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Public Mental Health, Discourse and Safety: Articulating an Ethical Framework

Public Mental Health, Discourse and Safety: Articulating an Ethical Framework Abstract This article positions ‘safety’ and ‘risk’ as key public health problems in mental health. I demonstrate that discourse about safety occurs extensively in relation to mental health, but it does not occur in a way where the mental health system gets any safer for the key actors involved. Ongoing unproductive discourse occurs because the different actors involved are speaking at cross purposes and about different things against the background of a ‘public’ discourse focused on safety crises. I map the general interests of the main set of actors to demonstrate the conflicted and complex nature of discourse around mental health safety. In response I outline a dialogical approach to safety and risk based on the work of Habermas and values of recovery. This is presented as a framework from which to assess whether discourse is occurring effectively to develop shared meanings. Shared understandings of safety will mean that the safety needs of relevant actors can be understood and negotiated rather than giving way to an actuarial process which does not take into consideration the context of a person’s life. Introduction Safety in relation to mental health care is a significant public health problem of concern to consumers,1 practitioners, carers, the ‘public’ and policy actors (Wood and Pistrang, 2004; Quirk et al., 2004; Stamp, 2008; Trinh et al., 2008; NMHCCF, 2010). However concepts of ‘safety’ and risk are differently articulated as a result of the different interests underpinning these terms—what is understood as ‘safe’ for one set of actors, may compete with, or be understood differently for, others. The contestation between the needs of different actors is played out through public discourse and performed within the institutional practices of mental health and associated services. These circumstances have led to what Snow and Austin (2009) have termed a continuous ‘ethical balancing act’ for policy makers, legislators and service directors. Conflicting priorities engender complex ongoing arrangements for the safety of mental health consumers, practitioners and the public (Fennell, 2005; Kahan et al., 2010) – arrangements which in reality often fall short of providing safe mental health care (ABC News Online, 2008, 2011; Hagen, 2011). This article positions ‘safety’ and ‘risk’ as key public health problems in mental health. I aim to demonstrate that discourse about safety occurs extensively in relation to mental health but it does not occur in a productive way where the mental health system gets consistently safer for the key actors involved. Ongoing unproductive discourse occurs because the different actors involved are speaking at cross purposes and about different things. I focus in on discourses of safety as they relate to the safety of consumers and decisions about compulsory treatment because it is in this context that decisions about safety and risk have the most significant material outcomes for individuals. I take a high-level approach and sketch the field of public mental health by identifying the actors with interests in safety and risk, the scope of these interests and what actions they produce. I then offer a dialogical approach to safety and risk based on the work of Habermas and values of recovery. This is a deliberately high-level article, as it is not possible to focus in on every place, process and actor where the complex issues of public mental health and safety interact. What I map here are the general interests of the main set of actors, grounding this where possible in examples of cases, mainly from the Australian context from which I write. This high-level approach is necessary because it needs to take in the complexity brought about by the inclusion of interests from a very disparate range of actors. My aim is to present a framework against which to compare and improve existing practice. While safety and risk are public health problems, services are the main site of action for controlling safety. For that reason I primarily focus my discussion on discourse ethics in the context of mental health services. My discussion also focuses in on recovery, which is discussed in this context in relation its use by consumer advocates. Recovery here does not refer to ‘cure’ but rather to the journey that mental health consumers travel to live a meaningful life with or without the symptoms of mental ill-health (Anthony, 1993). Recovery will be explained in further detail later in the article. The Context of Safety, Risk and Mental Health That safety is a concern for all those involved in mental health is well attested. Practices designed to ensure the safety of consumers, the public and service providers are enshrined in legislation and practice guidelines in most nations. For example in Australia each state and territory has mental health legislation whose purpose is the ‘care and protection’ of those experiencing mental ill-health, but also members of the public. This legislation mandates responsibilities and decision-making about safety from a wide range of actors including consumers, health service workers, the government, police and ambulance workers (Smith-Merry and Caple, 2014). Despite the steps outlined in mental health legislation, including compulsory treatment of consumers when at risk to themselves or others, a failure to use legislation and other frameworks to select and meet the correct interests in a given situation can have serious outcomes including death. Research on publicly available coronial findings shows that problems of safety related to mental health services most frequently arise in relation to errors of ‘assessment processes, communication and information transfer, documentation, planning and training’ (Smith-Merry and Caple, 2014). These failures are frequently the subject of coronial and other inquiries including, for example: Coronial inquiries on clusters of deaths, e.g. a ‘cluster inquiry’ into restraint-related deaths (Hagen, 2011) Federal senate inquiries, including inquiries into services and suicide (Australian Senate, 2008, 2010) State and Commonwealth ombudsmen reports on adverse events such as the NSW Clinical Excellence Commission reports on adverse events and Human Rights Commission Inquiries such as the National Inquiry into the Human Rights of People with Mental Illness (1993) State-based Royal Commissions such as the ‘Chelmsford’ Royal Commission into Deep Sleep Therapy leading to the establishment of the NSW Health Care Complaints Commission in 1993 (NSW Government, 1990) Health complaints commission investigations, e.g. an investigation into a number of suicides by the South Australian Health and Community Services Complaints Commissioner (HCSCC, 2009) As a result of the past failures and ongoing risks identified in these inquiries safety has been prioritized in policy and service design. In Australia safety is 1 of the 10 standards addressed in the 2010 National Standards for Mental Health Services, which requires that ‘The activities and environment of the [mental health service] are safe for consumers, carers, families, visitors, staff and its community’. As Rosen, Rosen and McGorry (2012) comment, the simplicity of this statement masks the difficult balancing act that must occur for this to happen and the fact that there is considerable debate over what makes treatment, including within an inpatient setting, ‘safe’ for patients and others (Bowers et al., 2007). Ruth Vine (2006), Director of Mental Health within the Department of Human Services of Victoria spoke about this ‘ethical balancing act’ in evidence before the Commonwealth Senate’s Select Committee on Mental Health: One of the challenges for public mental health policy is to strike a balance, and we have to strike lots of balances. One balance is between the issues of safety and autonomy, another is between the interests of the community and the interests of the individual, and another is between the individual’s immediate safety and their longer term safety. This complexity of interests means that it is difficult to understand just whose interests should take precedence in a given situation. Who Are the Actors and What Are Their Interests? The ‘ethical balancing act’ involved in public mental health balances the ‘safety’ interests of individuals and institutional actors (Snow and Austin, 2009). Many of these public and personal interests are interconnected and across multiple spheres. Here I map out the primary interest groups that populate discourse and action at the intersection of mental health and safety. Two overarching sets of safety needs underpin mental health safety discourse: the risk of the consumer to self and the risk of the consumer to others (Coffey et al., 2017), but the field will be shown to be more complex than such a binary might reveal. I focus in on primary or substantive interests here. While undoubtedly these actors may have minor interests that are beyond what is described here I have focused on the major interests described in public and academic discourse. Consumers Consumers have a need to feel safe when they are mentally unwell and to be protected from self-harm and suicide. Suicide rates in most countries remain stubbornly high, and are increasing in some places. In Australia the suicide rate has increased over the past 3 years to an age-standardized rate of 12.7 per 100,000 in 2015—up from 10.9 per 100,000 in 2013 (Australian Bureau of Statistics, 2016). This rate is similar to that in most European countries. Consumers have a primary interest in their own safety as users of a system that has a history of unsafe treatment practices (Dixon, 2015). Risk also arises from their position as members of a general public whose individual perceptions and collective voice as presented in the media is often highly stigmatizing toward mental ill-health. This particular aspect of risk is discussed further in my characterization of the interests of the general public below. The history of unsafe practices referred to above meets a contemporary context where people may be legally removed of their right to object to treatment, meaning that they may be forced to enter potentially unsafe environments. For most consumers their mental health needs will be met through talking-based therapies, medication or other low-intensity interventions. Others need to use more intensive services which involve interactions with community mental health teams or inpatient care. While some consumers feel that inpatient care, particularly that which involves isolation or locked rooms, is inherently unsafe, others feel safe when placed in hospital because they are able to get help with those aspects of their mental health which made them feel unsafe in the community (Lapsley et al., 2002; Wood and Pistrang, 2004; Quirk et al., 2004). Because individuals being treated involuntarily either within a hospital inpatient setting, within the community, or within a forensic facility have limited recourse to challenge their treatment regimes, there is evidence to show that those in these circumstances may be particularly at risk of harm (Freckleton, 1998; Trinh et al., 2008). Issues of safety also become more stark in these environments as media or political discourses of ‘community’ or ‘public’ safety are positioned in relation to—and often in opposition to—the safety of consumers. These public discourses therefore may distort the treatment framework. The use of compulsory treatment orders which mandate medication and/or inpatient stays has been increasing over the past decade with some arguing that this is as a result of calls to ensure public safety, rather than as a result of the effectiveness of the practice (Coffey et al., 2017). Light et al. (2012) draw attention to figures which show that while in Australia we have high rates of the use of compulsory treatment orders (e.g. 55 per 100,000 in Victoria compared to just 2 per 100, 00 in New York), neither Australian consumers nor the general public are at significantly less risk of harm. Rather it is the variable response of the overarching policy and service frameworks to discourses of risk which accounts for different use of these legal strictures on individual consumers. It is important that health consumers are able to speak up when they feel that their care has been compromised and that their accounts are given credence. This is a key accountability and quality assurance mechanism for the health system and ensures that poor practices do not become entrenched. However the consumer voice is frequently mistrusted when giving an account of their own risk. It was the 1982 Chelmsford