dangerousness and mental health policy

Dangerousness and mental health policyJ . L . H E W I T T r m n r g n r n t b s c ( h o n s ) p g c e p g c e r t c o u n s

Lecturer, Centre for Mental Health Studies, University of Wales Swansea, Singleton Park, Swansea,South Wales, UK

HEWITT J. L. (2008) Journal of Psychiatric and Mental Health Nursing 15, 186–194Dangerousness and mental health policy

Mental health policy development in the UK has become increasingly dominated by theassumed need to prevent violence and alleviate public concerns about the dangers of thementally ill living in the community. Risk management has become the expected focus ofcontemporary mental health services, and responsibility has increasingly been devolved toindividual service professionals when systems fail to prevent violence. This paper analysesthe development of mental health legislation and its impact on services users and mentalhealth professionals at the micro level of service delivery. Historical precedence, mediainfluence and public opinion are explored, and the reification of risk is questioned inpractical and ethical terms. The government’s newest proposals for compulsory treatment inthe community are discussed in terms of practical efficacy and therapeutic impact. Danger-ousness is far from being an objectively observable phenomenon arising from clinicalpathology, but is a formulation of what is partially knowable through social analysis andunknowable by virtue of its situation in individual psychic motivation. Risk assessment cantherefore never be completely accurate, and the solution of a ‘better safe than sorry’approach to mental health policy is ethically and pragmatically flawed.

Keywords: dangerousness, media, policy, risk, society

Accepted for publication: 5 September 2007

Correspondence:

J. L. Hewitt

Centre for Mental Health Studies

University of Wales Swansea

Singleton Park

Swansea

South Wales

SA2 8PP

UK

E-mail: [email protected]

Introduction

Since the 1990s, mental health policy development inthe UK has become increasingly dominated by theassumed need to prevent violence and alleviate publicconcerns about the dangers of the mentally ill living inthe community (Coffey 1996, Moon 2000, Cutcliffe &Hannigan 2001, Anderson 2003, Corbett & Westwood2005).

Supervision registers, supervised discharge, recent pro-posals to amend the 1983 Mental Health Act and propos-als for the management of people with severe personalitydisorders form a portfolio of legislation preoccupied withrisk assessment (Cutcliffe & Hannigan 2001) and coercivemanagement in mental health services (Eastman 1995,Rush 2004).

Links between violence, dangerousness and mentalillness have become embedded in cultural consciousnessover the course of hundreds of years (Ion & Beer 2003).The media’s reporting of violence attributed to mentallydisordered individuals in the last decade has fuelled beliefsthat dangerousness is an inevitable consequence of mentalillness and that dangerousness is predictable, measurableand controllable (Hallam 2002, Anderson 2003).

Public concern has inspired policy responses and con-siderable research in the fields of criminal justice andmental health in attempting to devise methods of predictingdangerousness (McGuire 2004). At the micro level ofservice delivery, risk assessment and management is theexpected focus of contemporary mental health services andresponsibility has increasingly been devolved to individualservice professionals when systems fail to prevent episodic

Journal of Psychiatric and Mental Health Nursing, 2008, 15, 186–194

186 © 2008 The Author. Journal compilation © 2008 Blackwell Publishing Ltd

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violence (Hallam 2002, Stein 2002, Crowe & Carlyle2003, Ion & Beer 2003, Godin 2004).

The following work analyses the development of mentalhealth legislation and its impact on services users andmental health professionals at the micro level of servicedelivery. Historical precedence, media influence and publicopinion are explored, and the reification of risk is ques-tioned in practical and ethical terms. The government’snewest proposals for compulsory treatment in the commu-nity are discussed in terms of practical efficacy and thera-peutic impact.

Dangerousness and mental illness

Society has tended to treat mental illness like a transmis-sible disease, whose capacity for cultural contaminationmight be controlled through some form of detention andsegregation (Rogers & Pilgrim 2001, Kelly 2005). Since the19th century, psychiatry has been a vehicle for the medi-calization of problematic behaviours and the managementof society through control of social risk and deviance (Scull1993, Paterson & Stark 2001, Crowe & Carlyle 2003, Ion& Beer 2003).

The asylums of the Victorian era functioned to containand separate the mentally ill from society (Pick 1989). Theclassification of mental health problems as illnesses, akin tothose developed for general medicine, meant that judge-ments about normality and deviance could now belegitimized in the name of health risk (Rush 2004).De-institutionalization removed the physical barriers ofsegregation and released patients into ‘the gaze of a popu-lation for whom mental ill-health was a matter of dreadincomprehension – a visible “other” from which the publichad once been shielded’ (Moon 2000, p. 241).

Historically, views of mental illness have ranged frompossession by evil spirits and moral degeneracy in medievaltimes (Nolan 1993) to moral weakness and social deviancyin the 18th century and mental defectiveness in the 19thcentury (Scull 1979, Rush 2004). Contemporary societyhas seen a return to historical values and beliefs, whichconflate ‘badness’ with ‘madness’ (Moon 2000, Corbett &Westwood 2005) and an association between mental illnessand in particular schizophrenia, with physical dangerous-ness (Stark et al. 2004).

