Assessing risk within primary care: Logics, contingencies, histories

There has been an explosion of discourse about risk and risk assessment beginning in the 1980s, growing during the 1990s and continuing to accelerate. This has extended to the arena of mental health care where there is an expectation for services to assess and manage risks, and high quality clinical assessment has been re-described to incorporate risk assessment. This expectation obscures certain problems with risk assessment such as its accuracy, the selective nature of the risks prioritised, and the potential for it to enhance stigma and encourage defensive practice. It also obscures how risk assessment emerged out of a particular social and historical context, and was linked to high profile homicides, the introduction of community care, and a cultural emphasis on accountability and litigation. This thesis reconceptualises risk assessment as a hegemonic discourse within mental health care through an engagement with the theoretical concepts of the logics approach, rooted in poststructuralist discourse theory. It turns towards the actual clinical practice of completing risk assessments through analysing assessments completed within an Improving Access to Psychological Therapies service. An articulation of the social, political and fantasmatic logics influencing these risk assessments is offered. These assessments are characterised as functioning according to the social logics of well-oiled administration and preservation where bureaucratic process is prioritised, contingency ironed out and managing potential risks to the service predominates. These social logics become comprehensible within a competitive commissioning context with political logics of difference preventing an equivalence between practitioners and clients. Fantasmatic logics generated an investment in the process of completing risk assessments with a well-documented assessment offering protection to practitioners and the service from the obstacles that clients could become. Implications are discussed and clinical perceptions of risks offered as an alternative social practice that recognises the radical contingency of the social world.