Royal Commission into mental health-care-related deaths which led to the development of Australian health complaints commissions (Walton, 2013). The 1982 Commission focused on unsafe practices at Chelmsford Hospital under the direction of Psychiatrist Harry Bailey which led to multiple deaths from the administration of deep sleep therapy. It showed that deaths were perpetuated through a system which was blind and deaf to the safety complaints of consumers who were dismissed as unreliable by the medical establishment and government administrators (Walton, 2013). These issues are ongoing. A recent Victorian government inquiry has focused on cases of violence in mental health facilities (Baker and McKenzie, 2011), including sexual assault, which have not been taken seriously and normal police reporting procedures not followed (Stamp, 2008). Research on complaints about mental health treatment has shown that mental health consumers are fearful of complaining when they feel unsafe or have problems with treatment because of a fear they will not be believed, will be labeled as ‘difficult’ or receive poorer treatment due to complaining (Kuosmanen et al., 2008; Victorian Government, 2009; Entwistle et al., 2010). Complaints relating to the mental health system are also less likely to be resolved and changes made to practice than complaints concerning other parts of the health system (Kuosmanen et al., 2008). This is at its heart a problem of discourse and power and is a direct result of the operation of a system in which decision making may be removed from an individual because they are not viewed as making safe choices about themselves or others. Carers Carers and family members of someone experiencing mental ill-health have both an interest in their own safety and in the safety of those who they care for. Carers informally manage risk to the consumers they care for within their own homes and communities on a daily basis, but are not routinely involved in discussions with services. Safety of both consumers and carers is often compromised when carers are not kept informed or included in discussions about treatment, including discharge (Smith-Merry and Caple, 2014). An analysis of coronial recommendations in Australia has shown that a significant number of recommendations arising from investigations into mental health-related deaths refer to poor inclusion of carers in treatment and discharge planning (Smith-Merry and Caple, 2014). This is despite most legislation in Australia mandating the inclusion of carers and family members in communication about care and treatment. The safety of carers and family members is also at risk of physical or emotional harm from the consumer themselves. Carer perceptions of this harm are often ignored in mental health treatment decisions, despite legislation in many contexts giving them significant powers including allowing them to make an application for an assessment order. The inquest findings into the deaths of Chloe Heuston and Nicholas Waterlow, who were killed by a close family member, provide an illustration of the frustrations of family members when carer perspectives are excluded or deprioritized in treatment decisions: … the circumstances of Nick’s death demonstrate how important it is for doctors to take seriously, the reports of family members and carers when assessing patients for hospital treatments. Antony tended to present well at hospital and repeated accounts of Antony’s psychotic symptoms and erratic, threatening behaviour at home, were not given sufficient weight by his doctors. Evidence of Juliet Darling (Partner of Nick Waterlow) reproduced in the findings of the Inquests into the deaths of Nicholas Waterlow and Chloe Heuston, NSW Coroner Court, March 2015. The legislation covering treatment in this case was the NSW Mental Health Act (2007) which includes in its objective the aim to ‘involve patients and carers in decision-making’. While the Heuston/Waterlow case is an extreme example of communication failure, it illustrates that although mental health legislation may direct the inclusion of carer perspectives in practice, this may not be occurring. In making recommendations in this case the Coroner found that carers must also be enabled to take part in treatment decisions and provided education and information about how to do so. Carers do not just need a voice in the proceedings but enough of an understanding of the context to enter into discourse on safety from an equal footing to that of other actors. These examples show that most of these problems arise from failures of discourse—either to include the carer voice or to have it included in a way in which the voice is listened to. Health-Care Workers Health-care workers have primary interests in the safety of those they care for and for their own safety. They also have a responsibility for fellow health-care workers and the public. To fulfill this they may have statutory responsibilities which require them to act as gatekeepers making decisions about whether a consumer is ‘safe’ or should be compulsorily treated. The identified risk is then managed through medication (Pilgrim and McCranie, 2013) or removal from the community. Incidents relating to the risk to staff from consumers in community or inpatient facilities or through mobile home visiting have been highlighted through the media and government inquiries (AHMAC, 2005; Arlington, 2011). Staff is taught to be aware of the risk posed to themselves from consumers (Brady, 2010) and manage their care according to that risk. Occupational health and safety guidelines which set limits around the safety of certain forms of interactions and interactions with consumers assessed as being at a higher-risk level (Worksafe Victoria, 2006). For example staff may be considered to be particularly at risk when consumers must be visited in ‘unsafe’ environments such as those associated with homelessness or drug use (Worksafe Victoria, 2006). The unintended service consequences of occupational health and safety rulings may mean that while keeping staff safe, they may also impact negatively on the safety of both consumers and carers. For example a reduction in mobile home-visiting services for those who are not able to attend centers for review may mean that those most in need of these services are left without them (Victorian Government, 2007). This withdrawal often occurs after work hours on weekdays and on weekends when a majority of crises actually occur (Victorian Government, 2007). This can mean that carers are put at risk, as they then have to informally care for individuals who may be unsafe. It can also mean that consumers who believe themselves to be unwell cannot get the support that they need, and their health deteriorates leading to their safety instead being addressed by those with statutory responsibilities outside of the mental health system (e.g. police or ambulance officers). Risk reduction initiatives that are effective for staff can thus place consumers and carers at risk at times when they may need help most acutely. Risk Assessment Systems Within services, processes of ‘risk assessment’ and ‘risk management’ are implemented by health-care workers to ensure that services are safe. Risk assessment practices are based either on actuarial risk assessment tools or on broader state or territory guidelines and involve balancing the competing safety needs of staff, consumers and the public (McSherry, 2004; dAHMAC, 2005; WA Department of Health, 2008). Actuarial systems of risk determination involve a risk matrix which can be used to understand those most at risk of violence to the public (Monahan et al., 2000). These seemingly neutral, value-free instruments have been labeled as essential for public safety (Dixon, 2015), but critics label them as ‘futile’ (Mulder et al., 2016) with low specificity and reliability (Coffey et al., 2017) and ‘poor predictive power’ (Chan et al., 2006). Their lack of reliability may give a false sense of security to staff and consumers and have been critiqued as merely ‘soothing someone else’s discomfort’ rather than offering something meaningful to consumers or others (Mead and MacNeil, 2008). Despite the overt focus on risk in mental health services, health-care workers feel uncomfortable engaging consumers in discourse about safety or sharing information gained from risk assessment exercises (Coffey et al., 2017). Coffey et al. (2017: 6) state that this ‘… seems to deny service users opportunities to engage and be involved in discussions about their safety and the consequences arising from risk assessments’. Poor quality relationships between staff and consumers and carers may also limit discourse. Research by Coffey et al. (2017) has shown that consumers do not readily open up about risk because of poor interpersonal relationships with staff. Consumers worry that they will be unable to challenge or shift the ‘label of ‘risky’ once it has been applied and, if labeled as such, would want to know so that they could discuss with it with staff (Coffey et al., 2017: 10). This trust is further eroded by the use of community treatment orders (Dixon, 2015) or other institutional practices such as isolation which take power from the consumer to direct their own treatment (Lapsley et al., 2002). Compulsory treatment means that risk decision making is taken out of the consumer’s hands. The Public, Politics and the Media The ‘public’ is a complex entity who has both shared generalized interests and individual interests in relation to safety. It is also a very powerful entity against which the safety interests of consumers is frequently positioned. The ‘general’ public is an entity ostensibly made up of individuals who have a personal interest in their own safety, but in ‘public’ discourse, it is usually articulated as a monolith to which is ascribed generalized needs and interests by others. Members of the public rarely ‘publicly’ articulate their own safety-related interests, but they are determined and articulated for them as members of the general public, mainly through media discourse. The media also conversely acts as educator of the public who are taught about their interests through the discourse it promotes. Risk from those with mental illness, though imagined, is felt significantly among the general population who conflates mental illness with danger and significantly overestimates the risk that they face (Link et al., 1999; Reavley and Jorm, 2011). Because of the low rate of acts of violence perpetrated toward strangers by those experiencing mental ill-health (Steadman et al., 1998), most individual members of the public will never experience their own safety being compromised. This risk is therefore imagined and is learned through the media’s portrayal of ‘public’ opinion. This portrayal can enforce and transmit negative stereotypes about safety. Generally the media’s interest in safety and risk is a self-interest predominantly motivated by increases in public consumption of media. A focus on safety is therefore dependent on the extent to which it appeals to the audience. Different voices—political, personal or organizational—are included according to the extent to which they will be known by, or provide interest, to the media audience. As pointed out by Meurk et al. (2015) media discourse on mental health is often centered on crises. These crises can be manufactured by policy actors (including prominent politicians, academics and lobby groups) or arise from a spontaneous event, which, in the case of safety and mental health relate to crime or legal cases (e.g. the Waterlow case referred to above). This focus on crises means that the discourse is often negative, reinforcing a perception that the public’s interest is about the risk they face from people who have a mental illness, thereby positioning the ‘public’ against people with mental illness (who are an invisible but large part of ‘the public’). Public safety discourse in the media frequently conflates ‘mad’ with ‘bad’ or excuses badness with recourse to madness (Clarke, 2004). This is particularly the case with reporting of recent terrorism, for example the case of Man Haron Monis, who killed a hostage at the Lindt Café siege in Sydney in 2014 (Hall, 2016). This public discourse may ease fears about terrorism but increase stigma of mental illness. The risk posed to the public by those with mental ill-health is also an unintended consequence of other forms of mediatized public and policy discourse such as that relating to gun control where people with mental ill-health are used for political purposes for those both pro and against control. For example, in New South Wales, a case where a Sydney woman with a history of psychotic illness was allowed to remove a weapon from a gun club and kill her father has been used