Balancing potential short-term harm against long-term benefits

This critical perspective does not deny that there is a genuine potential for harm to occur. However, it should be recognised that extreme harm relates to a minority of people in contact with mental health services (Reference Ryan, Nielssen and PatonRyan 2010; Reference Appleby, Kapur and ShawAppleby 2013). It is important, therefore, that risk management strategies recognise the relative rarity of these incidents (Reference Ryan, Nielssen and PatonRyan 2010; Reference Boardman and RobertsBoardman 2014). Developing a collaborative and contextual understanding of both the potential harms and gains of a decision means that therapeutic risk-taking is both possible and desirable within mental health practice. This perspective also aligns with best practice guidelines, which recognise that the elimination of risk is impossible and that preventing people from taking risks can inhibit personal recovery (Department of Health 2007; Reference MorganMorgan 2007; Reference Boardman and RobertsBoardman 2014). Therapeutic risk-taking can help patients to make informed decisions supported by collaborative person-centred care plans, which provide individualised support. Through a more personalised approach to risk, it is possible to balance the potential for harm to occur in the short term against the possibility of achieving gains over a longer timescale. Examples of this within mental healthcare include reducing medication and a harm minimisation approach to self-harm.

The concept of recovery

Throughout history, definitions of mental health and mental illness have been dominated by the professional and academic discourse. However, the growth of the consumer/survivor movement has led to increasing interest in the concept of recovery (Reference Davidson, Rakfeldt and StraussDavidson 2010). Recovery broadly refers to the real-life experience of people as they accept and overcome the challenge of being socially disabled by their mental ill health and ‘recover’ a new sense of self (Reference DeeganDeegan 1988).

Understanding and recognising the importance of an individual's experience of mental distress from their own perspective has gained increasing prominence (Reference Shepherd, Boardman and SladeShepherd 2008). At its core the consumer/survivor movement is based on ideas relating to self-help, empowerment and advocacy (Reference Shepherd, Boardman and SladeShepherd 2008) and it provides a challenge to the traditional notion of professional power and dominance (Reference Frese and DavisFrese 1997). Reference Shepherd, Boardman and SladeShepherd et al (2008) suggest that these are not new concepts and that they can be traced back to the American civil rights movement of the 1960s and 1970s. However, Reference Frese and DavisFrese & Davis (1997) argue that the modern consumer/survivor movement developed without any knowledge of its historical roots. In England, it dates back to the establishment of the Alleged Lunatics’ Friend Society (Reference HerveyHervey 1986) and in the USA to the period immediately following the American Civil War (Reference Frese and DavisFrese 1997). Promoting the rights of people with mental health problems to take risks has been a feature of the service user movement, advocated as a means of empowerment and an expression of citizenship (Reference Kemshall, Reynolds, Muston and HellerKelmshall 2009).

In reference to recovery, Reference AnthonyAnthony (1993: p. 527) argues that:

Thus, the recovery concept provides an alternative view to that which sees mental health problems as having an inevitable downward and deteriorating course. This is important in relation to notions of risk because if, as Reference Harding, Brooks and AshikagaHarding et al (1987) emphasise, people with mental health problems do recover, can have meaningful lives and can be successfully employed, then cocooning them in a risk-free environment does not help them to achieve these things. If instead the principles of recovery are incorporated into clinical practice and lived experience is valued, therapeutic risk-taking becomes a possibility. If as professionals we work with those with mental health problems and value their unique experiences we can enter into a power-sharing relationship, where risk and recovery are part of an ongoing dialogue. This will enable individuals to make choices, pursue self-determination, achieve their potential and move beyond the limitations imposed by severe mental health problems (Reference Davidson, O'Connell and TondoraDavidson 2006).

Principlism in ethical decision-making

Principlism, an approach that underpins ethical decision-making in healthcare, can confound the dilemmas experienced by professionals in relation to risk management and risk-taking. Practitioners may seek to justify decision-making based on promoting choice (autonomy) while also respecting professional duties to protect patients from harm (non-maleficence) and to promote good (beneficence) (Reference Beauchamp, Bloch, Chodoff and GreenBeauchamp 2000). Paternalism in mental healthcare is often justified on the premise of the best interests of the individual. Experiencing mental health problems can result in diminished capacity and difficulty exercising choices. When considered in this way, paternalistic practices that limit autonomy are justified if they are beneficent or non-maleficent.

