Risk assessment for compulsory detention under the Mental Health Act (1983) : a grounded analysis of psychiatrists' perspectives
This thesis explores how psychiatrists assess risk when making decisions about detention under the
Mental Health Act (1983). It comprises two studies. The first study, a content analysis of the legal
justifications provided for detentions, found that matters of risk were central to psychiatrists' decisionmaking.
It also found relatively high levels of disagreement between doctors about the nature of risk
posed. This raised the possibility that risk assessment may not be as straightforward as implied by sparse
legal guidelines, by mathematically generated lists of 'risk factors', or by the under-specified 'clinical
approach' to risk assessment in psychiatry.
The second, more substantial study of the thesis employed a grounded theory methodology to explore
psychiatrists' own understanding of their risk assessment practices when making detention decisions. Indepth
interviews were conducted with psychiatrists, using the Critical Incident Technique to focus
interviews on critical, or 'boundary' cases. The grounded theory methodology was employed as it allowed
for a theoretical account of psychiatrists' risk assessment approach to emerge directly from psychiatrists.
It also overcame some of the limitations of other potential approaches to the study of risk, namely the
overly narrow focus on the individual characterised by the psychometric approach and the overly broad
focus of the socio-cultural approaches to risk.
A grounded analysis of this interview data produced a model that describes and explains psychiatrists'
approach to risk assessment. This model makes two main arguments. First, it provides a theoretical
account of the previously hidden 'clinical approach' adopted by psychiatrists when assessing risk. Here, it
argues that psychiatrists organise their assessment of risk around the concept of a 'risk trajectory'.
Second, the thesis highlights the inherently contextual nature of risk assessment for detention. Here, it
identifies three forms of context which shape psychiatrists' risk trajectories and ultimately their decisions
about detention. The first is an epistemic context, in which various forms of knowledge inform both the
construction and management of the risk trajectory. Psychiatrists encounter multiple forms of uncertainty,
and respond by employing particular strategies to reduce their uncertainty. The second form of context
refers to multiple relationships, particularly the therapeutic relationship, which influence the risk
trajectory. Finally, the tempotal context of risk is explored as it impacts upon psychiatrists' assessments.
The thesis concludes with a discussion of these two contributions for psychiatry, particularly its
implications for future research, for legal and policy developments, and for psychiatric services.