European studies in societal attitudes show significantlevels of intolerance and stigma towards people with severemental illness (Huxley 1993, Angermeyer & Matschinger1996, Rose 1998, Crisp et al. 2001) and increasing concernabout the risk of violence from those who have beendischarged into the community (Coid 1996). In the lastdecade, intensified media reporting of violence attributedto mentally ill individuals has led to the emergence of a

‘new discourse of danger and threat’ directly attributed tomental illness and failure of health care systems (Cutcliffe& Hannigan 2001).

Media reports generally depict people with severemental illness, particularly schizophrenia, as highly likelyto be violent as a consequence of their mental illness ratherthan any other variable (Ward 1997). Calls are frequentlymade for the mentally ill to be controlled and assertions aremade that community care has failed, because of the neg-ligence of mental health practitioners (Timmins & Brown1996).

Public concern has been driven to some extent by a smallnumber of widely publicized cases in which, allegedly, acatastrophic outcome could or should have been foreseen(Hallam 2002, Anderson 2003, McGuire 2004). Thekilling of Jonathon Zito by Christopher Clunis at a Londontube station and the mauling of Ben Silcock by a lion atLondon Zoo was attributed to failure of ‘the system’ andan abdication of responsibility by mental health services(Rose 1998, Stark et al. 2004). Official reports on theChristopher Clunis case became important policy docu-ments, which led to government plans for legislation toenable supervised discharge (Ritchie et al. 1994).

In 1994, the requirement for official inquiries into allhomicides committed by individuals with severe mentalillness led to the production of lengthy reports, many ofwhich repeated the same recommendations, with the resultthat mental health systems were criticized for continuedfailings (Ryan 2004). Blame was displaced downwardsonto individual clinicians, who were greatly affected by thisincreased accountability and concerns over who would beheld liable for predictive errors (Coid 1996, McGuire2004).

Critical events have the capacity to significantly influ-ence beliefs and alter the perceptions of threat (Staggen-borg 1993). The sensational language often used to reportsuch incidences creates a sense of imminent danger andmay be significant in imprinting cognitive associationsbetween violence and mental illness (Stark et al. 2004). Thestory of Gilbert Steckel, who killed a teacher and her twodaughters after being discharged from a psychiatric hospi-tal, was reported as ‘Mental patient kills mother afterquitting hospital’ (Anderson 2003). Emotive, headline-catching language was also used to describe the incidencesinvolving Ben Silcock and Christopher Clunis (Hallam2002).

Socially constructed facts and conceptual uncertainties,which inform public perception of risk, may correspondonly loosely to the threats posed in reality (McGuire 2004).The press report only a selection of events, to which theyassign interpretations in order to give a cultural meaning tothem that is intelligible, meaningful and satisfying in terms

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© 2008 The Author. Journal compilation © 2008 Blackwell Publishing Ltd 187

of cause and effect (Stark et al. 2004). The result may be asimplistic rendering of a complex series of events anda magnification of threat in terms of incidence andprevalence.

The causality of media reports and public perception is,however, far from established. The public are not passiverecipients of information and acceptance of representative-ness and appropriateness of claims will depend on theircongruence with existing belief systems about mentalillness and sources of authority, developed through familialand cultural conditioning, professional influences and per-sonal life experiences (Anderson 2003, Stark et al. 2004).

The conceptual origins of risk

There is a lack of robust research into the risks that peoplewith mental illness pose to the public. Earlier researchsuggesting that patients discharged from mental hospitalsshowed increasing rates of offending over time is now seenas inadequate because of a progressive reduction in beds(Coid 1996). The risks that mentally ill people will commithomicide have been claimed to be both higher and lowerthan the risks for the general population, but neither asser-tion has been supported by adequate data (Coid 1996).

Paterson & Stark (2001) have discussed the incongru-ence between claims that have been made that the numberof killings by people experiencing mental illness increasedfollowing the acceleration of the government’s communitycare programme in 1991 and the statistical records ofauthoritative research from the same period. In 1994, 61out of the 479 convictions for homicides in England andWales were by people who were mentally ill (DoH 1998).In 1999, the National Confidential Inquiry into Suicide andHomicides in England and Wales found that only 8% ofhomicides were committed by people with a serious mentalillness (DoH 1999a). Statistical data alone do not appear tobe a justification for moral panic or radical revision ofmental health policy.

Whether the number of recorded violent incidents canbe used as a basis for deciding the proportionality of policyresponse has been the subject of some debate. Claims thatthe percentage of homicides committed by mentally disor-dered people has declined over the last 40 years and formonly a small fraction of homicides overall (Taylor & Gunn1999, Kelly 2005) have bolstered arguments that ‘madness’is a social construction and ‘dangerousness’ a product ofthe risk society (Barham & Hayward 1995, Moon 2000).Policies formulated on a concept of dangerousness havebeen heavily criticized by mental health professionals whohave argued that violent patients form a very small subsec-tion, and efforts would be better directed at improving carefor all (Taylor & Gunn 1999, Munro & Rumgay 2000).

