By Joy Adams-Jackson 
In this piece I write about my clinical observations and experiences from the perspective of a sociological ‘other’. While I work primarily as a registered nurse in a rural community mental health facility, I also have a background in sociology. Despite the current context of my clinical work, I readily identify as a clinical sociologist because I strive in my day-to-day work to challenge the status quo by unsettling some of the taken-for-granted assumptions about medic al interventions that underscore much of psychiatric/ biomedical practice.
This paper demonstrates the divide that exists when attempting to apply a sociological perspective to risk management that is underpinned by health policy and biomedical imperatives.
Risk discourse forms a ubiquitous part of the cultural and politic al landscape and dominates the thinking of many decision makers from politic al and economic forecasters to the architects of health policy. Indeed, the discourse of risk in mental health policy and practice has come to designate a domain that is problematic, dangerous or threatening, and in doing so tenders justification for intervention and management. Risk thinking, assessment and management are the significant features of this paper.
Risk management is essentially a means of ‘ ordering reality, of rendering it into a calculable form’ (Dean, 1999:131 cited in Schehr 2005). The need for order and control drives risk management strategies within the practice of contemporary psychiatry. Within contemporary psychiatric/ mental health practice, risk assumes an objective entity capable of measurement, management and control (Althaus, 2005).
Indeed, new zones of intervention have emerged to make risk management the responsibility of both individuals and governing authorities. For example, in common with other western jurisdictions, my local Area Health Corporate Manual defines risk as the ‘chance of some thing happening that will have an impact upon objectives’ (AS/NZS 2004). The manual goes on to explain that risk is inherent in all aspects of Health Service business and that ‘risk management is a culture, process and structure, which come together to optimise the management of potential opportunities and ad verse effects’ (AS/NZS 2004).
Such a view of risk and risk management posits risk in probabilistic and actuarial terms as a likely disease, epidemic or major catastrophe waiting to happen, and implies that with the application of appropriate knowledge and the implementation of strategic and anticipatory measures the risk can be contained (Althaus, 2005). That, at least, is the rhetoric. The reality of course is different, because people will feature in any risk equation and, unlike medicine or scientific approaches, people do not necessarily react to risks in predictable, logic al or rational ways.
Althaus (2005) states that an erosion of the dominant scientific paradigm has created a sense of despair concerning the definition and treatment of risk. She argues that because of this malaise or despair, the opportunity has arisen for politics and various players in the politic al process to determine what constitutes risk and how best to deal with it. Without scientific guidance our definition of risk ‘has become loaded with ideas of fear or trust’ (Althaus 2005). In the Australian context, as in many parts of the world, governments are preoccupied with both a desire and the determination to ‘ help’ us. Governments seek to protect us from smoking, from being fat, form irresponsible financial spending, from gambling and so on (Conde, 2005).
Risk resides within the government al strategies of disciplinary power to monitor individuals and populations in order to fulfil the goals of ‘democratic humanism’ (Lupton, 1999; Castel, 1991). The strategies, actions and thoughts that endeavour to ‘conduct the conduct of others’ (Fouc ault, 1994; Rose, 1996) form the basis for new techniques of governing not only the conduct of others, but also the conduct of oneself. While this might seem reasonable, within the ‘ad ministration of risk’ milieu, psychiatric/ mental health professionals now operate within a culture of blame ’ that regards ad verse events as avoidable tragedies for which someone is accountable (Rose, 1996).
Management is a bureaucratic and all-encompassing theme within the discourse of risk, shaping the professional obligations of all mental health clinicians to the extent that risk management and risk avoidance measures underscore all professional interventions, and in the process often replace previous forms of expert clinic al judgement and interventions.
While it would be foolish to argue against the necessity for and the importance of psychiatric risk assessments, I could suggest that it is equally important to understand that professional confidence and capacity in clinical decision-making are often at stake in the bureaucratic process. Furthermore, efforts to make clinical decisions and manage risk are complicated by the ever-increasing categories of mental disorders.
Drawing on current clinical experience, it is apparent that larger numbers of people are receiving psychiatric diagnoses for ‘problems’ that once sat outside the psychiatric scope. Problems such as homelessness, financial woes, anger, low mood, relationship difficulties and antisocial behaviours are just a few examples of the increasing biomedical/ psychiatric classification of mental disorders.
The ever-increasing categories of mental illness and mental disorders are set against a backdrop of limited resources and heightened community and consumer expectations which are further complications for clinicians who must assess and manage risk. This is because the current climate of heightened expectation ushers in a new discourse of uncertainty and apprehension.
As a registered nurse and clinic al sociologist I am positioned within both the nursing and sociological discourses which allow me to critique the dominant biomedical/ psychiatric perspectives. A sociological perspective underpins my ability to deconstruct the dominant psychiatric/ biomedical paradigm with its capacity to exacerbate the diagnoses and treatments of various mental disorders. Furthermore, a sociological perspective provides the basis for critiquing bureaucratic and managerial imperatives inherent in any discussion of risk assessment and risk management. My sociological position as ‘other’ is advantageous because it provides an opportunity for me to apply sociological theoretical thinking to new ways of doing clinical practice.
References available from the author.
Bio at the time of first publication (2008):
Joy Adams-Jackson was previously employed as a lecturer at Sydney University, the University of Canberra, and the University of Western Sydney; she has also worked for the NSW Police Academy (CSU), and as a policy analyst in the NSW Department of Health.
 This article was first published by Nexus in June 2008. Original Citation for this article: Adams-Jackson, J. (2008) Nexus June 20(2): 8-9.
Great piece. I’m a sociologist and I’ve been working in different positions in the health system for the las 7 years. I wonder if you have a view on a type of sociology that’s purely dedicated to measure the “social determinants” of health, a sociology that grew out of the idea of social determinants and that sometimes is conflated with epidemiology. I know sociology has so much to offer, especially it it retains its critical orientation, but there’s already a pretty much institutionalised sociology in health that simply acts as epidemiological support for whatever “social”.
Hi Cristián! Much like all other forms of sociology, there’s no one specific theory or practice through which sociology addresses the social determinants of health. There are a range of theories that address this; but the main way in which sociology contributes something unique to medical practice as a whole is in our approach to methods. We measure illness and wellbeing in local cultural context and take into consideration socioeconomic impact on health, which medicine as a whole still doesn’t (they focus more on race, for example, as a biological category, which leads to much misdiagnosis). Another article I’ve written elsewhere shows how we contribute to public health, beyond epidemiology. http://socialscienceinsights.com/2014/10/14/local-government-public-health/