to fight for tighter gun control in Australia (Robertson, 2016). President Trump’s campaign for the US Presidential election, unlike candidate Hilary Clinton’s campaign, which produced a wide-ranging mental health policy response, rarely referred to mental health except in the context of gun control (Trump, 2016) which positions people with mental ill-health as problematic, rather than guns. As these examples show, the public’s generalized interest in safety may be taken up through the media as a policy or political tool by those who wish to promote their own interests. While the ‘public’ interest in safety promoted through the media focuses largely on the risk posed by people with mental ill-health, individual consumers can also be thought about as at risk from the general public as a result of the negative impact of stigma on mental health and help seeking. Coffey et al. (2017) note that people experiencing mental ill-health are regularly at risk of ‘discrimination, stigma and possible physical attack’ from the public. The effect of this may be worsening mental health or even death. In the UK of the 5500 people who complete suicide annually only around 30% were in contact with mental-health related services (Coffey et al., 2017). Stigma plays a part in the decision of people not to seek support from friends or family, and thus the deaths of the other 70% of those who complete suicide may at least in part be attributed to the general population. A Discursive Approach to Safety and Risk in Mental Health This mapping of actors and interests shows safety to mean very different things for very different actors, with interests often positioned as competing. The concept of ‘safety’ is therefore effectively a boundary object upon which different meanings are hung according to the interests of those using the term. Here I use the concept of ‘boundary object’ as defined by Fox (2011: 72) who references Star and Griesemer’s (1989) work to describe them as ‘representations, abstractions or metaphors that have the power to ‘speak’ to different communities of practice’. However unlike Star and Griesemer’s (1989) conceptualization of boundary objects, safety and risk are shared concepts which bring communities together but are often not terms that build communities. It may also be thought of as a form ‘empty’ signifier which lacks a stable shared meaning (Offe, 2009). In this case different groups of actors hang their own meaning on the concept of safety. They may think that their representations of safety ‘speak to different communities of practice’, but in reality the other groups may have a significantly different understanding of the same concept (Fox, 2011: 72). In practice this means that decision-making around safety is complex and necessitates an understanding of multiple meanings and interests. What the discussion above also shows is that there is already considerable discourse around mental health and safety; however this discourse is not well structured and lacks underpinning values which could focus it toward more productive ends to allow more of a shared sense of safety to emerge. In this second section of the article I delineate a dialogical ethics influenced by the discourse ethics of Habermas. I then place this ethics in the context of a set of values centered in consumer understandings of recovery. This is presented as an ethical framework against which safety-related discourse in regarding compulsory treatment can be measured. Habermasian Discourse Ethics and Mental Health The main proponent in the development of a dialogical approach to ethics has been the German philosopher, public intellectual and social theorist Jürgen Habermas whose work has included the development of a structured discourse ethics. Habermas was associated with the Frankfurt School and shared their interest in the conditions from which social change could take place. He was also interested in the critical linguistic theories which focused on ‘speech acts’ or language in everyday use (Habermas, 1987). These preoccupations were crystallized in his work on discourse ethics which was most clearly articulated his 1981 book The Theory of Communicative Action (discussed below). Discourse ethics focuses on the way interaction through language may provide a resolution of ethical problems. The way that an individual speaks about their experiences and perspectives toward a given topic reveals their understanding and priorities. When different actors speak about their perspectives together through reasoned discourse with one another, then an understanding or shared meaning may arise which allows for a shared ethical approach to be developed. This discursive approach to ethical decision making has been used to consider various types of ethical decision making from that which takes place between individuals (Noddings, 1994), or within organizations (Meisenbach, 2006; Stansbury, 2009) and processes of deliberative democracy (Benhabib, 1994). Several authors have also linked discourse ethics with various facets of mental health, including participatory action research with consumers in forensic settings (Godin et al., 2007), consumer involvement in policy and practice design (Hodge, 2005, 2009) and consumer–practitioner interactions (Fardella, 2008). These papers share an interest in understanding which circumstances allow discourse to result in shared meaning making. It is this aspect of Habermas’ work which makes it relevant to questions of mental health and safety. Core to understanding Habermas’ approach is a recognition that communication and particularly communication through speech is the basis of social interaction and social change. Society and the interactions of individuals may therefore be understood through examining discourse. For Habermas rational debate is key to social change, and he aimed to understand under what circumstances rational and productive debate is able to take place. This approach to discourse ethics developed out of his initial conceptualization of ‘ideal speech’ which represents a set of ideal circumstances which allow speech to occur openly and freely and consensus to be reached. The other main concept relevant here is ‘communicative action’. Communicative action specifically refers to a process where actors step out of normal discourse to question what should be considered true in a given situation (Kemmis and McTaggart, 2005; Godin et al., 2007). It is therefore a distinct and actively productive communicative process where actors work with language to develop a shared sense of truth. According to Habermas (1984) those conditions of speech which promote free and ethical discourse—those which might make communicative action possible—are (i) freedom of uncoerced or unrestrained involvement in the discourse, (ii) equality between all actors involved and (iii) the ability to build a consensus. Fardella (2008: 120–121) explains that for ideal speech to occur ‘individuals committed toward the discursive resolution of differences need to be sincere in their efforts, motivated to find the truth and free from internal … . [and] external constraints …’. This open environment will create rational argument from which a true consensus can be reached even on difficult topics. This situation is relatively easy to create when actors are already coming from the same social context and share the same norms. However these conditions are largely absent from the discourses of mental health safety referred to above, which are instead characterized by inequality and constrained involvement. They therefore need to be actively created in this environment, as discussed further below. Habermas introduces the concept of the lifeworld to describe the social context of an individual’s life (Fardella, 2008). The lifeworld is viewed separately to the systems-world of those administrative and organizational practices that we are usually forced to interact with in our day-to-day lives (e.g. school system, welfare system, health system). The systems world still contains social spaces and interactions, but the rules of interaction (which Habermas terms ‘instrumental action’) that govern them are quite different. For Habermas the ‘systems world’ of organizations undermines the ‘life world’ of communicative action between individuals (Godin et al., 2007). Our own individual lifeworld is shared to a certain extent with those around us, and this allows free and rational discourse to happen easily. However the communicative action can stop and become irrational when our understanding of important topics is different to that of those around us. In the context of discourse on mental health and safety, this happens because of the very different understandings and interests held by the different actors involved. The aim of communicative action is to create the circumstances of communicative rationality, so that an ideal speech situation results. This does not mean that argument or disagreements do not take place, but that such arguments or disagreements when conducted as part of an ideal speech situation have the potential to lead to consensus (Habermas, 1984). Distortions of power must be addressed so that all actors are truly free to participate equally. Godin et al. (2007: 454) comment that for Habermas freedom: … involves the ability to communicate and learn with others using rationality to democratically question and agree understandings of the world, without resorting to power as a means of persuasion. Once any form of coercion is used to secure agreement, communication becomes distorted. This is a significant problem in mental health-related discourse (as demonstrated in the examples given earlier) with the power differential of the doctor (or other practitioner)–patient relationship a distorting factor that devalues the consumer voice in the ‘systems world’ of health care. While early work by Mishler (1984) showed that the lifeworld of health-care consumers in general practice settings is subsumed by the systems world and that this means that consumer needs are not prioritized, others have shown that the interactions are more subtle, and discursive agency is, in reality, more equal (Barry et al., 2001). However the subjugation of the lifeworld may be seen as particularly marked in mental illness treatment-related discourse where the consumer voice is readily labeled as irrational and ignored and where coercion is legally sanctioned for some. Godin et al. (2007) considered whether the type of rational communication involved in Habermasian discourse ethics is actually possible, given these power differentials. Their research involved interviews with individuals in secure mental health facilities and found that for some consumers communicative rationality was possible even in such a restricted environment, but only where the organizational environment actively minimized power differences through a focus on consensus and peer involvement in care (Godin et al., 2007). This is a case of the ‘systems world’ of the mental health facility opening up space for communicative action, rather than shutting it down (Godin et al., 2007). The main strategies for effecting communicative action in health care appear to be a leveling of power differentials and the validation of alternative forms of discourse through the inclusion of a wider range of voices in decision-making. Hodge (2005: 165) states that ‘communicative action’ can be utilized as a ‘normative theoretical framework’ against which to examine the way that consumers are involved in the development of mental health policy (Hodge, 2009). Within services it can therefore provide a framework for understanding whether shared discourse on safety is taking place. Discourse Ethics and Recovery Values If communicative action provides an idea about what shared discourse might look like, then principles of recovery provide a set of values to underpin that discourse. There is a danger, given the normalization of stigmatized views which exist in mental health care and the self-stigma that many people experiencing mental ill-health carry with them, that even if effective communicative action takes place, it would still result in practices which are not safe for consumers. Reflecting on narratives of recovery, Watts and Higgins (2016) demonstrate that some medical practitioners speak about risk in a very inappropriate way. It is therefore important that discourse takes place in a context that prioritizes empowerment and destigmatization. Recovery, when implemented meaningfully within organizations, is a framework which offers this context and has been promoted as such within policy and service frameworks, and by consumer activists (Anthony, 1993; Australian Senate, 2008; Mental Health Coordinating Council, 2013; American Psychiatric Association, 2017). Recovery