Perceived risks associated with mental illness: Beyond homicide and suicide

Pergamon

Plh S0277-9536(97)00161-5

Soc. Sci. Med. Vol. 46, No. 2, pp. 287 297, 1998 © 1998 Elsevier Science Ltd. All rights reserved

Printed in Great Britain 0277-9536/98 $19.00 + 0.00

PERCEIVED RISKS ASSOCIATED WITH MENTAL ILLNESS: BEYOND HOMICIDE AND SUICIDE

TONY RYAN

Department of Applied Social Science, Lancaster University, Lancaster LA1 4YL, U.K. and The Smithfield Project, Turning Point, Thompson Street, Manchester M4 5FY, U.K.

Abstract--This paper presents an exploratory study of factors of perceived risk related to people who experience serious mental illness. The study focuses upon four stakeholder groups: service users, their carers, mental health professionals and the general public. The development of a questionnaire to examine risk perceptions is described along with the data collection techniques employed in the study. A large number of data sets (n = 1076) was obtained from the four groups of stakeholders (n = 550). Factor analysis of the data produced six factors of perceived risk: underclass, medical disempowerment, threat, vulnerability, self-harm and dependency. This suggests that stakeholders have a wider perception of risk than perceptions defined through current policy. These factors are subsequently examined in relation to a range of independent variables of which gender is the most significant variable in the perception of risk. The findings support results from studies of other forms of risk where women have been found to perceive risks greater than men. © 1998 Elsevier Science Ltd. All rights reserved

Key words--mental illness, risk perception, risk management

INTRODUCTION

As we approach the end of the millennium it has been suggested that we are increasingly moving from a society based on the creation of wealth to one that is focused upon the production, identifi- cation and management of risk (Beck, 1992). Indeed risk has been identified as the unifying force of many groups within society (Douglas and Wildavsky, 1982). Consequently, there have been numerous studies of perceived risk in many areas of social science. Various features of how people perceive risks have been established from this work. It has been shown that risk perceptions are affected by the degree to which the risk is seen as voluntary or imposed (Starr, 1969), whether the risk is viewed as public or private (Brun, 1992), individual or so- cietal (Green and Brown, 1979), how it is presented (Kahneman and Tversky, 1984) and whether the risk can be interpreted qualitatively (Gardner and Gould, 1989). In the case of technological risk it has been found that women perceive such risks to be greater than men (Greenberg and Schneider, 1995). In relation to risk of fatality it has been established that the more vividly a death can be imagined the greater it will be perceived as likely to occur (Lichtenstein et al., 1978). Consequently, after a highly publicised homicide by a person with a mental illness, the public perception of the risk of homicide will increase even though the actual risk is no greater. Despite this there has been very little work carried out in relation to perceived risks associated with mentally ill people. Where work has been undertaken it has been concerned with a single

risk such as violence and limited to a particular incident (Appleby and Wessely, 1988).

In many fields the concept of risk is somewhat problematic and this is particularly true here; hence, this research. For many in the mental health field risk is conceptualised in terms of actual physical harms. However, this view fails to take account of psychosocial harms such as loss of dignity, repu- tation or even accommodation. Furthermore, responses to risk are not uniform either, for example, where risk is conceptualised by clinicians it is opera- tionalised in relation to a small number of individuals whose association with the concept will be unique to them. Individually tailored actions are therefore initiated to deal with these people, their situations and associated risks. This contrasts with the population based approach identified by epide- miologists and dealt with through broad policy initiatives. Here the goal is to deal with groups rather than individuals and hoping that in the majority of cases risk will be dealt with successfully. However, it is suggested in Britain that, as shown by the number of suicides and homicides by people with mental health problems, neither of these positions has produced the desired response (Steering Committee of the Confidential Inquiry into Homicides and Suicides by Mentally Ill People, 1996).

General perceptions of people with serious mental health problems have been based mainly upon two views; the dangers they pose to others and the danger they pose to themselves. There have been several studies of public attitudes towards mentally ill people that demonstrate the ambivalence this cre- ates (Brockington et al., 1993; Hall et al., 1993;

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Gould, 1992). People generally feel that society has a duty to care for those with mental health needs however many respondents feel this should be in someone else's neighbourhood. Link et al. (1987) found that people who perceived mentally ill people as dangerous wished to maintain a distance from such people while the reverse was the case with those who did not perceive such an association. While it is important to be cautious about the influence of the mass media upon public perception, studies in Britain (Philo et al., 1993) and the United States (Shain and Phillips, 1991; Steadman and Cocozza, 1978) have shown that mentally ill people are depicted mainly as violent and dangerous by the media. A further area where such perceptions may be reinforced is mental health legislation since beliefs about mentally ill people frequently drives mental health law and at the heart of legislation is the perception that such people are prone to violent acts (Monahan, 1992).

