Since the early 1990s, a new modality of community mental health care, strongly focussed on the control of risk, has taken shape in Britain. It is argued in this paper that this new regime of community mental health care is highly rational and indicative of what Castel (1991) termed the 'epidemiological clinic'. The study discussed in this paper aimed to develop a greater understanding of how community mental health nurses, who have become frontline operatives of the new regime of community mental health care, reflect on and practise risk assessment and risk management. Interviews with 20 community mental health nurses from various geographical and practice areas demonstrated that risk assessment and risk management formed an integral part of their work. Some considered standardised methods of risk assessment to be too reductive, stifling and unnecessary, whilst others found them useful and informative. 'Professional intuition' was valued by many as an alternative method of risk assessment, particularly when assessing their own safety. Though their risk assessments concentrated on the assessment of patients' potential to harm others or themselves, some thought about risk in a wider context, in terms of the risks faced by their clients from iatrogenic consequences of treatment and psychiatric care, and of victimisation within a hostile community. Thus, it would seem that the epidemiological clinic has not had a totalising effect on the work of community mental health nurses.
The thrust of this paper is to argue that Habermasian theory can provide useful insight and understanding to inform participatory research in the area of forensic mental health care. Habermasian theory about communication, participation, and democracy is used to explore retrospectively the relatively free discussions that took place within a user-led research project evaluating forensic mental health care. We (the academics within the research project team) first describe the stages of the research project, outlining how it opened up space for discussion about service users' experiences of the forensic mental health care they had received. Habermas's distinction between 'strategic action' (orientated towards getting things done) and 'communicative action' (interaction orientated towards freely agreeing consensual understanding) is then explored in a re-analysis of users' accounts of the interactions they recalled having with service providers. We then offer an account of interactions between service user researchers presenting their work at academic forums and their audiences of service providers. In particular, we look at the communication that occurred and, again using Habermasian theory, consider the issues that arose about open discussion and similarities and differences between therapy and participatory research.
In this paper the author argues that the development of community psychiatric nursing can be understood as a professional project. However, the case of community psychiatric nursing cannot be adequately understood from mainstream literature on the subject of professionalization within the health care division of labour. The inadequacy of such literature is that it either concentrates upon the pre-eminent case of medicine or regards nursing's professionalization as being unitary. The author posits that the professional projects of general nursing and community psychiatric nursing have different and even opposing interests. To contextualize community psychiatric nurses' (CPNs') professional project the author examines: the history of mental nursing, from which community psychiatric nursing evolved; the development of community mental health care, which allowed for the inception of community psychiatric nursing; CPNs' relationships with both psychiatrists, whose patronage assisted CPNs' initial growth as para-professionals, and general practitioners, who later assisted a more functionally autonomous role for CPNs in primary care; and social policy towards community care that enhanced CPNs' growth. In conclusion the author argues that recent government-led changes in the management of community mental health care now impel CPNs to change the direction of their strategy for occupational survival and advancement.
Medium/low secure units occupy a central role in forensic mental health care, bridging high secure and community services. Although outcomes, assessed in terms of readmission and identified reoffending, have been evaluated, little research exploring processes underlying attempted rehabilitation for offenders diagnosed as having mental health problems has been undertaken. The present qualitative study built upon previous research completed in a Northern England medium/low secure forensic mental health care institution for adults with learning disabilities . It was carried out in a medium/low secure forensic mental health care Unit located in London. In phase one, 43 staff, including general managers, doctors, nurses, psychologists and occupational therapists were interviewed about their philosophy of care, views about risk management for forensic mental health patients and perceptions of the Unit. In phase two, 10 case studies of patients were undertaken. As far as possible, patients were interviewed twice over a period of 11-20 months, and staff were asked about their progress. Two case conferences were observed. Data were analysed using the metaphorical concept of a rehabilitative risk escalator around three themes carried forward from the previous study: organisational issues; patient active risk management; and multiprofessional collaboration.
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