has been viewed as an emancipatory paradigm which allows mental health consumers to voice their own needs, set their own goals and develop an understanding of a meaningful life rather than that set for them by others. It focuses on the personal journey of an individual toward living a meaningful and contributing life, despite the effects of mental ill-health. One of the early consumer proponents of recovery, William Anthony (1993), has written that recovery is: … a deeply personal, unique process of changing one's attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one's life as one grows beyond the catastrophic effects of mental illness. The origins of recovery lie outside mainstream psychiatry, and consumer activists have driven its development to make it, over the past decade or so, the core value underpinning policy and practice in English-speaking countries (Slade et al., 2012; Smith-Merry and Sturdy, 2013). It is widely embraced by the consumer movement and is seen as an antithesis to a tradition of mental health care which has disempowered and marginalized consumers in relation to their own care. Writing in 2009 Hodge reflects on the changing nature of consumer involvement in mental health policy during the prior decade, which has meant that the lifeworld of consumers is more respected as a valid form of communication (Hodge, 2009). This may be a positive effect of the increasing orientation of mental health systems and services toward recovery. While recovery is slowly colonizing the mental health-care system, one of the areas that lags behind is discourse and practice on safety and risk. With its focus on the importance of an individual’s own experience of recovery, the operationalization of the concept will be different for different people. Nevertheless a significant amount of research has found that there are certain shared values which tend to characterize consumer accounts of recovery experiences (Oades et al., 2005; Slade et al., 2012; Bird et al., 2014). A recent study undertaken in the UK utilized focus groups with 48 consumers to develop a shared conceptual framework which articulates the core recovery values (Bird et al., 2014). The acronym CHIME was used to represent the five facets of the framework: connectedness; hope and optimism; identity; meaning and purpose; and empowerment. Connectedness refers to the feeling of being connected to and supported by others. Hope and optimism is a key value which motivates consumers, health-care workers and carers to look toward a positive future where recovery is possible. Identity relates to the development of a positive identity where consumers are not stigmatized either through their own negative self-talk about mental illness or the discourses of others. Meaning and purpose is about building a life that has meaning but also about making meaning from experiences of mental ill-health. Empowerment relates to personal efficacy and is enacted through encouraging individuals to understand and work from their strengths (Bird et al., 2014). While recovery is a personal journey for consumers, recovery values can be taken up in the lives and work of all actors with an interest in mental ill-health. Through developing a personal virtue ethics centered on recovery the actors involved in discourses of safety and risk are therefore able to enter into communicative action from a lifeworld built on common understandings. Recovery-Oriented Discourse Ethics in Practice Despite the spread of recovery values within the practices of mental health services, recovery discourse is largely absent from discussions of risk between consumers and staff members (Coffey et al., 2017). Here I examine how a discourse ethic based in recovery values might function in the context of safety in public mental health. Within service settings, whether inpatient or within the community, the aim for discourse is that it be inclusive and equal. It needs to connect all those who support the consumer and offer them a voice: likely bringing together consumer, carer(s) and health-care workers. One of the strong underlying principles of recovery is the minimization of power differentials between staff and consumers (Smith-Merry et al., 2011). This involves a humanization of the professional which would mean that the consumer, carer and health professional are included as equal actors whose voices are equally important and needs equally cared for (Fardella, 2008). This humanization can take place through an enculturation toward recovery principles in the lives and work of all actors (not just consumers) through asking: What does meaning, empowerment, identity and so forth mean for health-care workers personally and how they care? What does it mean for carers personally and how they care? There are several tools available which attempt to effect recovery orientation within services and may be helpful in this process including the Scottish Recovery indicator tool (for services), the Recovery Oriented Practice Index and the Recovery Oriented Service Self-Assessment Toolkit (Mental Health Coordinating Council, 2013). These tools attempt to reorient health and social care work and workers toward recovery in their work, but to become really effective, this must be taken out of the work context and embedded in their lives. This would reorient the lifeworlds of individuals so that they are more able to engage in free communicative action with consumers. Recovery orientation of discourse also comes about through an inclusion of a range of different perspectives. An important set of actors which should be involved in discourse around safety is peer support workers. Peer support is an important emancipatory tool, as it validates the consumer voice and helps individuals to realize that their problems are also shared by others and they are therefore not alone (Watts and Higgins, 2016). Stories of successful recovery-oriented risk management may promote hope for consumers and others. However there has been a wariness from services about the involvement of peers in discussions of risk and safety because of fears concerning the peer supporter’s own mental health. Mead and MacNeil (2008) speak about peer support for those who are suicidal and offer a range of approaches for peer support workers supporting someone at risk of suicide. At the heart of what they propose is the development of relationships and skills in negotiation: ‘safety happens in the context of mutually responsible, trusting relationships’ underpinned by honest discourse (Mead and MacNeil, 2008). Supportive peer dialog is also essential for carers to enable them to support those they care for and peer support between health-care workers may help to provide safety-related recovery-oriented support to consumers. Fardella (2008) states that it is a human right to engage in risk-taking activities. Likewise the consumer advocate Pat Deegan (cited in Dixon, 2015) states that ‘professionals must embrace the concept of dignity of risk and the right to failure if they are to be supportive or us’. Health-care workers though are often blamed when risk is not managed effectively, so the default action is to shut down all risk. However not all risks are equal and safety is differentially impacted by risk. Shepherd (in Watts and Higgins, 2016) writes that ‘risk taking needs to be differentiated into risks that must be minimized (self-harm, harm to others) and risks that people have a right to experience, which are necessary for growth and development’. Peer support for health-care workers can assist them to understand how they can personally deal with their role as responsible enabler of risk and how to discuss safe risk-taking with consumers and their supporters. The Open Dialog Approach as a Basis for the Development of Practice An effective existing model for promoting discourse around safety which brings all of these actors together and could be used to implement discourse ethics in health system practice is the Open Dialog approach. This approach has been used extensively in Scandinavian countries over the past 30 years and takes a discourse-based approach to treatment decisions which involves consumers, their family and friends and a range of different practitioners. The approach is underpinned by a model of mental illness which focuses on social functioning. This approach does not deny the illness that an individual experiences, but rather focuses on problems of functioning as relating more to social problems than the underlying illness per se. Practice is structured around seven principles: ‘(1) immediate support, (2) the social networks’ perspective, (3) flexibility and mobility, (4) responsibility, (5) psychological continuity, (6) tolerance of uncertainty, and (7) dialogism’ (Seikkula and Arnkil in Ulland et al., 2014: 412). It starts from the idea that psychosis might be a medical problem but that difficulties related to functioning are largely social problems (ABC, 2016). The approach is specifically designed for people experiencing crisis situations and severe mental ill-health, including psychosis, thereby addressing concerns that recovery-oriented discursive models are not effective in crisis situations or associated environments such as emergency departments (Marynowski-Traczyk et al., 2013). Discourse begins immediately after a consumer enters a facility with the aim of developing a treatment approach that will work in relation to the consumer’s individual needs and their life context (Ulland et al., 2014). Family and friends join the meetings to provide context, sort through any issues with their existing social support network and support the individual’s treatment. Alongside the consumer’s own network ‘dialogue teams’ include practitioners from social and health care according to the consumer’s particular needs (Seikkula et al., 2006). It is not explicitly recovery-oriented but in its focus on connections and empowerment, it can be adapted to reflect recovery values. There is a focus on equality between all members of the team, including consumer, carers and peers and the role of the health-care worker is to facilitate discourse, but not dominate: ‘The aim for the professionals is to carry out their work in network meetings on an equal basis and in the presence of and together with the help-seeker and private network and to adjust their professional roles and tasks according to the particular help-seeker’s need’ (Seikkula in Holmesland et al., 2014: 433). In taking this approach the Open Dialog method opens up space where communicative action can begin to take place and shared meanings develop. This is achieved through breaking down existing power relationships which devalue non-medical perspectives and bringing in more people who already share the consumer’s lifeworld. Successful communicative action breeds commonality and creates a ‘communicative space’ which allows for further communicative action to take place and engenders ongoing shared meaning-making (Habermas, 1981; Godin et al., 2007). Conclusion One of the main aims of public health is the control of disease for the good of the public. In public mental health this can involve prevention programs which aim to promote understanding of mental health, but it can also involve control of ‘unsafe’ individuals experiencing ill-health. As I have mapped here the topic of ‘safety’ in public mental health gives rise to a multiplicity of understandings, interests and paths of action. This creates a complex discursive environment characterized by conflicting and often incompatible needs enhanced by acute imbalances of power. This complexity shifts beyond the discursive and has real material outcomes for individuals, particularly consumers who may be subject to compulsory treatment because of perceived risk to self or others. I have argued in this article that we should consider using Habermas’ conceptualization of communicative action as a framework from which to assess whether discourse is occurring effectively to develop shared meanings. A shared understanding of safety will mean that the safety needs of relevant actors can be negotiated rather than giving way to an actuarial process which does not take into consideration the context of a person’s life. Underpinning this process with a focus on recovery values will mean that the process is empowering and provides hope to those involved. The process could then be viewed as part of an individual’s recovery journey, rather than as a statutory requirement or a reaction to an imagined and mediatized public risk. Footnotes 1. 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Public Mental Health, Discourse and Safety: Articulating an Ethical Framework

Smith-Merry, Jennifer
Public Health Ethics , Volume Advance Article (2) – Dec 13, 2017
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Oxford University Press
