A history of ‘risk’
Most commentators link the emergence of the word and concept of ‘risk’ with maritime activity during the pre-modern period. The early meaning referred to the perils of the natural world that could befall a voyage and therefore excluded the idea of human fault and responsibility.
This way of considering risk changed with modernity and was influenced by the notion, emerging from the Enlightenment, that the key to human progress and social order is an objective knowledge of the world through scientific exploration and rational thinking. This assumes that the social and natural worlds follow laws that may be measured, calculated and therefore predicted.
The development of the mathematics of probability further promoted the idea that rationalized counting and ordering could bring disorder under control. In this way ill defined hazards that previously affected only the individual became well defined ‘risks’ that could be statistically described and, theoretically at least, prevented.
Today the sociologists Beck and Giddens talk about the ‘risk society’. They refer to a society that is obsessed with risk and debates on how risk should be managed at both the institutional and personal levels. They also refer to the way that society organises itself to deal with these hazards which are caused by modernity itself.
Risk and psychiatry
The Lunatic Asylums Act 1845 made it mandatory for each borough and county to provide, at public expense, adequate asylum accommodation for its pauper lunatic population. This lead to an asylum building programme and to an increase in the psychiatric inpatient population. The peak of the asylum population was in the mid-1950s, after which this time asylums began to be closed and the overall number of inpatient beds reduced.
One of the factors behind asylum closures was the recognition of the potential harm caused by psychiatric hospitalization following a number of scandals that had uncovered mistreatment of patients. The policy of community care for psychiatric patients slowly emerged but with this the focus of concern also shifted from the restrictive nature of institutional care towards the seeming lack of control over mentally disordered patients in the community.
Initially disquiet was about the potential for subsequent homelessness in discharged patients. Since there was (and remains) a high level of mental illness amongst homeless people it was concluded that patients were being discharged ‘onto the street’. This was not substantiated by research and focus then shifted to public safety due to psychiatric patients. The murder of Jonathan Zito by Christopher Clunis in 1992 was particularly pivotal as it lead to the formation of the Zito Trust, an influential organisation that campaigned to improve community care.
Since 1994 health authorities have been obliged to hold an independent inquiry in cases of homicide committed by those who have been in contact with psychiatric services. And although the overall number of psychiatric beds has reduced, the number of compulsory and overall admissions has increased. The emergence of the concept of ‘dangerous and severe personality disorder’ was criticized as representing a sociopolitical rather than psychiatric rationale for justifying psychiatric detention.
Consideration of the quantification and prediction of the risk posed by patients has become a dominant force in the practice of clinical psychiatry and a public expectation has developed that mental health services should exert some influence over the individuals under their care. Whilst psychiatrists do perform a protective role both towards their patients and towards the public, there is a media and political expectation that serious incidents are totally preventable. This focus on mental health services on the prevention of untoward events means that other contributing factors are excluded.
Although firmly entrenched in practice, it is not a given that psychiatrists should be responsible for the behaviour of their patients. This is a situation unique in medicine, and places unhelpful restrictions on the therapeutic relationship as doctors are obliged to be responsible for the involuntary detention of patients whom they treat.
Defensive and over cautious practice carried its own risks and does not lead to creative thinking. Our focus on ‘risk’ we run the risk of following procedures that are more for the purpose of protecting staff than helping patients.
Risk (Key ideas) by Deborah Lupton
Risk society on Wikipedia
Challenging risk: a critique of defensive practice
BBC Radio 4 Thinking Allowed: Managment of risk in everyday life
‘Dangerous and severe personality disorder’: a psychiatric manifestation of the risk society