The Many Faces of Risk: A Qualitative Study of Risk in Outpatient Involuntary Treatment

In legislative provisions for involuntary mental health treatment, the “harm principle,” first advanced in Mill’s On Liberty (1) to delineate when state coercion of individuals may be justified, is usually defined in terms of the construct of “risk.” “Risk” has multiple meanings in various disciplines, although all approaches deal with areas in which the probability of an outcome is uncertain (2,3). “Risk assessment” in psychiatric practice is usually considered as the process of categorizing individuals by perceived likelihood of causing serious harm to themselves or others.

The move toward risk-based involuntary treatment laws in the United States and Commonwealth countries during the 1970s and 1980s was associated with an emphasis on civil liberties and a move away from medical paternalism (4). Coercive treatment was justified only in the name of preventing significant harm. Risk remains the primary feature of laws in many jurisdictions (4,5), justifying involuntary treatment in both inpatient and outpatient settings. There are, however, a number of criticisms of its use, including that actuarial approaches to categorizing people by relative likelihood of future harm to self or others (such as suicide or violence) have poor predictive value and little clinical utility (6,7); that a legal test of risk of harm will subject some people to coercive treatment unnecessarily, while it will delay or deny access to treatment for others (7); and that laws can stigmatize and inaccurately stereotype people living with a mental illness (5,8).

There is also the challenge of putting into practice an elusive concept that is open to a multitude of interpretations (2). Although it has positive elements, risk frequently speaks to an evaluative process that seeks to estimate the probability of a negative event. It can therefore be subject to biases that may, for example, overestimate the risk of violence posed by people with mental illness. Risk can also be ambiguous in various health care settings. Many considerations of “risk of harm” and mental illness focus only on acute and severe disturbances necessitating inpatient hospital detention. For involuntary treatment of less acute illness in outpatient settings, these concepts of risk of harm have less apparent value.

This qualitative study aimed to derive a comprehensive model of risk in involuntary outpatient treatment that is credible and meaningful among patients, caregivers, clinicians, and legal decision makers. Such a model seeks a nuanced understanding of risk that can inform clinical practice, policy, and law.

Methods

This study was conducted in New South Wales (NSW), Australia, from July 2009 to July 2012 and focused on involuntary community treatment orders (CTOs) under the NSW Mental Health Act (2007). Like other Australian and many international jurisdictions, NSW’s involuntary treatment law is often conceptualized by clinicians as risk based and establishes that psychiatric treatment cannot be delivered to persons without their consent, unless, because of a mental illness, a person requires protection from serious harm to self or others. [Further details about CTO provisions of the act are provided in an online supplement.]

The study had two aims: to identify how mental health professionals, patients, caregivers, and legal decision makers conceptualize risk in the context of decisions about involuntary psychiatric treatment in the community setting and to derive a comprehensive model of risk that has use and meaning to stakeholders. The study was conducted by researchers from the Centre for Values, Ethics and the Law in Medicine at the University of Sydney. Participants were recruited by using a theoretical, purposive method of sampling. The researchers recruited people from four groups: patients currently or previously subject to a CTO, relatives or caregivers of a person subject to a CTO, mental health clinicians, and members of the Mental Health Review Tribunal (MHRT), the legal body with oversight of involuntary psychiatric treatment. We sought to build a sample of maximum variation, rather than a representative sample. Recruitment used a variety of networks to distribute an invitation to participate.

After participants were given an information statement and an opportunity for questions about the project and the interviews, written informed consent was obtained. Patients and caregivers received $40 at the interview toward costs of participation. Patients were not recruited from or interviewed in clinical settings because we sought to maintain a clear distinction between patients’ voluntary study participation and their involuntary treatment status. The research was conducted with the approval of the University of Sydney Human Research Ethics Committee and the Sydney Local Health Network Ethics Review Committee.

During in-depth semistructured interviews, we prompted participants to speak from their unique understanding of CTO use by providing narrative accounts of their experience of CTO processes. Interviews were recorded digitally, transcribed, and deidentified. Data were managed with the NVIVO9 computer program. We used the general inductive method (9) of data analysis, in which interviews are first coded by using initial, a priori codes. As data are coded, themes are identified and a coding structure develops, facilitating the emergence of risk themes. These themes formed the basis of the model of risk.

We sought to confirm data saturation by triangulation (10,11) of the data coded separately by two team members (EL and MR) and through discussion with stakeholder reference group members at regular research meetings. [Further details about the methods are available in the online supplement.]

Results

Five patients and six caregivers were interviewed (six men and five women). Among the patient participants and the relatives of the caregiver participants were diagnoses of schizophrenia, depression, bipolar disorder, and anxiety. Fewer participants than anticipated were recruited because of the difficulty of recruiting through nonclinical pathways patients who were subject to CTOs; moreover, several individuals withdrew or were unable to participate because of health problems.