In Britain in recent years policy (Doll , 1993, 1994), practice (Crighton, 1995; Ryan, 1995) and media (Brindle and Bowcott, 1996; Marks, 1995; Grice, 1996) attention have all highlighted risk as an important concept in relation to the successful integration of people with mental health needs within society. A vast amount has been written in recent years about risk assessment and risk management concerning this group (Crighton, 1995; Hawton and Cowen, 1990; Monahan and Steadman, 1994). Despite this, very little attention has been given to perceptions of risk in the mental health field. Since what we perceive frequently dic- tates what we do, often despite evidence to the contrary, it would appear that understanding what people perceive is a prerequisite for any study of how risks are identified and then managed. Consequently, an exploratory study is described here with the principal aim of investigating the factors that underpin risk perceptions held by the four stakeholder groups closest to these issues: service users, carers, professionals and the general public.

Most of the attention to risk in the mental health field has been upon risks posed by mentally ill people, either to themselves or to other people. These risks relate primarily to high consequence/ low frequency events such as homicide (Sheppard, 1995; Peay, 1996) and suicide (National Health Service Executive, 1994). However, there are also everyday risks which people with mental health needs face that are usually associated with low consequence/high frequency events and range from being made homeless through to being mocked or exploited in some way (Ryan, 1995). Consequently, this study attempted to deal with all points of the risk continuum by using a wide range of stakeholder generated "risk items" in a questionnaire. Whilst the risk items used in the study were not exhaustive they appear to cover most areas of risk

and particularly those highlighted in the mental health literature.

M E T H O D O L O G Y

The area of perceived risk in the mental health field has been largely unexplored which suggested that this study should be exploratory in nature rather than attempting to test a particular hypoth- esis. Consequently, a qualitative approach was con- sidered essential since it would provide a rich and illuminating source of data which is particularly useful in exploratory studies (Hakim, 1987). Additionally qualitative research can often form the basis for more quantitative work and it allows for the development of ideas as the researcher can fol- low leads given by the respondents (Hoinville and Jowell, 1978). In this way the results which emerge can reflect the position of those under study rather than that of the researcher (Burgess, 1984). Thus, a series of semi-structured interviews provided the material to define risk perceptions from which a survey questionnaire was developed and used to examine these perceptions.

Questionnaire construction

It was not possible to use an existing research instrument or repeat previous research with modifi- cations in order to explore perceived risk due to the lack of work in this area. Therefore, it was necess- ary to develop an instrument to explore the under- lying factors of perceived risk pertaining to mentally ill people. Over a five month period 25 brainstorming interviews were completed; 76 people from the stakeholder/respondent groups were seen in 14 group interviews and there were 11 individual interviews. Although originally developed as a problem solving technique in organisational management, brainstorming is a useful method for obtaining numerous ideas from respondents on a given topic (Osborn, 1963). During the interviews respondents were asked to suggest risks which they felt people who suffered schizophrenia, manic epi- sodes of manic depression and severe depressive illnesses may face or pose as a result of their illness. Following the inital brainstorming respondents were asked to base their responses on personal experiences in order to ground the data in their own realities. Interviews were conducted with service users, carers and professionals and took place on the respondent's territory, for example, in staff offices, day centres and venues where support groups were held. Interviews with the general public took place in neutral areas such as shopping centres and libraries. Broad areas to be covered were identified in advance based on issues identified in the mental health and risk literatures. A semi-structured schedule was used which did not predefine risk items since the principal objective was to obtain the respondents' perceptions of risk. Data from eight of

Perceived risks associated with mental illness 289

the interviews were recorded on cassette tape, tran- scribed and formatted for a software package in order to manage the data. These interviews lasted between 20 minutes and one hour and covered a wide range of areas and issues. Sections of text which were judged to be "perceived risks" were identified from the data. The remaining 18 interviews with stakeholders were not recorded. However, fieldnotes were made and subsequently analysed for use in the questionnaire. An initial list of 62 risk items was formulated from all the inter- view data. This was reduced to 56 items after four phases of piloting the questionnaire with 29 individuals from the four respondent groups. The re- duction in items resulted from respondents consistently identifying ambiguities in the wording of some items or items being viewed as the same but merely worded differently. The 56 items were further reduced to 53 when frequency counts for the items showed no discrimination between individuals or across respondent groups.