Barham & Hayward (1995) have argued that locatingthe problem within society and ignoring the reality that asmall number of people with serious mental illness havebeen failed by mental health services only decreasespublic confidence in mental health professionals andincreases stigmatizing attitudes. They call for a realisticdiscussion of the approaches to people with seriousmental illness that avoid polarities of inclusive anddemocratic versus demonizing and dehumanizing. Whilesuch a position may be sensible for mental health prac-tice, fear that any acknowledgement of associationsbetween violence and mental illness may be used politi-cally may prevent serious discussion by mental healthpractitioners who advocate increased partnership forservice users.

Socio-cultural perspectives on risk can be categorized inthree major groups. The cultural or symbolic perspectiveidentifies ways in which the notion of risk is used to main-tain conceptual boundaries between self and others. Therisk society perspective is concerned with the macro-socialprocesses involved in the breakdown of traditional normsand values. Governmentality approaches focus on surveil-lance, discipline and regulation of populations and howconcepts of risk construct norms of behaviour whichencourage individuals to engage in self-regulation as aresponse (Lupton 1999).

The integration of the mentally ill into the communityhas taken place in a context of a growing preoccupation inWestern societies with threats and risks arising in manypublic spheres and a belief that they can be understood interms of choice, responsibility and blame (Crowe &Carlyle 2003). The focus on ‘riskiness’ in society is particu-larly associated with a fear of violence, a perception thatthe existence of danger has increased and that it can belocated in particular individuals. Contemporary threats aretherefore conceived to be objectively observable and pre-ventable through the accuracy of predictive protocols andappropriate risk management (McGuire 2004, Corbett &Westwood 2005).

Societal fears about previously disparate concepts ofmental illness and safety have converged to amplify realevents in terms of their threat potential for society (Pater-son & Stark 2001). Social constructionists have argued,however, that humans and their social worlds exist in arelationship in which each creates the other and thereforerisk is not a static, objective phenomenon but is born out ofthe network of social interaction (Lupton 1999). Culturalstigma and fear contributes to isolation and alienation ofpeople with mental illness, whose reactions to the experi-ence of a hostile society, in turn, reinforce perceptions thatbeliefs about the dangerous differences of ‘the other’ arejustified.

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The growing demands on the National Health Service(NHS) have led to a governmental focus on preventionrather than cure and individual responsibility for health-promoting behaviour. Ill health is increasingly seen to bethe consequence of risk-taking behaviour, the blame forwhich may be firmly located with the individual, whoselfishly depletes the resources available for the collective.Behaviours that transgress the normative rules of societyhave therefore become not only socially undesirable butalso dangerous to public health and safety.

The public perception is that violence involving peoplewith mental illness is always a function of their disorder,whose indicators mental health professionals may reliablydiscern to successfully prevent dangerousness. Psychiatristsare the accepted ‘experts’ in the domain of risk associatedwith mental illness (Corbett & Westwood 2005), and suchexpertise is expected to encompass knowledge of objectiveindicators of clinical decline and methods of medical inter-vention, which may reliably prevent violence (Barham &Hayward 1995). However, scientific knowledge is notvalue-free. Experts are equally constructed through socialand cultural processes as lay persons and their judgementsare always the product of a way of seeing (Lupton 1999).The psychiatric assessment of dangerousness has moral andpolitical utility, as it serves to strip actions (past, presentand future) of their social meaning and interpretively con-verts them into psychiatric theories of personal pathologies(Pfohl 1978).

Coid (1996) reviewed six major epidemiological studiescarried out in the United States, Sweden, Switzerland andthe UK which assessed whether risks of violence areincreased for people who have serious mental illness. Allbut one study found that people suffering from majormental illness are more dangerous than the general publicin terms of self-reported violent behaviour, official recordsof arrests and violent convictions. Risks of violence wereincreased about fourfold for men and were considerablyhigher for women in five of the studies. Factors that areassociated with criminality and violence in the generalpopulation, such as younger age, male sex, low social classand unemployment, also characterized violent mentallyill patients. However, statistical associations with majormental disorder still remained in three studies thatappeared to have controlled for these factors.

Bonta et al. (1998) disputed evidence that psychiatricdiagnosis was the best predictor of dangerousness. In areview of a large series of long-term follow-up studiesincorporating 68 independent samples of individuals witha serious mental illness, the most accurate predictors ofviolent recidivism were demographic and criminal historyvariables. Clinical variables such as psychosis had theweakest correlation with recurrent episodes of violence.