Twelve MHRT members were interviewed (five women and seven men): four psychiatrists, four lawyers, and four other members from social work, nursing, psychology, and mental health service administration. Fifteen clinicians were interviewed (four men and 11 women): three psychiatrists, eight nurses, two social workers, one psychologist, and one occupational therapist. The clinicians had worked in inpatient and community settings, and their clinical loads included general adult mental health, youth mental health, older persons’ mental health, and Aboriginal mental health.

Analysis of participants’ accounts revealed six themes: actual harm, social adversity, therapeutic outcome or compromised treatment, the system, interpersonal distress, and epistemic issues (Table 1). Significant overlaps were noted among the interdisciplinary perspectives of clinicians and MHRT members and between the perspectives of patients and caregivers, and all perspectives were integrated as the analysis progressed. Overlaps were also evident between all the discourses on risk, particularly in regard to actual harm, social adversity, and the system; however, variation was noted in how participant groups emphasized the causative properties of various aspects of risk. For example, clinicians were often more influenced by notions of actual harm and epistemic questions of risk quantification, whereas patients and caregivers were motivated more by the distress of mental illness and social and interpersonal disadvantage related to mental illness.

Discussion

Using an inductive method of qualitative research, this study sought to describe how patients, caregivers, clinicians, and MHRT members conceptualized risk and to derive a model of risk in the context of outpatient involuntary psychiatric treatment.

A model of risk that accommodated the ways in which the different study participants understood risk required integration of the risk discourses. Grounded in these rich and varied accounts of participants’ experiences, a model was systematically developed that identified four domains: risk of harm to self or others, encompassing suicide, misadventure, neglect, exploitation or victimization, and deteriorated physical health; risk of social adversity, encompassing homelessness, poverty, isolation, deprivation, and limited access to services and social goods; risk of excess distress emerging from the symptoms of mental illness and from interpersonal conflict, coercive inpatient treatment, and the traumatic affronts to the self of severe psychotic or mood disturbance; and risk of compromised treatment, manifesting as delays or loss of treatment opportunities or iatrogenic harm from treatment decisions, emerging as more severe illness, psychiatric and medical comorbidities, and an inability to participate in recovery. In considerations of risk and involuntary outpatient treatment, all domains in the model apply. However, different domains will be important at different times, depending on who is involved (for example, the patient or legal decision maker) and the context (for example, clinical history or setting).

Our findings and model are consistent with the literature about the multidimensional nature of risk, particularly in the mental health setting, where a “rich stew” of risk discourses means that several meanings of risk are weighed and countenanced by treating professionals (12). As in Ryan’s (13) study of factors of perceived risk related to individuals with mental illness in the United Kingdom, this study also determined that the multidimensional character of risk covered both risk faced by and risk posed by people with mental illness.

In graduating arguments for and against involuntary outpatient treatment beyond the limited scope of harm (that is, beyond solely violence or “dangerousness”), the model offers a number of potential improvements for practice. It offers opportunity for improved communication and informed decision making. It allows broader consideration of grounds to justify decisions to initiate, renew, or cease involuntary community-based treatment. It also provides a framework for developing treatment plans and increases transparency and accountability of decisions about involuntary treatment.

By describing risk in context, these findings also offer opportunities for informed debates about policy and ethical issues. Risk sits at the center of ongoing deliberations about involuntary psychiatric treatment: reform of policies and legal criteria, including moves away from risk-based systems to capacity-based systems (4,5); and unresolved ethical and epistemic questions of what we are trying to do (and not do) when using involuntary outpatient treatment orders (14). Discussion of risk is often homogeneous, and the model allows for elaboration of the concerns of various groups.

Conclusions

Risk-based mental health laws are recognized as problematic in terms of clinical utility and the potential for delays or loss of treatment opportunities and for stigmatizing illness. However, consideration of risk remains an important and irreducible feature of mental health care. We need ways to communicate about risk that have meaning to people, that decrease stigma and discrimination, and that are broadly shared by stakeholders.

This study derived an empirically based model of risk that may have instrumental value in jurisdictions that have risk-based laws for involuntary treatment in the community. The model also enables an important contextualized understanding of NSW’s well-established system (more than 20 years old), which has high rates of use by international standards (15).

A better understanding of how involuntary community treatment systems work in practice—including how key concepts such as risk are applied—is worthwhile as part of any efforts to improve how mental health policy and services respond to people with severe and chronic mental illness. The model provides some architecture for public and professional discourse on matters related to community mental health services and involuntary psychiatric treatment.