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© The Author 2017. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org
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1754-9973
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Abstract

Abstract This article positions ‘safety’ and ‘risk’ as key public health problems in mental health. I demonstrate that discourse about safety occurs extensively in relation to mental health, but it does not occur in a way where the mental health system gets any safer for the key actors involved. Ongoing unproductive discourse occurs because the different actors involved are speaking at cross purposes and about different things against the background of a ‘public’ discourse focused on safety crises. I map the general interests of the main set of actors to demonstrate the conflicted and complex nature of discourse around mental health safety. In response I outline a dialogical approach to safety and risk based on the work of Habermas and values of recovery. This is presented as a framework from which to assess whether discourse is occurring effectively to develop shared meanings. Shared understandings of safety will mean that the safety needs of relevant actors can be understood and negotiated rather than giving way to an actuarial process which does not take into consideration the context of a person’s life. Introduction Safety in relation to mental health care is a significant public health problem of concern to consumers,1 practitioners, carers, the ‘public’ and policy actors (Wood and Pistrang, 2004; Quirk et al., 2004; Stamp, 2008; Trinh et al., 2008; NMHCCF, 2010). However concepts of ‘safety’ and risk are differently articulated as a result of the different interests underpinning these terms—what is understood as ‘safe’ for one set of actors, may compete with, or be understood differently for, others. The contestation between the needs of different actors is played out through public discourse and performed within the institutional practices of mental health and associated services. These circumstances have led to what Snow and Austin (2009) have termed a continuous ‘ethical balancing act’ for policy makers, legislators and service directors. Conflicting priorities engender complex ongoing arrangements for the safety of mental health consumers, practitioners and the public (Fennell, 2005; Kahan et al., 2010) – arrangements which in reality often fall short of providing safe mental health care (ABC News Online, 2008, 2011; Hagen, 2011). This article positions ‘safety’ and ‘risk’ as key public health problems in mental health. I aim to demonstrate that discourse about safety occurs extensively in relation to mental health but it does not occur in a productive way where the mental health system gets consistently safer for the key actors involved. Ongoing unproductive discourse occurs because the different actors involved are speaking at cross purposes and about different things. I focus in on discourses of safety as they relate to the safety of consumers and decisions about compulsory treatment because it is in this context that decisions about safety and risk have the most significant material outcomes for individuals. I take a high-level approach and sketch the field of public mental health by identifying the actors with interests in safety and risk, the scope of these interests and what actions they produce. I then offer a dialogical approach to safety and risk based on the work of Habermas and values of recovery. This is a deliberately high-level article, as it is not possible to focus in on every place, process and actor where the complex issues of public mental health and safety interact. What I map here are the general interests of the main set of actors, grounding this where possible in examples of cases, mainly from the Australian context from which I write. This high-level approach is necessary because it needs to take in the complexity brought about by the inclusion of interests from a very disparate range of actors. My aim is to present a framework against which to compare and improve existing practice. While safety and risk are public health problems, services are the main site of action for controlling safety. For that reason I primarily focus my discussion on discourse ethics in the context of mental health services. My discussion also focuses in on recovery, which is discussed in this context in relation its use by consumer advocates. Recovery here does not refer to ‘cure’ but rather to the journey that mental health consumers travel to live a meaningful life with or without the symptoms of mental ill-health (Anthony, 1993). Recovery will be explained in further detail later in the article. The Context of Safety, Risk and Mental Health That safety is a concern for all those involved in mental health is well attested. Practices designed to ensure the safety of consumers, the public and service providers are enshrined in legislation and practice guidelines in most nations. For example in Australia each state and territory has mental health legislation whose purpose is the ‘care and protection’ of those experiencing mental ill-health, but also members of the public. This legislation mandates responsibilities and decision-making about safety from a wide range of actors including consumers, health service workers, the government, police and ambulance workers (Smith-Merry and Caple, 2014). Despite the steps outlined in mental health legislation, including compulsory treatment of consumers when at risk to themselves or others, a failure to use legislation and other frameworks to select and meet the correct interests in a given situation can have serious outcomes including death. Research on publicly available coronial findings shows that problems of safety related to mental health services most frequently arise in relation to errors of ‘assessment processes, communication and information transfer, documentation, planning and training’ (Smith-Merry and Caple, 2014). These failures are frequently the subject of coronial and other inquiries including, for example: Coronial inquiries on clusters of deaths, e.g. a ‘cluster inquiry’ into restraint-related deaths (Hagen, 2011) Federal senate inquiries, including inquiries into services and suicide (Australian Senate, 2008, 2010) State and Commonwealth ombudsmen reports on adverse events such as the NSW Clinical Excellence Commission reports on adverse events and Human Rights Commission Inquiries such as the National Inquiry into the Human Rights of People with Mental Illness (1993) State-based Royal Commissions such as the ‘Chelmsford’ Royal Commission into Deep Sleep Therapy leading to the establishment of the NSW Health Care Complaints Commission in 1993 (NSW Government, 1990) Health complaints commission investigations, e.g. an investigation into a number of suicides by the South Australian Health and Community Services Complaints Commissioner (HCSCC, 2009) As a result of the past failures and ongoing risks identified in these inquiries safety has been prioritized in policy and service design. In Australia safety is 1 of the 10 standards addressed in the 2010 National Standards for Mental Health Services, which requires that ‘The activities and environment of the [mental health service] are safe for consumers, carers, families, visitors, staff and its community’. As Rosen, Rosen and McGorry (2012) comment, the simplicity of this statement masks the difficult balancing act that must occur for this to happen and the fact that there is considerable debate over what makes treatment, including within an inpatient setting, ‘safe’ for patients and others (Bowers et al., 2007). Ruth Vine (2006), Director of Mental Health within the Department of Human Services of Victoria spoke about this ‘ethical balancing act’ in evidence before the Commonwealth Senate’s Select Committee on Mental Health: One of the challenges for public mental health policy is to strike a balance, and we have to strike lots of balances. One balance is between the issues of safety and autonomy, another is between the interests of the community and the interests of the individual, and another is between the individual’s immediate safety and their longer term safety. This complexity of interests means that it is difficult to understand just whose interests should take precedence in a given situation. Who Are the Actors and What Are Their Interests? The ‘ethical balancing act’ involved in public mental health balances the ‘safety’ interests of individuals and institutional actors (Snow and Austin, 2009). Many of these public and personal interests are interconnected and across multiple spheres. Here I map out the primary interest groups that populate discourse and action at the intersection of mental health and safety. Two overarching sets of safety needs underpin mental health safety discourse: the risk of the consumer to self and the risk of the consumer to others (Coffey et al., 2017), but the field will be shown to be more complex than such a binary might reveal. I focus in on primary or substantive interests here. While undoubtedly these actors may have minor interests that are beyond what is described here I have focused on the major interests described in public and academic discourse. Consumers Consumers have a need to feel safe when they are mentally unwell and to be protected from self-harm and suicide. Suicide rates in most countries remain stubbornly high, and are increasing in some places. In Australia the suicide rate has increased over the past 3 years to an age-standardized rate of 12.7 per 100,000 in 2015—up from 10.9 per 100,000 in 2013 (Australian Bureau of Statistics, 2016). This rate is similar to that in most European countries. Consumers have a primary interest in their own safety as users of a system that has a history of unsafe treatment practices (Dixon, 2015). Risk also arises from their position as members of a general public whose individual perceptions and collective voice as presented in the media is often highly stigmatizing toward mental ill-health. This particular aspect of risk is discussed further in my characterization of the interests of the general public below. The history of unsafe practices referred to above meets a contemporary context where people may be legally removed of their right to object to treatment, meaning that they may be forced to enter potentially unsafe environments. For most consumers their mental health needs will be met through talking-based therapies, medication or other low-intensity interventions. Others need to use more intensive services which involve interactions with community mental health teams or inpatient care. While some consumers feel that inpatient care, particularly that which involves isolation or locked rooms, is inherently unsafe, others feel safe when placed in hospital because they are able to get help with those aspects of their mental health which made them feel unsafe in the community (Lapsley et al., 2002; Wood and Pistrang, 2004; Quirk et al., 2004). Because individuals being treated involuntarily either within a hospital inpatient setting, within the community, or within a forensic facility have limited recourse to challenge their treatment regimes, there is evidence to show that those in these circumstances may be particularly at risk of harm (Freckleton, 1998; Trinh et al., 2008). Issues of safety also become more stark in these environments as media or political discourses of ‘community’ or ‘public’ safety are positioned in relation to—and often in opposition to—the safety of consumers. These public discourses therefore may distort the treatment framework. The use of compulsory treatment orders which mandate medication and/or inpatient stays has been increasing over the past decade with some arguing that this is as a result of calls to ensure public safety, rather than as a result of the effectiveness of the practice (Coffey et al., 2017). Light et al. (2012) draw attention to figures which show that while in Australia we have high rates of the use of compulsory treatment orders (e.g. 55 per 100,000 in Victoria compared to just 2 per 100, 00 in New York), neither Australian consumers nor the general public are at significantly less risk of harm. Rather it is the variable response of the overarching policy and service frameworks to discourses of risk which accounts for different use of these legal strictures on individual consumers. It is important that health consumers are able to speak up when they feel that their care has been compromised and that their accounts are given credence. This is a key accountability and quality assurance mechanism for the health system and ensures that poor practices do not become entrenched. However the consumer voice is frequently