Nina Rovinelli Heller, Elaine Sharland, Joanne Warner, Robert Bland, Marianne Wyder

8. NEGOTIATING THE INTERFACE BETWEEN RISK MANAGEMENT AND HUMAN RIGHTS-BASED CARE

Abstract
Since the advent of deinstitutionalization and the shift to community-based models of care, Australia, and many other Western countries, have seen distinct and marked changes in public policy, legislation, and service delivery approaches in mental health. Each major shift in public policy and service delivery has been accompanied by different understandings and interpretations of risk and these, in turn, have reshaped practice, service priorities and procedures – and even the experience of being a professional. This chapter concerns two such recent changes in public policy and service delivery: the political shift to neoliberalism, often referred to as ‘New Public Management’, which transformed the public sector of Western democracies from the 1980s with the introduction of market-based principles into the provision of services and new demands for accountability and transparency (Hood, 1995; Osborne & Gaebler, 1992); and the emphasis on individualized service delivery, conceptualized as ‘recovery-oriented’ practice in contemporary mental health policy (Stanhope & Solomon, 2008; Yeatman, 2009).
Sonya Stanford, Nina Rovinelli Heller, Elaine Sharland, Joanne Warner, Anne-Maree Sawyer

9. LEADERSHIP, CRITICAL REFLECTION AND POLITICS: THE MANAGEMENT OF RISK IN MENTAL HEALTH ORGANIZATIONS

Abstract
This chapter is written from the perspective of three mental health social workers. The first two authors are mental health team managers working in the cash-starved and perennially restructuring National Health Service (NHS) in the UK (Lee, 2014). The third author is an academic who has explored the interface between mental ill-health of individuals, organizations and communities (Kapur & Campbell, 2005). In our own lives and practices, and in our relationships with colleagues and service users, we have experienced difficulties in managing our emotions when making decisions about risk. As managers, two of us attempted to use a number of strategies to manage intra- and interpersonal relationships when anxieties about risk emerged amongst colleagues. However, a broader political analysis was missing from our own understanding of what was wrong about how the organization, and how we as staff, approached issues of risk. We wondered if we had become intellectually atrophied, too exhausted by organizational demands, and limited by the ever-constricting spaces for professional judgement and organizational change. We now believe that leaders in a team should be able to talk back to power. This belief has helped us to reflect critically on the complex, interlocking processes whereby risk narratives are often unproblematically accepted and internalized by professionals. We found that we needed to strive towards facing up to and challenging the organizational and political processes that were constructing notions of risk in our work.
Sonya Stanford, Nina Rovinelli Heller, Elaine Sharland, Joanne Warner, Catherine Hartley, Chris Lee, Jim Campbell

10. BEYOND SOCIAL MEDIA PANICS FOR ‘AT RISK’ YOUTH IN MENTAL HEALTH PRACTICE

Abstract
It has been argued that ‘self harm hashtags may be driving [an] increase of cutting in young people’ (Chang, 2014). These discourses frame self-harm, suicidal or eating disorder content that circulates across online sites – such as Instagram, Tumblr, Facebook and Snapchat – as seductive and powerful, posing a significant risk to young people with mental health problems. Young people in recovery from mental illness have conveyed similar concerns, as expressed in these television and radio accounts (ABC 7:30 and ABC Radio respectively).
Sonya Stanford, Nina Rovinelli Heller, Elaine Sharland, Joanne Warner, NatalieAnn Hendry, Brady Robards, Sonya Stanford

11. MENTAL HEALTH RISK, POLITICAL CONFLICT AND ASYLUM: A HUMAN RIGHTS AND SOCIAL JUSTICE ISSUE

Abstract
This chapter examines the dominant discourses concerning asylum seekers and refugees and the intersection of these with human rights in social work practice. The term discourse is used in a ‘more open sense to uncover all forms of spoken interaction, formal and informal, and written texts of all kinds’ (Potter & Wetherell, 1987, p. 7) that are used to talk about asylum seekers. The chapter problematizes the notion of risk and in particular how asylum seekers and refugees are framed in a binary position as a risk to the host society or at risk of poor mental health. It also explores the concept of ‘othering’ in relation to the experience of discrimination faced by asylum seekers and the complex relationship between poor mental health outcomes and the experience of migration. There are wider implications of these processes in terms of their influence on other practice domains, where ‘othering’ and racism are thrown into even sharper relief. The racist demand to ‘go back where you came from’ is directed at third and fourth generation citizens as much as the newly arrived. Our discussion provides insights into how contemporary social work practice can challenge and disrupt the dominant risk paradigm in this field.
Sonya Stanford, Nina Rovinelli Heller, Elaine Sharland, Joanne Warner, Shepard Masocha, Kim Robinson

12. CONCLUSION: REMORALIZING RISK IN MENTAL HEALTH POLICY AND PRACTICE

Abstract
This book started life when a group of like-minded colleagues from across the world came together at a conference in Prato, Italy, in May 2012 and again in 2013. We were animated by a shared interest in ‘Moving beyond the risk paradigm’, taking the latter to mean the predominant neoliberal discourse that overdetermines public and professional thinking, practice and policies in human services. We recognized that much has already been said and written about the architecture of the risk paradigm, its discourse and operations. But our core focus was different. True, we wanted to develop a shared understanding of how the paradigm works, and indeed our debates about, for example, the functions and value of contemporary Western approaches to risk assessment and management were lively, not to say heated at times. But our core purpose, through critical engagement with what the risk paradigm is and what it does, was to challenge it and to identify how it might be – perhaps already is being – resisted, or more radically, transcended.
Sonya Stanford, Nina Rovinelli Heller, Elaine Sharland, Joanne Warner
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