Two types of questionnaires were designed, one covered all three illness groups whilst the other covered only one illness. The former was administered to professionals and the latter to the other respondent groups. Hence, carers and service users were administered questionnaires relating to the illness of their experience, while members of the general public were randomly administered questionnaires relating to only one illness. The 53 items were split into two sections and randomly ordered within each section: risks posed by and risks faced by mentally ill people. To reduce bias from ordering effects in the questionnaire three randomised orderings of risk items were developed for each illness. For non-professionals this produced nine versions of the questionnaire (three orderings by three illnesses). The same randomised orderings were used in the version of the questionnaire for professionals. The three illnesses were also ordered in three ways thereby producing a further nine versions of the questionnaire. Respondents were asked to rate each of the items on a seven point Likert scale. Ratings commenced at 1 which was termed LOW and moved through to 7 which was termed HIGH. Information on a number of respondent demographic variables was also collected within the questionnaire including age group, gender, ethnicity, respondent status and some variables concerned with the specific respondent position.

Questionnaire administration

Two cities in the north of England were used for the study both of which have fairly comprehensive community and hospital mental health services. Research Ethics Committee approval was obtained at each site prior to commencing the study.

A combination of approaches was used to obtain completed questionnaires. The group of mental health professionals involved in the research were

psychiatrists, mental health nurses, psychiatric social workers, psychologists and occupational therapists. The questionnaire was distributed anon- ymously by personnel staff via the internal mail sys- tems of the mental health services. The personnel staff maintained a double blind coding system which allowed them to identify non-responders to whom they sent second copies of the questionnaire. A final response rate of 57% (n = 263) was achieved with professionals. All professionals at the two sites who were working in acute hospital and generic community mental health services were included in the mailing. Professionals working within specialist services such as substance misuse, forensic psychiatry, rehabilitation and services for elderly people with organic illnesses were not asked to participate in the study.

A charity for carers and service users of schizophrenia distributed 69 copies of the questionnaire by post with return stamped envelopes to their carers. This procedure produced a response rate of 29 (42%). It was supplemented with a mailshot to 49 members of a support group for carers of people with schizophrenia run by mental health professionals and produced a response rate of 11 (36%). Carers and service users of the other illness groups were approached through hospital and community nurses during their everyday work. Staff in several day centres administered the questionnaire to 25 willing members of the centres. Finally, 44 questionnaires were also completed at several manic depression support groups.

In the case of the general public the questionnaire was administered to a convenience sample outside a library and in two shopping centres. Respondents were asked to complete the questionnaire on site at a table provided by the researcher. This produced 178 completed questionnaires.

Characteristics of respondent groups

Questionnaires were completed by 550 people. These included 263 professionals who provided data for each of the three illness categories. Service users completed 56 questionnaires whilst 54 were completed by carers and 178 by the general public. This resulted in a total response of 1076 sets of data across the three illness categories.

Female respondents accounted for 58% of response data and 92% of respondents were white. The majority of respondents were aged between 21 and 50 years of age (84%). Around two thirds of respondents (64%) were from site A and just over one third (36%) from site B.

Of professionals 35 psychiatrists, 133 mental health nurses, 48 social workers, 15 psychologists, 28 occupational therapists and four managers completed the questionnaire. The professionals were largely an experienced group with nearly half (128) having had more than 10 years' experience in this field. Professionals who worked solely in hospital

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Table 1. Final statistics for factor analysis

Eigenvalue Percentage of Cumulative Factor variance percentage

1 16.90933 31.9 31.9 2 3.52362 6.6 38.6 3 3.19092 6.0 44.6 4 2.53761 4.8 49.4 5 1.60244 3.0 52.4 6 t.24432 2.3 54.7 7 1.06284 2.0 56.7

accounted for 46% (121) of respondents, a further 25% (67) worked only in community settings and the remaining 29% (75) worked in both hospital and community.

In the service user groups 84% (43) had endured their illness for more than two years and 43 (23%) had been detained under sections of the 1983 Mental Health Act. Just over half of the carers, 54% (28), had been carers for more than 10 years.