The presumption that dangerousness resides exclusivelywithin individuals can therefore be seen as a form of reifi-cation of risk that extracts events from their situationalcontext and excludes complex encompassing issues of law,social policy and organizational strategy in addition toindividual clinical judgement (McGuire 2004, Stark et al.2004). In the majority of instances, the occurrence of aviolent act requires an intersection of several abstractfactors, both environmental and contextual (Castel 1991,McGuire 2004).

Two factors appear to increase the risk of violence inpeople with a major mental illness. While individuals withdiagnosed drug and alcohol misuse are much more likely tobe violent than those with a major mental disorder, alcoholand drug misuse increase the risk of violence in people witha serious mental illness (Coid 1996, Swanson et al. 1997).There are also emerging findings of a strong associationbetween violent behaviour and the times when symptomsof severe mental illness are active rather than in remission(Coid 1996).

Coid (1996) has argued that violence is more likely inthe specific context of perceived threat, sometimes leadingto a ‘pre-emptive strike, and when psychotic symptomsresult in a weakening of self control mechanisms, such asthought insertion and mind dominance by outside forces(threat/control override)’. This implies that vigilant surveil-lance of psychotic symptoms experienced by people withserious mental illness should allow mental health profes-sionals to reliably prevent violence through clinicalmanagement.

Barham & Hayward (1995), however, question theassumption that there is a clearly defined stage, separatingthe experience of mental disorder from that of seriousmental illness, of such a degree that it warrants detentionor compulsion because of its inherent dangerousness. Theyargue that violent ideation is not an unusual feature ofpsychosis, but is not invariably translated into action. Dete-rioration is not a sole product of clinical decline, but ratheran indication that ‘something has gone awry in the socialnexus of which the patient is a part’ (Barham & Hayward1995). This social nexus is often fragmented by the stig-matizing and often hostile attitudes of society towardspeople with mental illness. The ‘pre-emptive strike’ referredto by Coid (1996) may not be the result of irrationalideation but rather the experience of social isolation andlack of civic identity. The medicalization of violent behav-iour adds little to the understanding of its genesis, servingrather to demarcate discrete risk factors for the purposes ofcontainment.

Strategies for evaluating risk are usually grouped undertwo main headings. The clinical approach derives from thesubjective judgements of individual practitioners, whereas



the actuarial approach involves the systematic recordingand analysis of a predefined set of variables, according toan agreed formula which converts information into scoresthat denote an individual’s level of risk (McGuire 2004).Although actuarial methods of risk assessment havebeen advocated as a means of avoiding practitionerbias (Monahan et al. 2001), mental health nurses haveexpressed the view that the use of standardized risk assess-ment tools is too mechanical, behaviourally reductive anddehumanizing, adding little to the understanding of under-lying motivational factors (Godin 2004).

Godin (2004) studied the ways in which communitymental health nurses (CMHNS) reflect on and practise riskassessment and risk management as an integral part of theirdaily work. Interviews were undertaken with 20 CMHNSfrom various geographical and practice areas. Actuarialmethods of risk assessment were not prized and profes-sional judgement was valued by many as the most effectivemethod of risk assessment. Although risk assessments con-centrated on the patients’ potential to harm others or them-selves, CMHNS also recognized that the notion of risk hada wider context, in terms of the risks faced by clients fromiatrogenic consequences of psychiatric treatment and care,and of victimization within a hostile community.

Stein (2002) also examined the use of actuarially basedrating scales by community mental health teams (CMHTS)in the UK, in aiding the process of discharge risk assess-ment. A postal survey of 171 NHS Trusts who treatedmentally ill adult inpatients revealed that all respondingTrusts (33.9%) used or were in the process of developingrisk assessment and management protocols. Using semi-structured interviews to follow up nine CMHTS, Stein(2002) also found that professional intuition was valuedmore highly than the numerical outcome of statistical pro-tocols. Although the extent of implementation of the CareProgramme approach varied from Trust to Trust, fear ofrisk assessments being used as evidence during ‘witchhunts’ following a suicide or homicide had the potential toact as a deterrent to truthful completion of instruments(although the most serious concerns were not usually con-cealed). Thus, Stein’s (2002) study reveals the unintendedconsequences of risk assessment policies for mental healthpractitioners may have been the replacement of therapeuticconcerns with litigious fears, resulting in professionalrather than public or patient protection.

Control in the community

Mental health policy has tended to reflect the majorityviews and scientific fashions of each era over the last threecenturies, where approaches to the mentally ill have

entailed control and punishment (Rush 2004), moral treat-ment ideals, guardianship and social control (Scull 1989).

Contemporary mental health legislation has historicalresonance with the 19th century, where the role of the Statein defining mental health policy and the extent of its powerand responsibilities continues to cause debate. Mentalhealth professionals, politicians, scientists and researchersare immersed in cultural milieus, and are equally suscep-tible to societal influences and ‘fashions’ (Dudley & Gale2002). Current fashion is geared towards the prediction ofrisk and the protection of society from citizens who assumerisk through alleged deviance or dangerousness. This hasled to a portfolio of mental health legislation which isfocused on surveillance and control of people with mentaldisorder living in the community (Coffey 1996, Moon2000, Cutcliffe & Hannigan 2001, Anderson 2003,Corbett & Westwood 2005).