mistrusted when giving an account of their own risk. It was the 1982 Chelmsford Royal Commission into mental health-care-related deaths which led to the development of Australian health complaints commissions (Walton, 2013). The 1982 Commission focused on unsafe practices at Chelmsford Hospital under the direction of Psychiatrist Harry Bailey which led to multiple deaths from the administration of deep sleep therapy. It showed that deaths were perpetuated through a system which was blind and deaf to the safety complaints of consumers who were dismissed as unreliable by the medical establishment and government administrators (Walton, 2013). These issues are ongoing. A recent Victorian government inquiry has focused on cases of violence in mental health facilities (Baker and McKenzie, 2011), including sexual assault, which have not been taken seriously and normal police reporting procedures not followed (Stamp, 2008). Research on complaints about mental health treatment has shown that mental health consumers are fearful of complaining when they feel unsafe or have problems with treatment because of a fear they will not be believed, will be labeled as ‘difficult’ or receive poorer treatment due to complaining (Kuosmanen et al., 2008; Victorian Government, 2009; Entwistle et al., 2010). Complaints relating to the mental health system are also less likely to be resolved and changes made to practice than complaints concerning other parts of the health system (Kuosmanen et al., 2008). This is at its heart a problem of discourse and power and is a direct result of the operation of a system in which decision making may be removed from an individual because they are not viewed as making safe choices about themselves or others. Carers Carers and family members of someone experiencing mental ill-health have both an interest in their own safety and in the safety of those who they care for. Carers informally manage risk to the consumers they care for within their own homes and communities on a daily basis, but are not routinely involved in discussions with services. Safety of both consumers and carers is often compromised when carers are not kept informed or included in discussions about treatment, including discharge (Smith-Merry and Caple, 2014). An analysis of coronial recommendations in Australia has shown that a significant number of recommendations arising from investigations into mental health-related deaths refer to poor inclusion of carers in treatment and discharge planning (Smith-Merry and Caple, 2014). This is despite most legislation in Australia mandating the inclusion of carers and family members in communication about care and treatment. The safety of carers and family members is also at risk of physical or emotional harm from the consumer themselves. Carer perceptions of this harm are often ignored in mental health treatment decisions, despite legislation in many contexts giving them significant powers including allowing them to make an application for an assessment order. The inquest findings into the deaths of Chloe Heuston and Nicholas Waterlow, who were killed by a close family member, provide an illustration of the frustrations of family members when carer perspectives are excluded or deprioritized in treatment decisions: … the circumstances of Nick’s death demonstrate how important it is for doctors to take seriously, the reports of family members and carers when assessing patients for hospital treatments. Antony tended to present well at hospital and repeated accounts of Antony’s psychotic symptoms and erratic, threatening behaviour at home, were not given sufficient weight by his doctors. Evidence of Juliet Darling (Partner of Nick Waterlow) reproduced in the findings of the Inquests into the deaths of Nicholas Waterlow and Chloe Heuston, NSW Coroner Court, March 2015. The legislation covering treatment in this case was the NSW Mental Health Act (2007) which includes in its objective the aim to ‘involve patients and carers in decision-making’. While the Heuston/Waterlow case is an extreme example of communication failure, it illustrates that although mental health legislation may direct the inclusion of carer perspectives in practice, this may not be occurring. In making recommendations in this case the Coroner found that carers must also be enabled to take part in treatment decisions and provided education and information about how to do so. Carers do not just need a voice in the proceedings but enough of an understanding of the context to enter into discourse on safety from an equal footing to that of other actors. These examples show that most of these problems arise from failures of discourse—either to include the carer voice or to have it included in a way in which the voice is listened to. Health-Care Workers Health-care workers have primary interests in the safety of those they care for and for their own safety. They also have a responsibility for fellow health-care workers and the public. To fulfill this they may have statutory responsibilities which require them to act as gatekeepers making decisions about whether a consumer is ‘safe’ or should be compulsorily treated. The identified risk is then managed through medication (Pilgrim and McCranie, 2013) or removal from the community. Incidents relating to the risk to staff from consumers in community or inpatient facilities or through mobile home visiting have been highlighted through the media and government inquiries (AHMAC, 2005; Arlington, 2011). Staff is taught to be aware of the risk posed to themselves from consumers (Brady, 2010) and manage their care according to that risk. Occupational health and safety guidelines which set limits around the safety of certain forms of interactions and interactions with consumers assessed as being at a higher-risk level (Worksafe Victoria, 2006). For example staff may be considered to be particularly at risk when consumers must be visited in ‘unsafe’ environments such as those associated with homelessness or drug use (Worksafe Victoria, 2006). The unintended service consequences of occupational health and safety rulings may mean that while keeping staff safe, they may also impact negatively on the safety of both consumers and carers. For example a reduction in mobile home-visiting services for those who are not able to attend centers for review may mean that those most in need of these services are left without them (Victorian Government, 2007). This withdrawal often occurs after work hours on weekdays and on weekends when a majority of crises actually occur (Victorian Government, 2007). This can mean that carers are put at risk, as they then have to informally care for individuals who may be unsafe. It can also mean that consumers who believe themselves to be unwell cannot get the support that they need, and their health deteriorates leading to their safety instead being addressed by those with statutory responsibilities outside of the mental health system (e.g. police or ambulance officers). Risk reduction initiatives that are effective for staff can thus place consumers and carers at risk at times when they may need help most acutely. Risk Assessment Systems Within services, processes of ‘risk assessment’ and ‘risk management’ are implemented by health-care workers to ensure that services are safe. Risk assessment practices are based either on actuarial risk assessment tools or on broader state or territory guidelines and involve balancing the competing safety needs of staff, consumers and the public (McSherry, 2004; dAHMAC, 2005; WA Department of Health, 2008). Actuarial systems of risk determination involve a risk matrix which can be used to understand those most at risk of violence to the public (Monahan et al., 2000). These seemingly neutral, value-free instruments have been labeled as essential for public safety (Dixon, 2015), but critics label them as ‘futile’ (Mulder et al., 2016) with low specificity and reliability (Coffey et al., 2017) and ‘poor predictive power’ (Chan et al., 2006). Their lack of reliability may give a false sense of security to staff and consumers and have been critiqued as merely ‘soothing someone else’s discomfort’ rather than offering something meaningful to consumers or others (Mead and MacNeil, 2008). Despite the overt focus on risk in mental health services, health-care workers feel uncomfortable engaging consumers in discourse about safety or sharing information gained from risk assessment exercises (Coffey et al., 2017). Coffey et al. (2017: 6) state that this ‘… seems to deny service users opportunities to engage and be involved in discussions about their safety and the consequences arising from risk assessments’. Poor quality relationships between staff and consumers and carers may also limit discourse. Research by Coffey et al. (2017) has shown that consumers do not readily open up about risk because of poor interpersonal relationships with staff. Consumers worry that they will be unable to challenge or shift the ‘label of ‘risky’ once it has been applied and, if labeled as such, would want to know so that they could discuss with it with staff (Coffey et al., 2017: 10). This trust is further eroded by the use of community treatment orders (Dixon, 2015) or other institutional practices such as isolation which take power from the consumer to direct their own treatment (Lapsley et al., 2002). Compulsory treatment means that risk decision making is taken out of the consumer’s hands. The Public, Politics and the Media The ‘public’ is a complex entity who has both shared generalized interests and individual interests in relation to safety. It is also a very powerful entity against which the safety interests of consumers is frequently positioned. The ‘general’ public is an entity ostensibly made up of individuals who have a personal interest in their own safety, but in ‘public’ discourse, it is usually articulated as a monolith to which is ascribed generalized needs and interests by others. Members of the public rarely ‘publicly’ articulate their own safety-related interests, but they are determined and articulated for them as members of the general public, mainly through media discourse. The media also conversely acts as educator of the public who are taught about their interests through the discourse it promotes. Risk from those with mental illness, though imagined, is felt significantly among the general population who conflates mental illness with danger and significantly overestimates the risk that they face (Link et al., 1999; Reavley and Jorm, 2011). Because of the low rate of acts of violence perpetrated toward strangers by those experiencing mental ill-health (Steadman et al., 1998), most individual members of the public will never experience their own safety being compromised. This risk is therefore imagined and is learned through the media’s portrayal of ‘public’ opinion. This portrayal can enforce and transmit negative stereotypes about safety. Generally the media’s interest in safety and risk is a self-interest predominantly motivated by increases in public consumption of media. A focus on safety is therefore dependent on the extent to which it appeals to the audience. Different voices—political, personal or organizational—are included according to the extent to which they will be known by, or provide interest, to the media audience. As pointed out by Meurk et al. (2015) media discourse on mental health is often centered on crises. These crises can be manufactured by policy actors (including prominent politicians, academics and lobby groups) or arise from a spontaneous event, which, in the case of safety and mental health relate to crime or legal cases (e.g. the Waterlow case referred to above). This focus on crises means that the discourse is often negative, reinforcing a perception that the public’s interest is about the risk they face from people who have a mental illness, thereby positioning the ‘public’ against people with mental illness (who are an invisible but large part of ‘the public’). Public safety discourse in the media frequently conflates ‘mad’ with ‘bad’ or excuses badness with recourse to madness (Clarke, 2004). This is particularly the case with reporting of recent terrorism, for example the case of Man Haron Monis, who killed a hostage at the Lindt Café siege in Sydney in 2014 (Hall, 2016). This public discourse may ease fears about terrorism but increase stigma of mental illness. The risk posed to the public by those with mental ill-health is also an unintended consequence of other forms of mediatized public and policy discourse such as that relating to gun control where people with mental ill-health are used for political purposes for those both pro and against control. For example, in New South Wales, a case where a Sydney woman with a history of psychotic illness