in Thinking about psychiatry


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

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  1. I agree that defensive and over cautious practice can impede thinking in general, however I do think the profession whilst not “responsible” for the patients’ behaviour is certainly responsible for helping said patients take responsibility, considering risks to self or others and intervening where necessary. Psychiatrists have often been more comfortable with risk to self (rather than others) particularly in the context of psychotic or affective disorder.

    Unfortunately some psychiatrists seem to think they can pick and choose what exactly it is they are responsible for. It might be nice for some to consider Psychiatry the domain of psychotic and affective disorders only, but we know that’s simply not the case. Psychiatry is the medical treatment of mental and behavioural disorders, and that might mean antsocial, illegal or problemtic behaviour, either in an ICD/DSM category of its own or those commonly (if not diagnostically) associated with severe mental illness.

    Like it or not psychiatry’s a risky business, and despite that vast majority of patients being non-violent, the disorders confer upon them a higher actuarial risk of violence:

    Psychosis is more prevalent in prisoners remanded for violent offences than non-violent offences.
    Amongst homicide offenders in the UK there’s a 5% prevalence of schizophrenia (commonly quoted as 1% in the general popn.)

    As I’ve said whilst most patients are non-violent being aware of the associated risk between mental disorder and violence, is part of the business of psychiatry. Ignoring that and conveniently adopting moral concepts of free will when people do bad things yet not when they’re barking mad but well behaved isn’t helping the patient, society or the profession.


  2. @ declerambault
    You’ve made some massive generalisations and seem to want to argue not discuss. You sound dangerous to me and I think you should be locked up.

  3. That’s a good and interesting posting, FP (one coffee coming up). I would like to add my views, though I am not a psychiatrist (heaven forbid!). I’m a former service user who has never presented a risk to others (and whose only risk to self was in volunteering myself for psychiatric treatment in the sixties).

    I think psychiatrists are put in an incredibly difficult position when they’re expected to decide if someone might pose a risk and take responsibility for it. If psychiatrists use coercion to prevent the possibility of a person becoming dangerous, they’ll be criticised. Psychiatrsts will also be criticised if they don’t do this and then the person does act violently. But risk assessment is bound to be fallible, and people shouldn’t lose their liberty on the basis of what they might or might not do in the future.

    Blimey, it’s complicated! Psychiatrist have my sympathy on this one. They can’t win.

  4. @Chritopher
    As FP’s post suggests: risk is a complicated issue in psychiatry and an emotive one, when one considers overzealous risk management can lead to unecessary deprivation of liberty. Similarly, in not taking risk assessment seriously (and I’m thinking in this instance of risk of violence), psychiatrists are doing a disservice to their patients, their patients’ families and society at large, when suboptimal treatment and risk management permits sometimes preventable violence.

    The ideas of risk are important for society to debate not just the profession. You may disagree with my position which is of course part of any healthy debate however I’m not quite sure which “massive generalisation” you take issue with or what you disagree with.

    Another fact that I hope you won’t take as a generalisation is that the prevalence of schizophrenia amongst homicide offenders in Sweden is 9%, which is significantly greater than the population as a whole (and of the Uk’s 5%). I’m not sure why it’s higher. Do they have better or worse access to psychiatric services? A more coercive or more liberal mental health law?

    These issues need to be discussed, mindful of stigma I say once again: the vast majority of mentally ill individuals are not of risk to others, however as a group people with mental disorder have an increased risk of perpetrating violence.

  5. @declerambault
    I’d hazard violent people are more likely to be called schizophrenic, not schizophrenics are more likely to be violent.

  6. @declerambault
    I think we need to be careful about statistics and the way statistics are interpreted. As Christopher Crook points out, it does seem that violent people are more likely to be called schizophrenic, rather than people diagnosed with schizophrenia more likely to be violent. It seems also that the validity of a schizophrenia diagnosis is questionable (with psychiatrists sometimes disagreeing about who does or doesn’t fit the diagnostic criteria for schizophrenia), so how does that skew the studies and statistics? Violent behaviour is rare among persons diagnosed with schizophrenia. Other factors, such as substance abuse, bring higher ratings of violence than for people with schizophrenia.

    Discussion about risk should acknowledge that risk does not flow just one way. A person diagnosed with schizophrenia is more likely to be at risk FROM others than TO others. They face the risk of damage done by stigmatisation (often due to public perceptions of dangerousness). They are also at risk from mental health services, which I can’t go into at length here (I could write a book about this!).

    It seems to me unhelpful to use figures about risk from those diagnosed with schizophrenia to suggest these confirm the need for coercion, without looking at the full picture. It’s far more complicated than that.

    Nobody is sectioning drivers for tearing down the motorway with mobile phones clamped to their ears (psychiatric hospitals in my area would be full to overflowing if they were). Yet they put far more people at risk than those with a schizophrenia diagnosis.

  7. @Christopher Crook
    I was being a bit jokey when I said “I could write a book about this!” because actually I have done (published last year). Thanks for the site link to your book; I’ll take a look.

  8. @ Jean Davison
    I could write an encyclopedia! I haven’t as yet.


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