Risk Management vs. the Dignity of Risk
By Jonathan Dosick
Observing public policy trends here in Massachusetts, one thing I’m struck by is the lack of clarity around the concept of “risk.”
What does “risk” really mean? Is it something to be afraid of and avoided at all costs, or something to be embraced? Perhaps both? One thing is clear: the juggernaut of increased and often-duplicative ‘risk management’ continues to pick up speed. New policies, rules and regulations are constantly being proposed, in the guise of ensuring safety for staff and peer/survivors.
Seeking to prevent harmful situations is necessary in the world of health care. But when is it enough? When does ‘risk management’ – the attempt to stop all incidents of potential harm to self and/or others – become a hindrance to healing? While the preponderance of ‘risk management’ may assuage public and political fears in the present, it creates more danger in the long run.
Of course, we know that ‘risk management’ is geared towards ‘negative’ risk – i.e., harm to self or others. But there’s another way of looking at ‘risk’ – taking positive risk, even if not sanctioned by traditional care, is a necessary part of recovery, empowerment and wellness.
Unfortunately, awareness of productive risk-taking – so eloquently expressed by the term “dignity of risk” – is getting drowned out by ceaseless calls for increased ‘risk management.’ And I fear that these attempts are keeping people from realizing true freedom and wellness.
Lessons From a Tragedy?
A few years ago, a young woman working at a Department of Mental Health (DMH) – licensed group home near Boston was killed by a resident – unquestionably, a terrible tragedy. The ensuing media coverage of that event has been a major catalyst for providers, DMH and lawmakers to consider measures that are significantly changing the mental health care system; in many ways, making the system more and more restrictive.
It’s difficult to address these issues in the face of such tragedy without the appearance of disrespect for the victim and her family, which is absolutely unintentional. It’s understandable that there are calls for change. But at the same time, it’s alarming that what is widely understood as fact seems to get lost so easily in the public arena – that persons with mental health diagnoses pose no greater of a threat of violence towards selves or others than the general population, and in fact are more likely to be the victims of violence. The mainstream media must be called out for their complicity in selling the lie.
In the last several months, we have seen the following in Massachusetts:
- More “official” mental health committees focused on safety and risk, with little or no peer/survivor involvement;
- A vaguely-defined bill calling for all residential mental health employees to be equipped with a “panic button;”
- ‘Advocacy’ confused with maintenance of ‘status quo.” Large “advocacy” groups, afraid to challenge mainstream thought, see ‘mental health advocacy’ as seeking more funding for inpatient beds, increased access to medication and involuntary treatment – rather than empowerment and rights.
- A pronounced shift by labor unions away from idealistic support of human rights and toward “protect our worker members;” and
- The ever-present threat of involuntary commitment laws.
Myself and other advocates have worked for eight years to make access to the outdoors a requirement at inpatient units and residential facilities – a simple concept that gets shot down every legislative session. Why? ‘Costs too much, too much risk.’ Efforts to improve human rights in the system stay on the back burner.
Quest for the Quick Fix
“In America we like solutions. We like solutions to problems. And there are so many companies that offer solutions. Companies with names like: The Pet Solution, The Hair Solution, The Debt Solution, The World Solution, the Sushi Solution.”
– Laurie Anderson, “Only an Expert”
Modern America: the land of buy now, pay later. We’re perpetually at war with the unknown. Every day, advertisements offer the false promises of permanent fixes: Take a pill! Call a lawyer! Lose weight without dieting! In today’s fast-paced, always-on, plugged-in culture, we yearn for quick fixes to anything that ails, disturbs, or inconveniences us.
I see an unmistakable parallel with the mental health system. New rules on safety and risk are the result of a system desperately seeking a ‘quick fix’ where there is none.
Risk as Growth
When I first heard the term “dignity of risk,” it was a startling moment of clarity. Must ‘risk’ always have a negative connotation? Taking risks is a crucial part of recovery and wellness; I know it firsthand.
For me, recovery began with acceptance of the unknown. Since my first psychiatric hospital stay in 1989, which I saw as a temporary “respite” from a troubled adolescence, being admitted to the hospital was my “quick fix.” There, I could surrender my pain and insecurity (or so I thought) to people who would pay attention to me, and find a sense of community with my peers. When I left, I’d be a new, “fixed” person. Only thing was, that never happened. I always felt just as lost at discharge as when I went in – in fact, there was the added burden of disappointment that I wasn’t healed.
Between 1989 and 2002, I went inpatient ten more times. During my second-to-last hospital stay, supported by the insight of an empathetic staff member, I finally realized: hospitals aren’t truly therapeutic places.
I was forced to realize the truth: yes, others could help me. But it was up to me alone to go through the pain of living and getting better. That was as close to a “fix” as possible! Over the next few years, I gradually became more independent. I found housing that wasn’t connected to mental health; obtained employment, and got off Social Security benefits. I’m not boasting here; my point is, if I had been prevented from taking these risks, I wouldn’t be living the kind of life I choose, wouldn’t be an adequate peer specialist or advocate. My self-esteem, while still not perfect now, would be very low or non-existent.
I see so many of my peers who, having been ‘in the system’ for so long, have absorbed and internalized “learned helplessness.” They believe they cannot make their own decisions. Years of ‘custodial’ care, infantilizing “privilege” systems, and other forms of inequality have extinguished independence and self-determination from their psyches.
REAL recovery and self-determination relies on than the ability to choose what’s best for oneself. Choices like:
- Living on one’s own;
- Obtaining employment;
- Getting off benefits;
- Beating addictions;
- Managing one’s own money;
- Expressing oneself freely; and
- Choosing what kind of healing one truly wants.
The ‘system’ needs to get serious about this, moving beyond using the lingo of self-determination to actually implementing it. Only then can people truly recover.
“Risk Management” is based on a rigid, fear-based view of health care services – made possible by a health care system focused on profit, insurance and liability. When I hear more plans for “risk management” (a new, duplicative policy was just introduced a few weeks ago), I see a system creating future lives of stifling dependency. That’s not only tragic, but it makes no economic sense: without taking healthy risks, people will remain dependent, and utilize far more services (costs) in the long term.
The Mass. Department of Mental Health deserves great commendation for introducing a peer specialist workforce, and there has been some real progress. Accepting “dignity of risk” is a process, which may be uncomfortable for the mental health system. Insurers will fight it. Liability issues will inevitably be cited. And of course, any act of violence that can possibly be linked to ‘mental illness’ will continue to be catapulted to the public’s attention. The involuntary commitment crowd will be glad to amplify the stereotypes and fear. But to me, risk is a key to moving forward.
Maybe we need to understand that no matter how hard we try to prevent them, tragedies will always happen. As a society, the more we strive toward total control, the less likely we will achieve it. What if we looked at it another way – acknowledging that in the long run, there would probably be far fewer tragedies of all kinds if the peer/survivor population was allowed MORE freedom?
We must revisit the idea of risk and be alert to the dangers that new “risk management” rules pose to our civil liberties. When the dignity of risk is respected, we can achieve true recovery and wellness.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.