was allowed to remove a weapon from a gun club and kill her father has been used to fight for tighter gun control in Australia (Robertson, 2016). President Trump’s campaign for the US Presidential election, unlike candidate Hilary Clinton’s campaign, which produced a wide-ranging mental health policy response, rarely referred to mental health except in the context of gun control (Trump, 2016) which positions people with mental ill-health as problematic, rather than guns. As these examples show, the public’s generalized interest in safety may be taken up through the media as a policy or political tool by those who wish to promote their own interests. While the ‘public’ interest in safety promoted through the media focuses largely on the risk posed by people with mental ill-health, individual consumers can also be thought about as at risk from the general public as a result of the negative impact of stigma on mental health and help seeking. Coffey et al. (2017) note that people experiencing mental ill-health are regularly at risk of ‘discrimination, stigma and possible physical attack’ from the public. The effect of this may be worsening mental health or even death. In the UK of the 5500 people who complete suicide annually only around 30% were in contact with mental-health related services (Coffey et al., 2017). Stigma plays a part in the decision of people not to seek support from friends or family, and thus the deaths of the other 70% of those who complete suicide may at least in part be attributed to the general population. A Discursive Approach to Safety and Risk in Mental Health This mapping of actors and interests shows safety to mean very different things for very different actors, with interests often positioned as competing. The concept of ‘safety’ is therefore effectively a boundary object upon which different meanings are hung according to the interests of those using the term. Here I use the concept of ‘boundary object’ as defined by Fox (2011: 72) who references Star and Griesemer’s (1989) work to describe them as ‘representations, abstractions or metaphors that have the power to ‘speak’ to different communities of practice’. However unlike Star and Griesemer’s (1989) conceptualization of boundary objects, safety and risk are shared concepts which bring communities together but are often not terms that build communities. It may also be thought of as a form ‘empty’ signifier which lacks a stable shared meaning (Offe, 2009). In this case different groups of actors hang their own meaning on the concept of safety. They may think that their representations of safety ‘speak to different communities of practice’, but in reality the other groups may have a significantly different understanding of the same concept (Fox, 2011: 72). In practice this means that decision-making around safety is complex and necessitates an understanding of multiple meanings and interests. What the discussion above also shows is that there is already considerable discourse around mental health and safety; however this discourse is not well structured and lacks underpinning values which could focus it toward more productive ends to allow more of a shared sense of safety to emerge. In this second section of the article I delineate a dialogical ethics influenced by the discourse ethics of Habermas. I then place this ethics in the context of a set of values centered in consumer understandings of recovery. This is presented as an ethical framework against which safety-related discourse in regarding compulsory treatment can be measured. Habermasian Discourse Ethics and Mental Health The main proponent in the development of a dialogical approach to ethics has been the German philosopher, public intellectual and social theorist Jürgen Habermas whose work has included the development of a structured discourse ethics. Habermas was associated with the Frankfurt School and shared their interest in the conditions from which social change could take place. He was also interested in the critical linguistic theories which focused on ‘speech acts’ or language in everyday use (Habermas, 1987). These preoccupations were crystallized in his work on discourse ethics which was most clearly articulated his 1981 book The Theory of Communicative Action (discussed below). Discourse ethics focuses on the way interaction through language may provide a resolution of ethical problems. The way that an individual speaks about their experiences and perspectives toward a given topic reveals their understanding and priorities. When different actors speak about their perspectives together through reasoned discourse with one another, then an understanding or shared meaning may arise which allows for a shared ethical approach to be developed. This discursive approach to ethical decision making has been used to consider various types of ethical decision making from that which takes place between individuals (Noddings, 1994), or within organizations (Meisenbach, 2006; Stansbury, 2009) and processes of deliberative democracy (Benhabib, 1994). Several authors have also linked discourse ethics with various facets of mental health, including participatory action research with consumers in forensic settings (Godin et al., 2007), consumer involvement in policy and practice design (Hodge, 2005, 2009) and consumer–practitioner interactions (Fardella, 2008). These papers share an interest in understanding which circumstances allow discourse to result in shared meaning making. It is this aspect of Habermas’ work which makes it relevant to questions of mental health and safety. Core to understanding Habermas’ approach is a recognition that communication and particularly communication through speech is the basis of social interaction and social change. Society and the interactions of individuals may therefore be understood through examining discourse. For Habermas rational debate is key to social change, and he aimed to understand under what circumstances rational and productive debate is able to take place. This approach to discourse ethics developed out of his initial conceptualization of ‘ideal speech’ which represents a set of ideal circumstances which allow speech to occur openly and freely and consensus to be reached. The other main concept relevant here is ‘communicative action’. Communicative action specifically refers to a process where actors step out of normal discourse to question what should be considered true in a given situation (Kemmis and McTaggart, 2005; Godin et al., 2007). It is therefore a distinct and actively productive communicative process where actors work with language to develop a shared sense of truth. According to Habermas (1984) those conditions of speech which promote free and ethical discourse—those which might make communicative action possible—are (i) freedom of uncoerced or unrestrained involvement in the discourse, (ii) equality between all actors involved and (iii) the ability to build a consensus. Fardella (2008: 120–121) explains that for ideal speech to occur ‘individuals committed toward the discursive resolution of differences need to be sincere in their efforts, motivated to find the truth and free from internal … . [and] external constraints …’. This open environment will create rational argument from which a true consensus can be reached even on difficult topics. This situation is relatively easy to create when actors are already coming from the same social context and share the same norms. However these conditions are largely absent from the discourses of mental health safety referred to above, which are instead characterized by inequality and constrained involvement. They therefore need to be actively created in this environment, as discussed further below. Habermas introduces the concept of the lifeworld to describe the social context of an individual’s life (Fardella, 2008). The lifeworld is viewed separately to the systems-world of those administrative and organizational practices that we are usually forced to interact with in our day-to-day lives (e.g. school system, welfare system, health system). The systems world still contains social spaces and interactions, but the rules of interaction (which Habermas terms ‘instrumental action’) that govern them are quite different. For Habermas the ‘systems world’ of organizations undermines the ‘life world’ of communicative action between individuals (Godin et al., 2007). Our own individual lifeworld is shared to a certain extent with those around us, and this allows free and rational discourse to happen easily. However the communicative action can stop and become irrational when our understanding of important topics is different to that of those around us. In the context of discourse on mental health and safety, this happens because of the very different understandings and interests held by the different actors involved. The aim of communicative action is to create the circumstances of communicative rationality, so that an ideal speech situation results. This does not mean that argument or disagreements do not take place, but that such arguments or disagreements when conducted as part of an ideal speech situation have the potential to lead to consensus (Habermas, 1984). Distortions of power must be addressed so that all actors are truly free to participate equally. Godin et al. (2007: 454) comment that for Habermas freedom: … involves the ability to communicate and learn with others using rationality to democratically question and agree understandings of the world, without resorting to power as a means of persuasion. Once any form of coercion is used to secure agreement, communication becomes distorted. This is a significant problem in mental health-related discourse (as demonstrated in the examples given earlier) with the power differential of the doctor (or other practitioner)–patient relationship a distorting factor that devalues the consumer voice in the ‘systems world’ of health care. While early work by Mishler (1984) showed that the lifeworld of health-care consumers in general practice settings is subsumed by the systems world and that this means that consumer needs are not prioritized, others have shown that the interactions are more subtle, and discursive agency is, in reality, more equal (Barry et al., 2001). However the subjugation of the lifeworld may be seen as particularly marked in mental illness treatment-related discourse where the consumer voice is readily labeled as irrational and ignored and where coercion is legally sanctioned for some. Godin et al. (2007) considered whether the type of rational communication involved in Habermasian discourse ethics is actually possible, given these power differentials. Their research involved interviews with individuals in secure mental health facilities and found that for some consumers communicative rationality was possible even in such a restricted environment, but only where the organizational environment actively minimized power differences through a focus on consensus and peer involvement in care (Godin et al., 2007). This is a case of the ‘systems world’ of the mental health facility opening up space for communicative action, rather than shutting it down (Godin et al., 2007). The main strategies for effecting communicative action in health care appear to be a leveling of power differentials and the validation of alternative forms of discourse through the inclusion of a wider range of voices in decision-making. Hodge (2005: 165) states that ‘communicative action’ can be utilized as a ‘normative theoretical framework’ against which to examine the way that consumers are involved in the development of mental health policy (Hodge, 2009). Within services it can therefore provide a framework for understanding whether shared discourse on safety is taking place. Discourse Ethics and Recovery Values If communicative action provides an idea about what shared discourse might look like, then principles of recovery provide a set of values to underpin that discourse. There is a danger, given the normalization of stigmatized views which exist in mental health care and the self-stigma that many people experiencing mental ill-health carry with them, that even if effective communicative action takes place, it would still result in practices which are not safe for consumers. Reflecting on narratives of recovery, Watts and Higgins (2016) demonstrate that some medical practitioners speak about risk in a very inappropriate way. It is therefore important that discourse takes place in a context that prioritizes empowerment and destigmatization. Recovery, when implemented meaningfully within organizations, is a framework which offers this context and has been promoted as such within policy and service frameworks, and by consumer activists (Anthony, 1993; Australian Senate, 2008; Mental