The concept of control in the community has its roots inthe 1959 Mental Health Act, where the power of guard-ianship allowed a mental health professional to consent totreatment on behalf of a patient (Coffey 1996). Reluctanceto assume this responsibility led to the revised guardianshippowers of the 1983 Mental Health Act, which set condi-tions for residence, access and attendance for treatment forpatients that also proved difficult to enforce in practice(Coffey 1996).

The policy of community care for people with mentalillness came under intense scrutiny during the 1990s,following a series of homicides and incidents of violence,suicide and neglect (Hallam 2002). This led to are-emergence of legislation which aimed to tighten controlof people with mental illness living within the community.

The Care Programme Approach (CPA) was introducedin 1991 (DoH 1990), as a framework for the organizationof community mental health care, including procedures fordifferentiating and managing patients according to theirlevel of risk, with measures of community supervisionapplied to patients of particularly high risk (Godin 2004).Supervised discharge followed in the Mental Health(Patients in the Community) Act in 1996 (DoH 1995a).This allowed conditions to be placed on people with mentalillness living in the community who were inpatientsdetained for treatment under the Mental Health Act 1983(or already in the community but still formally detained)(Eastman 1995). The main power was one of ‘take andconvey’ granted to the supervisor (normally a communitypsychiatric nurse), who was allowed access the person’shome for assessment purposes and had the power toconvey the patient to a place of treatment, occupation,education or training. The government directed that mentalhealth care professionals should ensure that a full assess-ment of risk should be fundamental to assessment

J. L. Hewitt


processes, including both risks to the patient and from thepatient towards others (DoH 1995b).

The Mental Health (Patients in the Community) Act1995 was criticized as being clinically unachievable as legalcontrol of treatment and living arrangements could not bepractically extended to the community (Coid 1996). Theexpectation that community psychiatric nurses would forceunwilling patients into their cars and convey them to treat-ment centres was seen to be anti-therapeutic and legallyflawed, restricting civil rights as an alternative to providingadequate resources in the community (Eastman 1995,Coffey 1997). The alternative of the community respon-sible medical officer or supervisor instructing the police toconvey patients was seen to be little different in its thera-peutic effect. Nearly all groups that would implement or beaffected by aftercare under supervision opposed superviseddischarge (Eastman 1995).

Paterson & Stark (2001) have explored the view that theintroduction of CPA and supervised discharge orders weremore attributable to negative media reporting of one ortwo notorious cases and the government’s subsequent needto regain public confidence than a genuine responsivenessto the needs of mental health service users. Palfrey (2000)has argued that the need for a government to take action toimprove people’s health is always prompted by a mixtureof economic and political motives rather than an exclu-sively humanitarian urge. Marketization has meant thateconomic burdens arising from groups existing outside ofproductive processes must be targeted for governmentreform and democratic electoral dependence creates a needfor constant supervision of those who have the potentialfor social disruption (Goodwin 1997). Thus, the intendedbeneficiaries of the welfare state have become its victims(Rogers & Pilgrim 2001).

Godin (2004) has described the changing face of mentalhealth care practice, which followed the introduction anddevelopment of CPA and community supervision. Theresulting emphasis on risk meant that health and social careneeds of patients with serious mental illness were eclipsedby the imperative to assess and manage assumed risks,preventing the eruption of the dangerousness. The pressureon mental health nurses to accurately predict violentbehaviours has resulted in a culture of fear and blame, inwhich the only way to prevent failure might be to subjectfar more people than would actually go on to commit anoffence to compulsory measures of some form (Paterson &Stark 2001). Such a position is ethically untenable. Thegovernment appears to support a position in which greaternumbers of people with mental illness would be broughtunder compulsory powers. Care in the community has beenpronounced a failure (DoH 1998), and the government hasspent the past 7 years redrafting the Mental Health Bill

with a specified intent of increasing the remit of surveil-lance and coercion in community mental health care (DoH2000). Following numerous concerns raised by the JointCommittee appointed to look at these proposals DoH(1999b), the government’s plans for a Mental Health Billhave now been revised and will instead be introduced in ashorter, streamlined bill that amends the existing MentalHealth Act 1983.

Two of the key issues proposed by the government1

build on the powers of supervised discharge introduced inthe Mental Health (Patients in the Community) Act 1995.These amendments will now extend to supervised treat-ment in the community, for suitable patients, following aninitial period of detention and treatment in hospital, toensure that patients comply with treatment and enableaction to be taken to prevent relapse and readmission tohospital. The government therefore plans to expand theskills base of professionals responsible for the treatment ofpatients treated without their consent (DoH 2006).

