Risk in mental health: a review on and of the psychiatrist
| Date | 08 January 2018 |
| Pages | 14-21 |
| Published date | 08 January 2018 |
| DOI | https://doi.org/10.1108/JMHTEP-04-2017-0030 |
| Author | Giles Newton-Howes |
| Subject Matter | Health & social care,Mental health,Mental health education |
Risk in mental health: a review on
and of the psychiatrist
Giles Newton-Howes
Abstract
Purpose –The purpose of this paper is to review the perceptions of risk from the viewpoint of the
psychiatrist, in the context of the expectations of patients, staff and society.
Design/methodology/approach –The paper is a reflection on clinical practice and narrative review of
the literature.
Findings –There are significant problems in the prediction of risk, to do with the difficulty in attempting to
predict any low prevalence outcome. Additional complications relate to societal expectations and the legal
frameworks within which mental health is practiced. The evidence related to poor outcomes, such as suicide
is very complex, occasionally appears contradictory, and caution is required in application. The paradigm of
recovery provides a way forward in the assessment and management of risk that moves away from any
pretence of future prediction and aims to engage with service users and their families in a supportive and
complimentary way.
Practical implications –Use of a recovery framework, with a focus on need, as opposed to risk, would
appear to benefit patients, carers and those delivering service.
Originality/value –This viewpoint enables a broader gestalt of the literature in the context of day-to-day
clinical practice. This prevents the limitation of only examining the (largely) epidemiological literature, or just
commenting on one clinician’s practice. It provides for a conceptualization of a way to move forward in the
consideration of risk.
Keywords Risk, Risk assessment, Mental illness, Recovery, Suicide, Review
Paper type Viewpoint
Introduction
There are known knowns; there are things we know we know. We also know there are known
unknowns; that is to say we know there are some things we do not know. But there are also unknown
unknowns –the ones we don’t know we don’t know (Secretary of Defence Rumsfeld, briefing paper,
12 February, 2002).
Working in mental health provides for multiple challenges and rewardsin a way that is somewhat
different from other branches of medicine. Although the skills and expert knowledge acquired
through medical training, both in terms of content knowledge and the process of enquiry are
invaluable tools a psychiatrist has, appreciation of the expectations of patients, family and wider
society means these are often applied differently. Possibly this is no more clear than in the
conceptualisation of risk, and the “management”thereof. It wouldbe a rare thing for an oncologist
to contemplatea course of managementfor a patient with cancer largelypredicated on the basis of
the possibility thatthe cancer in question might lead to the patient’s death, to the exclusion of the
multiple other factors that might come into play. Similarly, it would be difficult to conceptualise a
situation wherea surgeon would refuse to operate on a patient for whom that operation might be
beneficial, solely based on the small but realistic likelihood of a negative outcome. Nonetheless,
corollaries to these situations are a common experience for psychiatrists working in adult mental
health: where risk runs the risk of overshadowing all other elements of assessment.
Increasingly the practice of psychiatry focuses on risk, a nebulous if threatening term that has
wide-reaching implications in all aspects of psychiatric practice. How these are played out differs
Received 26 April 2017
Revised 4 July 2017
23 August 2017
Accepted 5 September 2017
Giles Newton-Howes is a
Senior Lecturer at the
Department of Psychological
Medicine, University of Otago,
Wellington, New Zealand.
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THE JOURNAL OF MENTALHEALTH TRAINING, EDUCATION AND PRACTICE
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VOL. 13 NO. 1 2018, pp.14-21, © Emerald Publishing Limited, ISSN 1755-6228 DOI 10.1108/JMHTEP-04-2017-0030
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