The pressures are becoming overwhelming for mental health professionals to place risk assessment and management at the centre of their engagement with their patients (or clients as they are currently termed). In area of risk assessment the framing of the main research questions and the articulation of the resulting data is increasingly in terms of actuarial risks and the generation of standardized questionnaires which will generate predictive scores. The technology of risk assessments could become one of the primary mediators of the relationship between the professional and the mentally disordered person. This will radically alter how the patient and their disorders and disabilities are revealed to us. The technological focus on risk potentially strips the patient of much of their personal and social context and objectifies them and their disorder as an embodiment of a quantum of riskiness.
Technology is about performance and control, it is about domination, and the objects of technological manipulation are just that, objects. (9 ,.9Z> To the extent that technological approaches to risk assessment come to dominate clinical practice, whatever benefit they may bring, the price will be reframing the clinician's view of their patients as potentially dangerous things. Risk assessment forms part of a major shift in psychiatric practice and theory away from individually based engagements between clinicians and uniquely troubled individuals to a world of standardized best practice. Instruments direct diagnosis, diagnosis determines which system of treatment is to be applied, and risk assessments enable us to prevent damage to, or by, the objects of our professional responsibilities. Efficient, effective, and properly evaluated performances of mandated procedures becomes the definition not only of the normative but the ethical.
This chapter began with a quotation from a Nobel Prize winner; it will end with the story of another. In reading the account provided by Nasser (98) of the schizophrenic illness of the Nobel Laureate John Nash images emerge of the complex interactions between illness and the sufferer's humanity, life, and even genius. Nash had a devastating mental illness; as a result of this illness he was compulsorily treated and even at times regarded as dangerous. He finally entered a stable remission in which he could once more work as a mathematician. This was without the continuing aid of medication or any other form of mental health ministrations. What has this to do with risk assessment and management? Everything. The outcome of an illness such as one of the schizophrenias in an individual case remains enormously difficult to predict. We must, as mental health professionals, act on our estimates of future probabilities. We should struggle to make our risk assessments and risk management strategies as effective as possible. But in the end we should remain modest about our capacities to perform such predictive and preventive functions, and not lose curiosity about what really delivers Nash and others from insanity and even dangerousness.
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