Custodians of care

Given the resistance the government faced from mentalhealth professionals in response to its proposals for super-vised discharge in 1996 (Eastman 1995, Coid 1996, MIND1999, Cutcliffe & Hannigan 2001), it may be assumed thatthe extension of powers to include compulsory treatmentwill be greeted with even less acceptance. Similar proposalsfor supervised discharge in the United States were ulti-mately unsuccessful because staff were unwilling to usesuch powers (Coffey 1997).

Numerous authors have identified the ability of medi-cine to restrict the vital autonomy of people, disabling anddominating by its bureaucracy, scientific expertise and tech-nology (Illich 1977, Weber 1978, Kennedy 1983, Parsons1994). Psychiatrists increasingly combine professionaland managerial roles, and the dominance of managerialconcerns and the pressure for fiscal rationing increase thedanger that professional and ethical imperatives may beeclipsed (Dudley & Gale 2002). Practitioners confrontedwith a choice between an ‘individualist’ and a ‘collectivist’orientation to the task of risk management must choosebetween the welfare of the client or that of society(McGuire 2004).

Hewitt (2002) has reviewed the arguments that identifypatient advocacy as one of the roles that separates nursing

1Others include order-making powers with regard to the MentalHealth Review Tribunal; a new, simplified single definition of mentaldisorder; replacement of the ‘treatability’ with a test that appropriatetreatment must be available for all groups of patients; amendment ofthe European Convention for Human Rights incompatibility in rela-tion to the nearest relative; and introduction of Bournewood safe-guards for patients who lack capacity; and safeguards for children.



from medical ethics. Moral and ethical reasoning,autonomy and patient empowerment are inextricablylinked with the triad of nurse, patient and advocacy(Holden 1991). The nurse’s intermediary role has beenvital in tempering both the authorities of medical paternal-ism and statutory licence.

The primacy of the therapeutic nurse–patient relation-ship has been viewed as fundamental to mental healthnursing for over 50 years, with its emphasis firmly placedon sensitivity to the individual needs of service users andthe essential characteristics of a positive non-blamingattitude (Hewitt & Coffey 2005). The consequences ofusing force to compel patients to comply with treatment inthe community will be to return mental health nurses to therole of custodial attendants, rescinding a hundred years oftherapeutic development and destroying a professionalidentity separate to the biomedical aims of psychiatry.

Pragmatically, legal control of treatment and livingarrangements cannot be extended into the community(Eastman 1995). The most dangerous patients do notreadily accept supervision or treatment in the communityand such an approach will reduce risk only in those whoare willing to cooperate in its implementation (Coid 1996).

Practical problems arise in relation to what sort ofperson would be an appropriate candidate. Such an indi-vidual would need to be capable enough to survive in thecommunity, strong enough to confront authority and refusetreatment and yet disturbed enough to warrant forcedintervention (Goodwin 1997). Community mental healthnurses would need to operate in teams large enough toensure their own safety or be accompanied by some typeof security force in order to ‘compel’ patients to receivetreatment.

Supervised treatment orders are an absurd accompani-ment to the government’s own frameworks set out formental health practitioners, which direct towards ethicalpartnerships with service users, the need to challengestigma and discrimination, and empowerment of theperson to decide on the level of risk he or she is prepared totake with his or her health and safety (DoH 2004). Thesepractices, which require the existence of trust fosteredthrough the therapeutic relationship, would negate anypossibility of non-pharmacological intervention.

Recommendations of increasing powers of supervisionto encompass compulsory treatment in the communitywere rejected by the government in 1995, followingadvice that such an action, other than under a restrictionorder, would contravene article 5 of the European Con-vention of Human Rights (Coid 1996). The importanceof ethical determinants of mental health care appears tohave been subordinated to instrumental rationality, wherealignment with political thinkers has eclipsed issues of

morality and individual rights to citizenship (Dudley &Gale 2002).

The implications for mental health nursing practice andresearch are tripartite. The medical view of mental illnessdominates mental health policy, which has tended toexclude the views of other stakeholders (Rogers & Pilgrim2001). Mental health nurses require a greater knowledge ofthe skills required to influence government policy, workingin collaboration with voluntary agencies and service usergroups to actively challenge the prevailing hegemony. Com-munity care should focus on the social nexus of the patientas it does on the medical management of symptoms, equip-ping people with the necessary cognitive and social skills topromote recovery and form and maintain supportive rela-tionships. Few studies have identified the components andprocesses of risk assessment arising from clinical judgementrather than actuarial methods (Buchanan 1999). Furtherinvestigation is necessary to delineate those factors thatinfluence clinical perception of risk and whether these canbe shown to have predictive utility.

Conclusion

Whether the source of public concerns with the perceivedrisk of violence posed by people with mental disorder livingin the community can be traced to historical, media orcultural influence, its outcome has had considerable influ-ence on the focus of contemporary mental health servicestowards risk assessment and risk management. The 21stcentury has seen an increase in mental health legislationorientated towards control and public protection, ratherthan partnership with service users reflected in superviseddischarge policy and the extensions proposed in the draftMental Health Bill (Cutcliffe & Hannigan 2001, Rush2004).

