Anne-Maree Sawyer

Should the nurse change the light globe?: Human service professionals managing risk on the frontline

Over the last two decades New Public Management, de-institutionalization and the growth of community care have radically altered the landscape of human service delivery in Australia. As a consequence of these changes, human service agencies have been compelled to develop mechanisms for regulating and managing the risks involved in frontline community care — and the management of risk is now pivotal to the practices of professional workers in this field. British research suggests that the emphasis on risk gives rise to greater monitoring and administrative supervision of workers and a focus on managerial rather than therapeutic skills. This article presents some early findings from an Australian study that finds a very different picture. Based on interviews with 24 social workers and nurses employed in community care, we found that these workers expressed a strong sense of agency when interpreting and negotiating the risk management policies of their respective organizations, and were focused primarily on the needs of their clients rather than bureaucratic procedures.

From therapy to administration: deinstitutionalisation and the ascendancy of psychiatric ‘risk thinking’

Abstract Crisis Assessment and Treatment Teams (CAT Teams) were established in Victoria, Australia, in 1988 to provide crisis intervention and home treatment as an alternative to hospitalisation for the seriously mentally ill. These teams were set up to prepare for the closure of the large-scale, state-run psychiatric institutions over the following decade. Increasingly, concerns are being expressed in the media over the failure of the new community-based services to provide adequate care and protection to the mentally ill. This paper offers a preliminary attempt to make sociological sense of one such aspect of deinstitutionalisation, the major changes that have occurred in the practice and delivery of CAT Team services since inception. I suggest that a shift has taken place from a therapeutic consciousness, centred on providing home treatment, to a risk consciousness, centred on protocols to evaluate and document a client’s ‘risk factors’. Drawing on my personal experiences as a clinician in a Melbourne-based CAT Team since 1991, I probe these changes through the lens of sociology. In so doing, I utilise several insights from Nikolas Rose’s (1998) analysis of risk as a foundation for social intervention.

Risk and new exclusions in community mental health practice

Abstract Over the past two decades, mental health practice has become increasingly focused on assessing and managing the risks posed by service users. British researchers have made significant advances in studying the consequences of risk management for community-based health and welfare services, but in Australia this field remains largely undeveloped. Drawing on my experiences as a social worker in a Melbourne-based Crisis Assessment and Treatment Team from 1991 to 2008, the present paper offers a reflective analysis of the shift in practice orientation that has emerged through the growing prominence of risk as a foundation for intervention. Specifically, I argue that this shift has led to a narrowing of service provision and that “low-risk” clients are newly disadvantaged, often excluded from service.

Mental Health Workers Negotiating Risk on the Frontline

Abstract Following deinstitutionalisation and the shift to models of community care, mental health practice has become increasingly focused on managing the risks posed by service users. However, the effects of risk management on workers’ professional identities have not been investigated empirically in Australia. Drawing on in-depth interviews with mental health workers from Victoria, Australia, this paper explores the diverse ways in which these workers adapted the formal technologies of risk management (e.g., the completion of risk assessment screens) to their professional identities. Some workers experienced risk management technologies as constraining their interventions with clients, while others saw these technologies as providing opportunities to strengthen and enhance their professional skills. Pondering these differences, the author speculates on the emergence of a new form of professional identity in the broader context of contemporary community mental health care.

Social Inclusion and Individualised Service Provision in High Risk Community Care: Balancing Regulation, Judgment and Discretion

Since the late twentieth century, health and welfare policy in Australia and the UK has focused on enhancing the freedom, life choices and participation of service users. Public policy, based on the construct of social inclusion, requires greater individualisation of services, active engagement with service users, and innovative partnerships between different providers. At the same time, however, the management of risk through a range of compliance procedures can discourage the exercise of discretion by workers, limit the participation of their clients and reduce incentives for innovative cooperation between services. Drawing on in-depth interviews with community care professionals and their managers engaged in high risk social care in Australia, this article gives particular attention to the relevance of risk to social inclusion and individualised service provision.

Supporting People With an Intellectual Disability and Mental Health Problems: A Scoping Review of What They Say About Service Provision

This article reports on the findings of a scoping review of peer-reviewed research that investigates the formal support experiences of adults with an intellectual disability and mental health problems. Seven databases and 21 sources of grey literature were searched and 17 articles were retained for review, demonstrating the dearth of literature in this area. Key findings were organized in terms of service types studied and social justice issues. Findings indicate that people with an intellectual disability and mental health problems often experience distress and alienation in both mainstream and specialist psychiatric inpatient units, and in emergency departments. Since respect for personhood is central to positive experiences of formal support the significance of service users’ appeals to be treated with dignity and respect should not be underestimated. A new “integrated” model of inpatient care offers the potential of redressing some of the shortcomings of conventional care, but further research is needed. Despite well-documented challenges in conducting research with people with an intellectual disability, the authors conclude that the use of inclusive research designs must be expanded in order to enhance the formal support experiences of people with an intellectual disability and mental health problems.

Trust and the Dilemmas of Suicide Risk Assessment in Non-government Mental Health Services

ABSTRACT Reducing suicide rates is a national mental health priority as over 2,200 people die from suicide each year in Australia. Increasingly, nongovernment organisations (NGOs) provide services to people experiencing severe and persistent mental illnesses—a significant cohort at risk of suicide. While clinical services are generally seen as the arbiters of risk, little is known of how suicide risk assessments are undertaken in NGOs. This article reports the findings of a survey-based pilot study of 44 frontline workers in mental health-focused NGOs in Tasmania, Australia, with the aim of sketching a preliminary picture of this under-studied terrain. We identified the assessment practices utilised by workers, and the challenges and dilemmas they experienced in navigating issues of trust in suicide risk assessment in contexts where they often felt vulnerable and under-prepared. We argue that these early findings demonstrate the need for organisations to foster cultures of trust to facilitate both the activities of relationship building between practitioners and clients, and those of monitoring risk.

Mental Health Social Work: Perspectives on Risk, Regulation, and Therapeutic Interventions

As we write this editorial, the Australian Government has launched a major reform of the Australian mental health system. According to Professor Ian Hickie, one of the National Mental Health Commis...

Introduction: Longevity and sociology

Population ageing is an historically unprecedented global phenomenon. The (World Health Organization [WHO], 2013) reports that, in almost every country, the proportion of people aged over 60 years is increasing faster than any other age group. It predicts that between 2000 and 2050 this proportion of the worlds population will double from about 11 to 22% or, in absolute terms, increase from 605 million to 2 billion (WHO, 2013). The ageing of populations around the world is clearly a cause for celebration. Longevity reflects human success in instituting effective public health measures, dealing with killer childhood diseases, significantly reducing maternal mortality, and producing the means of effective fertility control. Yet, many people around the world are not advantaged by this progress: they do not expect to make old bones. Such groups as Indigenous populations, people with disabilities and those with serious mental illnesses lag behind others in terms of health status and propensity for long life. It is estimated that Indigenous Australians, for example, have a life expectancy at birth of 59.4 years for males, and 64.8 years for females, some 16-17 years less than the overall Australian population (Australian Institute of Health and Welfare, 2013).