If a person at risk is considered unable to make decisions because they have impaired competence (capacity), interventions against the person's will are not considered ethically disrespectful (Reference ChildressChildress 1982). However, the notion of best interests is difficult, and in some instances the interpretation of paternalism can become muddled with the protection of others (Reference Szmukler and HollowaySzmukler 2001). In this situation, the focus becomes on what the patient (or others) needs, as opposed to what that individual might prefer in an informed (competent) moment. A diagnosis of mental illness alone does not exclude someone from making an autonomous decision (Reference Beauchamp and McCulloughBeauchamp 1984), a fact that leads to some criticism that principlism prioritises rational, universal and detached ethical reasoning (Reference RobertsRoberts 2004). Therapeutic risk-taking often represents a situation in which one principle will conflict with another. If an autonomous decision is respected, it could be argued that this will conflict with the principle of beneficence. Likewise if a person's wishes are ignored, on the basis of preventing harm and promoting good, this would be in conflict with the principle of autonomy.

Such tensions underpin the need to provide practitioners with effective guidance and support to enable careful negotiation and a balance to be sought. However, in practice therapeutic risk-taking may be inhibited by organisational, professional and social constraints. In the next section, we examine these challenges and consider how some of these difficulties may be addressed to support patients towards recovery.

Barriers to risk-taking

Mental health professionals consistently identify organisational policies as undermining therapeutic risk-taking, through a lack of either clear guidance or organisational commitment (Reference Robertson and CollinsonRobertson 2011; Reference Boardman and RobertsBoardman 2014). However, both are recognised as facilitating risk-taking practices that are safe and enable professionals to have the confidence to support patients in taking risks to achieve their goals. Organisations should have an interest in ensuring effective systems of risk assessment and management. In his analysis of the ‘risk management of everything’, Power states that such systems characterise a successful organisation, as they perpetuate a ‘myth of control’ over uncertainty and instil public confidence (Reference PowerPower 2004: p. 31). He advocates a new approach to risk for organisations, which involves recognising that risk is about imagining possibilities rather than predicting outcomes. Some shifts may have been made towards promoting this perspective, with influential bodies such as the Royal College of Psychiatrists (2016) recognising that the prediction of risk is problematic.

Organisational processes that are committed to supporting rather than blaming professionals and to facilitating learning in the context of adverse events are essential (Reference PowerPower 2004; Reference Shepherd, Boardman and BurnsShepherd 2010). These are important features of developing a culture that is able to tolerate uncertainty, that values the patient's role in decision-making and that shares responsibility with the patient (Reference Boardman and RobertsBoardman 2014). Healthcare organisations also have the opportunity to commit to a different approach by extending the involvement of patients in local policy development on risk. Further embedding training in collaborative risk assessment and safety planning for professionals at an undergraduate and postgraduate level could continue to exert a positive influence on organisational practices (Reference Higgins, Doyle and DownesHiggins 2016b; Royal College of Psychiatrists 2016).

The risks of harm to self and others dominate risk assessment practice in psychiatry (Reference Ryan, Nielssen and PatonRyan 2010). One of the challenges that this poses to enabling therapeutic risk-taking is that risk becomes situated within the individual patient. Such embodiment of danger makes it difficult to move away from the perception that people with mental health problems are inherently risky (Reference FeltonFelton 2015b; Reference Clarke and MantleClarke 2016). In fact, extensive evidence shows that they are more likely to experience extrinsic harm, for example as victims of domestic violence, violent crime and physical morbidity (Reference ManiglioManiglio 2009; Reference Pettitt, Greenhead and KhalifehPettitt 2013), than cause harm. When promoting autonomous decision-making and facilitating choices, people with mental illness should not be considered solely in terms of the dangers they present: recognising the full range of threats to their safety, alongside their strengths, successes and protective factors, can overturn their perceived identity as creators of risk. Refocusing risk in this manner creates further potential that the iatrogenic harms that result from restrictions may be incorporated into risk management. This would therefore facilitate a more balanced approach (Reference Sykes, Brabban and ReillySykes 2015).

Alongside these barriers, there are a number of practices that support therapeutic risk-taking and enable it to be a reality in mental healthcare.

Relational decision-making and risk

Individualised knowledge of patients’ subjective experiences promotes a contextual and detailed understanding of risk and safety (Reference FeltonFelton 2015b). Connecting with the person's narrative enables a broad interpretation of threats and opportunities, and involving the individual in decision-making promotes therapeutic risk-taking. Additionally, this approach may create more accurate assessment as the quality and detail of information are enhanced. Assessing risk therefore becomes reconnected with the clinical examination, which is complemented rather than driven by documentation (Reference MorganMorgan 2013).