Dangerousness is far from being an objectively observ-able phenomenon arising form clinical pathology, but is aformulation of what is partially knowable through socialanalysis and unknowable by virtue of its situation in indi-vidual psychic motivation. Risk assessment can thereforenever be completely accurate and the solution of a ‘bettersafe than sorry’ approach to mental health policy is politi-cally expedient but ethically and pragmatically flawed.

The challenge for mental health nurses is to address thenormalized culture of stigma and discrimination towardspeople with mental illness and prevent the use of stereo-typical perceptions of threat to social order being used ascriteria for justifying and legitimating exclusion, surveil-lance and coercion (Johnstone 2001, Tomov 2001). Whilecompulsory community care may be seen by some as lessstigmatizing than removal to hospital (Barham & Hayward1995), its realities for practice will be to deny vital patient

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autonomy and remove the possibilities for trusting partner-ships between CMHNS and service users.

References

Anderson M. (2003) ‘One flew over the psychiatric unit’: mentalillness and the media. Journal of Psychiatric and Mental HealthNursing 10, 297–306.

Angermeyer M.C. & Matschinger H. (1996) The effect of violentattacks by schizophrenic persons on the attitude of the publictoward the mentally ill. Social Science and Medicine 43, 1721–1728.

Barham P. & Hayward R. (1995) Relocating Madness: FromMental Patient to the Person. Free association Books, London.

Bonta J., Law M. & Hanson K. (1998) The prediction of criminaland violent recidivism amongst mentally disordered offenders: ameta-analysis. Psychological Bulletin 123, 123–142.

Buchanan A. (1999) Risk and dangerousness. Psychological Medi-cine 29, 465–473.

Castel R. (1991) From dangerousness to risk. In: The FoucaultEffect: Studies in Governmentality (eds Burchell, G. & Miller,P.), pp. 281–298. Harvester-Wheatsheaf, Hemel Hempstead.

Coffey M. (1996) Supervised discharge. Nursing Times 92, 50–53.

Coffey M. (1997) Supervised discharge: concerns about thenew powers for nurses. British Journal of Nursing 6, 215–218.

Coid J.W. (1996) Dangerous patients with mental illness:increased risks warrant new policies, adequate resources, andappropriate legislation. British Medical Journal 312, 965–966.

Corbett K. & Westwood T. (2005) Dangerous and severe person-ality disorder: a psychiatric manifestation of the risk society.Critical Public Health 15, 121–133.

Crisp A.H., Gelder M., Rix S., et al. (2001) Stigmatisation ofpeople with mental illness. British Journal of Psychiatry 177,4–7.

Crowe M. & Carlyle D. (2003) Deconstructing risk assessmentand management in mental health nursing. Journal of AdvancedNursing 43, 19–27.

Cutcliffe J.R. & Hannigan B. (2001) Mass media ‘monsters’ andmental health clients: the need for increased lobbying. Journalof Psychiatric and Mental Health Nursing 8, 315–321.

Department of Health (1990) The NHS and Community CareAct. HMSO, London.

Department of Health (1995a) Building Bridges: A Guide toArrangements for Inter-Agency Working for the Care and Pro-tection of Severely Mentally Ill People. HMSO, London.

Department of Health (1995b) Mental Health (Patients in theCommunity) Act 1995: Chapter 52. HMSO, London.

Department of Health (1998) Modernising Mental HealthServices: Safe, Sound and Supportive. HMSO, London.

Department of Health (1999a) The National Confidential Inquiryinto Suicide and Homicide by People with Mental Illness.HMSO, London.

Department of Health (1999b) Report of the Expert Com-mittee: Review of the Mental Health Act 1983. HMSO,London.

Department of Health (2000) Reforming the Mental Health Act.HMSO, London.

Department of Health (2004) The Ten Essential Shared Capabili-ties – A Framework for the Whole of the Mental Health Work-force. HMSO, London.

Department of Health (2006) Mental Health – Written MinisterialStatement. 23 March 2006. DoH. Ref No 2006/0108.

Dudley M. & Gale F. (2002) Psychiatrists as a moral community?Psychiatry under the Nazis and its contemporary relevance.Australian and New Zealand Journal of Psychiatry 36, 585–594.

Eastman N. (1995) Anti-therapeutic community mental healthlaw. British Medical Journal 310, 1081–1082.

Godin P.M. (2004) ‘You don’t tick boxes on a form’: a study ofhow community mental health nurses assess and manage risk.Health, Risk and Society 6, 347–360.

Goodwin S. (1997) Comparative Mental Health Policy. Sage,London.

Hallam A. (2002) Media influences on mental health policy: long-term effects of the Clunis and Silcock cases. InternationalReview of Psychiatry 14, 26–33.

Hewitt J. (2002) A critical review of the arguments debating therole of the nurse advocate. Journal of Advanced Nursing 37,439–445.

Hewitt J. & Coffey M. (2005) Therapeutic working relationshipswith people with schizophrenia: literature review. Journal ofAdvanced Nursing 52, 561–570.