Health Coordinating Council, 2013; American Psychiatric Association, 2017). Recovery has been viewed as an emancipatory paradigm which allows mental health consumers to voice their own needs, set their own goals and develop an understanding of a meaningful life rather than that set for them by others. It focuses on the personal journey of an individual toward living a meaningful and contributing life, despite the effects of mental ill-health. One of the early consumer proponents of recovery, William Anthony (1993), has written that recovery is: … a deeply personal, unique process of changing one's attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one's life as one grows beyond the catastrophic effects of mental illness. The origins of recovery lie outside mainstream psychiatry, and consumer activists have driven its development to make it, over the past decade or so, the core value underpinning policy and practice in English-speaking countries (Slade et al., 2012; Smith-Merry and Sturdy, 2013). It is widely embraced by the consumer movement and is seen as an antithesis to a tradition of mental health care which has disempowered and marginalized consumers in relation to their own care. Writing in 2009 Hodge reflects on the changing nature of consumer involvement in mental health policy during the prior decade, which has meant that the lifeworld of consumers is more respected as a valid form of communication (Hodge, 2009). This may be a positive effect of the increasing orientation of mental health systems and services toward recovery. While recovery is slowly colonizing the mental health-care system, one of the areas that lags behind is discourse and practice on safety and risk. With its focus on the importance of an individual’s own experience of recovery, the operationalization of the concept will be different for different people. Nevertheless a significant amount of research has found that there are certain shared values which tend to characterize consumer accounts of recovery experiences (Oades et al., 2005; Slade et al., 2012; Bird et al., 2014). A recent study undertaken in the UK utilized focus groups with 48 consumers to develop a shared conceptual framework which articulates the core recovery values (Bird et al., 2014). The acronym CHIME was used to represent the five facets of the framework: connectedness; hope and optimism; identity; meaning and purpose; and empowerment. Connectedness refers to the feeling of being connected to and supported by others. Hope and optimism is a key value which motivates consumers, health-care workers and carers to look toward a positive future where recovery is possible. Identity relates to the development of a positive identity where consumers are not stigmatized either through their own negative self-talk about mental illness or the discourses of others. Meaning and purpose is about building a life that has meaning but also about making meaning from experiences of mental ill-health. Empowerment relates to personal efficacy and is enacted through encouraging individuals to understand and work from their strengths (Bird et al., 2014). While recovery is a personal journey for consumers, recovery values can be taken up in the lives and work of all actors with an interest in mental ill-health. Through developing a personal virtue ethics centered on recovery the actors involved in discourses of safety and risk are therefore able to enter into communicative action from a lifeworld built on common understandings. Recovery-Oriented Discourse Ethics in Practice Despite the spread of recovery values within the practices of mental health services, recovery discourse is largely absent from discussions of risk between consumers and staff members (Coffey et al., 2017). Here I examine how a discourse ethic based in recovery values might function in the context of safety in public mental health. Within service settings, whether inpatient or within the community, the aim for discourse is that it be inclusive and equal. It needs to connect all those who support the consumer and offer them a voice: likely bringing together consumer, carer(s) and health-care workers. One of the strong underlying principles of recovery is the minimization of power differentials between staff and consumers (Smith-Merry et al., 2011). This involves a humanization of the professional which would mean that the consumer, carer and health professional are included as equal actors whose voices are equally important and needs equally cared for (Fardella, 2008). This humanization can take place through an enculturation toward recovery principles in the lives and work of all actors (not just consumers) through asking: What does meaning, empowerment, identity and so forth mean for health-care workers personally and how they care? What does it mean for carers personally and how they care? There are several tools available which attempt to effect recovery orientation within services and may be helpful in this process including the Scottish Recovery indicator tool (for services), the Recovery Oriented Practice Index and the Recovery Oriented Service Self-Assessment Toolkit (Mental Health Coordinating Council, 2013). These tools attempt to reorient health and social care work and workers toward recovery in their work, but to become really effective, this must be taken out of the work context and embedded in their lives. This would reorient the lifeworlds of individuals so that they are more able to engage in free communicative action with consumers. Recovery orientation of discourse also comes about through an inclusion of a range of different perspectives. An important set of actors which should be involved in discourse around safety is peer support workers. Peer support is an important emancipatory tool, as it validates the consumer voice and helps individuals to realize that their problems are also shared by others and they are therefore not alone (Watts and Higgins, 2016). Stories of successful recovery-oriented risk management may promote hope for consumers and others. However there has been a wariness from services about the involvement of peers in discussions of risk and safety because of fears concerning the peer supporter’s own mental health. Mead and MacNeil (2008) speak about peer support for those who are suicidal and offer a range of approaches for peer support workers supporting someone at risk of suicide. At the heart of what they propose is the development of relationships and skills in negotiation: ‘safety happens in the context of mutually responsible, trusting relationships’ underpinned by honest discourse (Mead and MacNeil, 2008). Supportive peer dialog is also essential for carers to enable them to support those they care for and peer support between health-care workers may help to provide safety-related recovery-oriented support to consumers. Fardella (2008) states that it is a human right to engage in risk-taking activities. Likewise the consumer advocate Pat Deegan (cited in Dixon, 2015) states that ‘professionals must embrace the concept of dignity of risk and the right to failure if they are to be supportive or us’. Health-care workers though are often blamed when risk is not managed effectively, so the default action is to shut down all risk. However not all risks are equal and safety is differentially impacted by risk. Shepherd (in Watts and Higgins, 2016) writes that ‘risk taking needs to be differentiated into risks that must be minimized (self-harm, harm to others) and risks that people have a right to experience, which are necessary for growth and development’. Peer support for health-care workers can assist them to understand how they can personally deal with their role as responsible enabler of risk and how to discuss safe risk-taking with consumers and their supporters. The Open Dialog Approach as a Basis for the Development of Practice An effective existing model for promoting discourse around safety which brings all of these actors together and could be used to implement discourse ethics in health system practice is the Open Dialog approach. This approach has been used extensively in Scandinavian countries over the past 30 years and takes a discourse-based approach to treatment decisions which involves consumers, their family and friends and a range of different practitioners. The approach is underpinned by a model of mental illness which focuses on social functioning. This approach does not deny the illness that an individual experiences, but rather focuses on problems of functioning as relating more to social problems than the underlying illness per se. Practice is structured around seven principles: ‘(1) immediate support, (2) the social networks’ perspective, (3) flexibility and mobility, (4) responsibility, (5) psychological continuity, (6) tolerance of uncertainty, and (7) dialogism’ (Seikkula and Arnkil in Ulland et al., 2014: 412). It starts from the idea that psychosis might be a medical problem but that difficulties related to functioning are largely social problems (ABC, 2016). The approach is specifically designed for people experiencing crisis situations and severe mental ill-health, including psychosis, thereby addressing concerns that recovery-oriented discursive models are not effective in crisis situations or associated environments such as emergency departments (Marynowski-Traczyk et al., 2013). Discourse begins immediately after a consumer enters a facility with the aim of developing a treatment approach that will work in relation to the consumer’s individual needs and their life context (Ulland et al., 2014). Family and friends join the meetings to provide context, sort through any issues with their existing social support network and support the individual’s treatment. Alongside the consumer’s own network ‘dialogue teams’ include practitioners from social and health care according to the consumer’s particular needs (Seikkula et al., 2006). It is not explicitly recovery-oriented but in its focus on connections and empowerment, it can be adapted to reflect recovery values. There is a focus on equality between all members of the team, including consumer, carers and peers and the role of the health-care worker is to facilitate discourse, but not dominate: ‘The aim for the professionals is to carry out their work in network meetings on an equal basis and in the presence of and together with the help-seeker and private network and to adjust their professional roles and tasks according to the particular help-seeker’s need’ (Seikkula in Holmesland et al., 2014: 433). In taking this approach the Open Dialog method opens up space where communicative action can begin to take place and shared meanings develop. This is achieved through breaking down existing power relationships which devalue non-medical perspectives and bringing in more people who already share the consumer’s lifeworld. Successful communicative action breeds commonality and creates a ‘communicative space’ which allows for further communicative action to take place and engenders ongoing shared meaning-making (Habermas, 1981; Godin et al., 2007). Conclusion One of the main aims of public health is the control of disease for the good of the public. In public mental health this can involve prevention programs which aim to promote understanding of mental health, but it can also involve control of ‘unsafe’ individuals experiencing ill-health. As I have mapped here the topic of ‘safety’ in public mental health gives rise to a multiplicity of understandings, interests and paths of action. This creates a complex discursive environment characterized by conflicting and often incompatible needs enhanced by acute imbalances of power. This complexity shifts beyond the discursive and has real material outcomes for individuals, particularly consumers who may be subject to compulsory treatment because of perceived risk to self or others. I have argued in this article that we should consider using Habermas’ conceptualization of communicative action as a framework from which to assess whether discourse is occurring effectively to develop shared meanings. A shared understanding of safety will mean that the safety needs of relevant actors can be negotiated rather than giving way to an actuarial process which does not take into consideration the context of a person’s life. Underpinning this process with a focus on recovery values will mean that the process is empowering and provides hope to those involved. The process could then be viewed as part of an individual’s recovery journey, rather than as a statutory requirement or a reaction to an imagined and mediatized public risk. Footnotes 1. 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Public Health Ethics – Oxford University Press

Published: Dec 13, 2017

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