A therapeutic relationship with patients in which professionals clearly understand each individual's capabilities and draw these into decision-making both enables risk-taking and helps professionals to find a balance between safety and opportunity. In a study exploring risk-taking and recovery (Reference Young, Green and EstroffYoung 2015) it was suggested that patients valued practitioners who used person-centred knowledge to encourage them to challenge themselves. Open discussion recognises patients’ own expertise and, through the development of advanced statements and plans, provides opportunity to plan for times when they may be more likely to be exposed to or cause harm (Reference Gosling and WeinsteinGosling 2010).

Capturing different viewpoints, including those of family and significant others, is important to gain a contextual understanding of risk. Family perspectives on risk and safety are particularly marginalised, leaving carers feeling unheard (Reference Gosling and WeinsteinGosling 2010). Professionals must negotiate these different viewpoints and draw on them in reaching their own conclusions and helping patients to make decisions. They will need to find ways of having a conversation about risk using language understood by all the stakeholders (Reference Higgins, Doyle and DownesHiggins 2016b).

Principlism, which we mentioned above, has been recognised as a limited framework for promoting therapeutic risk-taking. Another approach can be found in ‘ethics of care’ theory, which draws on relational aspects of decision-making and calls for a greater focus on the patient's goals (Reference GilliganGilligan 1982). This approach requires a consideration of how a person feels and will introduce perspectives into the professional's ethical reasoning that may have been ignored using other frameworks. In seeking to negotiate different perspectives on risk and promote self-determination, professionals may benefit from drawing on these alternatives.

The collective expertise of professionals, patients and carers can be an important foundation for therapeutic risk-taking. Clinical judgements are vital when understanding risk (Reference MorganMorgan 2013; Reference Higgins, Doyle and MorrisseyHiggins 2016a) and the opportunity to exercise autonomous decision-making facilitates recovery (Reference DeeganDeegan 1988). Underpinned by collaborative planning and clear documentation, therapeutic risk-taking that promotes personal development while supporting safety is possible. This also reflects that therapeutic risk-taking is not a reason to do nothing or ignore sources of harm in the name of autonomy.

Therapeutic risk-taking and the Mental Health Act

For patients being cared for under the provisions of the Mental Health Act, small choices can have a significant impact; teams can seek ways to optimise choice within restrictions (Reference Roberts, Dorkins and WooldridgeRoberts 2008). This might include finding creative ways of sharing information with patients and advanced planning to enable them to communicate when ill choices that they made when well, including how to keep safe and when to take risk (Reference Roberts, Dorkins and WooldridgeRoberts 2008; Reference Gosling and WeinsteinGosling 2010). Further research is needed to fully examine the development of risk-taking when patients are detained or subject to compulsory treatment in other ways, such as by community treatment orders.

Supporting the professionals

Creating a safe place for professionals to hold uncertainty is an important supportive component of risk-taking. Enabling therapeutic risk-taking is consistently recognised as a multidisciplinary rather than unidisciplinary process (Reference Boardman and RobertsBoardman 2014; Royal College of Psychiatrists 2016). Regular, inclusive and open discussion can promote shared responsibility, flexibility and creative decision-making. Clinical supervision and, increasingly, ‘open dialogue’ (Reference Razzaque and StockmannRazzaque 2016) are recognised as examples of spaces where uncertainty can be safely held. Such spaces form part of Reference PowerPower's (2004) new politics of uncertainty for organisations in which these spaces nurture institutions’ trust in professional judgements, enhancing less restrictive approaches to risk management.

Organisational polices and professional guidelines with an emphasis on protection, public safety and duties of care have been presented as undermining therapeutic risk-taking and more easily justifying restrictions. However, guidelines articulate a role for mental health professionals to support therapeutic risk-taking, enabling people to exercise choices and rights, striking a balance between this and a duty of care (Reference MorganMorgan 2007; Royal College of Psychiatrists 2014). Guidance from the Royal College of Psychiatrists (2016), Department of Health (2007) and Implementing Recovery through Organisational Change (ImROC) (Reference Boardman and RobertsBoardman 2014) promotes therapeutic risk-taking and recognises that some of the current problems with risk assessment and management undermine autonomy and restrict opportunities for recovery. Recognising these values within policy and professional guidelines provides a framework to help justify therapeutic risk-taking.