Holden R.J. (1991) Responsibility and autonomous nursing prac-tice. Journal of Advanced Nursing 16, 398–403.

Huxley P. (1993) Location and stigma: a survey of communityattitudes to mental illness. Part 1. Enlightenment and stigma.Journal of Mental Health 2, 73–80.

Illich I. (1977) Limits to Medicine. Medical Nemesis: The Explo-ration of Health. Marion Boyars, London.

Ion R.M. & Beer M.D. (2003) Valuing the past: the importance ofan understanding of the history of psychiatry for healthcareprofessionals, service users and carers. International Journal ofMental Health Nursing 12, 237–242.

Johnstone M.-J. (2001) Stigma, social justice and the rights ofthe mentally ill: challenging the status quo. Australian andNew Zealand Journal of Mental Health Nursing 10, 200–209.

Kelly B. (2005) Structural violence and schizophrenia. SocialScience and Medicine 61, 721–730.

Kennedy I. (1983) The Unmasking of Medicine. Paladin, London.Lupton D. (1999) Risk. Routledge, London.McGuire J. (2004) Minimising harm in violence risk assessment:

practical solutions to ethical problems? Health, Risk andSociety 6, 327–345.

MIND (1999) 10 Questions about Compulsory Treatment in theCommunity. MIND National Association for Mental Health,London.

Monahan J., Steadman H.J., Silver E., et al. (2001) RethinkingRisk Assessment: The Macarthur Study of Mental Disorder andViolence. Oxford University Press, New York.

Moon G. (2000) Risk and protection: the discourse of confine-ment in contemporary mental health policy. Health and Place 6,239–250.

Munro E. & Rumgay J. (2000) Role of risk assessment in reducinghomicides by people with mental illness. British Journal ofPsychiatry 176, 116–120.

Nolan P. (1993) A History of Mental Health Nursing. Chapman& Hall, London.



Palfrey C. (2000) Key Concepts in Health Care Planning. Mac-Millan Press Ltd, London.

Parsons E.P. (1994) Technology and the nursing dilemma. In:Critical Care Nursing (eds Millar, B. & Burnard, P.), pp. 290–312. Ballière-Tindall, London.

Paterson B. & Stark C. (2001) Social policy and mental illness inEngland in the 1990s: violence, moral panic and critical dis-course. Journal of Psychiatric and Mental Health Nursing 8,257–267.

Pfohl S.J. (1978) Predicting Dangerousness. Lexington Books,Toronto.

Pick D. (1989) Faces of Degeneration – A European Disorder1848–1919. Columbia University Press, New York.

Ritchie J., Dick D. & Lingham R. (1994) The Report of theInquiry into the Care and Treatment of Christopher Clunis.North East and South Thames Regional Health Authority.HMSO, London.

Rogers A. & Pilgrim D. (2001) Mental Health Policy in Britain,2nd edn. Palgrave, Hampshire.

Rose D. (1998) Television, madness and community care.Journal of Community and Applied Social Psychology 8, 213–228.

Rush B. (2004) Mental health service user involvement inEngland: lessons from history. Journal of Psychiatric andMental Health Nursing 11, 313–318.

Ryan T. (2004) Risk management and system failure analysis inmental health investigations. Health, Risk and Society 6, 303–305.

Scull A. (1979) Museums of Madness. Penguin, Harmondsworth.Scull A. (1989) Social Order/Mental Disorder. Anglo American

Psychiatry in Historical Perspective. University of CaliforniaPress, Berkeley, CA.

Scull (1993) The Most Solitary of Afflictions. Madness and Societyin Britain. Yale University Press, New Haven.

Staggenborg S. (1993) Critical events and the mobilization of thepro-choice movement. Research in Political Sociology 6, 319–345.

Stark C., Paterson B. & Devlin B. (2004) Newspaper coverage ofa violent assault by a mentally ill person. Journal of Psychiatricand Mental Health Nursing 11, 635–643.

Stein W.M. (2002) The use of discharge risk assessment tools ingeneral psychiatric services in the UK. Journal of Psychiatricand Mental Health Nursing 9, 713–724.

Swanson J.W., Estroff S., Swartz M., et al. (1997) Violence andsevere mental disorder in the clinical and community popula-tions: the effects of psychotic symptoms, comorbidity and lackof treatment. Psychiatry 60, 1–22.

Taylor P. & Gunn J. (1999) Homicides by people with mentalillness: myth and reality. British Journal of Psychiatry 174,9–14.

Timmins N. & Brown C. (1996) NHS accused over mentally illkillers. Independent 15 January, p. 1.

Tomov T. (2001) Mental health reforms in Eastern Europe. ActaPsychiatrica Scandinavica 104, 21–26.

Ward G. (1997) Mental Health and the National Press. HealthEducation Authority, London.

Weber M. (1978) Economy and Society (trans. and eds Roth, G.& Wittick, C.). University of California Press, California.

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