DATA ANALYSIS

Principal components factor analysis was undertaken on the data from which seven factors were extracted with an eigenvalue greater than 1 and which explained 57% of the total variance (Table 1). An orthogonal factor rotation of the data was then undertaken using the Varimax procedure thereby producing factors which were independent of one another rather than interrelated. This served to clar- ify the best position of those items which weighted strongly in more than one factor from the principal components analysis. The results produced from the rotated factor analysis were used throughout the subsequent analysis of data. Items with factor weighting scores of + or -0.35 or greater were included within each of the seven factors produced. In cases where scores indicated the item could be included in more than one factor the highest score was taken and the item placed within the corre- sponding factor. The seventh and weakest factor was deleted from further analysis as it contained just two risk items and accounted for only 2 0 of the total variance. From the 53 risk items used in

Table 2. Underclass

Risk items Factor weighting

Being teased by youngsters 0.70435 Being made fun of 0.70389 Being avoided by neighbours 0.67777 Verbal aggression from others 0.64533 Being assaulted 0.52742 Living in below standard 0.60362 accommodation Becoming a vagrant 0.54517 Going to prison 0.43663 Living on the streets 0.61785 Losing their accommodation 0.64270 Losing contact with their family 0.54865 Being rejected by their family 0.63395 Being rejected by their friends 0.60000

Table 3. Medical disempowerment


Being coerced into hospital 0.42647 against their wishes Not having their complaints 0.66244 taken seriously Not being informed of side 0.75970 effects of their medications Not getting legal help apart from 0.61683 for their illness Being given too much medication 0.55507 by their carers Being given too much medication 0.67030 by professionals Not being believed when they 0.50844 say they are mentally well Not getting enough information 0.73215 about their illness Having everyday problems 0.65562 regarded as part of their illness Not getting proper treatment for 0.66509 other illnesses Having their illness used as a 0.69992 weapon against them

Cronbach's ~ = 0.8888.

Table 4. Threat


Assaulting someone they know 0.79918 Setting fire to property 0.77807 Being involved in crime 0.79881 Killing someone at random 0.83595

Cronbach's :t = 0.9038

the questionnaire six did not feature in any of the factors, consequently 47 risk items were extracted and included in the resulting factors.

New variables were created for the six factors by summing the respondent scores for the risk items within each factor. An alpha reliability analysis was then undertaken for each of the factors. Items that did not contribute to the alpha score were deleted throughout the reliability analysis. The factors contained 13, 11, 4, 9, 7 and 3 risk items respectively and were given names based on the risk items within each factor (see Tables 2, 3, 4, 5, 6 and 7). The six risk factors were named underclass, medical disempowerment, threat, vulnerability, self-harm and dependency.

Table 5. Vulnerability


Being abused by their families 0.48779 Catching the AIDS virus because of sleeping 0.55034 around Being exploited by criminals 0.57243 Being taken advantage of financially 0.57248 Having someone move into their home 0.45573 against their wishes Becoming addicted to illegal drugs 0.50700 Not getting benefit payments 0.42323 Being sexually exploited (if female) 0.52893 Being sexually exploited (if male) 0.54287

Cronbach's • = 0.9270. Cronbach's ~ = 0.8578.


Table 6. Self-harm


Accidentally killing themselves 0.42744 Becoming addicted to alcohol 0.52981 Committing suicide 0.78965 Intentionally harming themselves 0.76483 Neglecting themselves 0.55619 Setting fire to themselves 0.37294 Becoming socially isolated 0.46757

Cronbach's ~ - 0.7714.

While there is a degree of subjectivity involved in naming factors efforts were made to justify each of these names. Discussions on the appropriateness of the names given to factors took place at three semi- nars. Feedback indicated agreement with the chosen names and this was further reinforced by colleagues who also found them appropriate. Furthermore, the names chosen have a basis in the existing mental health literature.

One-way ANOVA was carried out using each of the six new risk factors as dependent variables. Since this procedure does not control for the effect of other independent variables it was used to provide an initial investigation of the data. Demographic variables were used as independent variables and were collapsed separately over all other variables. These variables covered respondent group, age, gender, where the professional worked and the length of time in mental health work of the professional. LSD (least squares difference) and modified LSD (Bonferroni) multiple range tests were carried out to determine statistical differences between subgroups in relation to each factor. Where a statistical significance was identified it has been reported in the subsequent section.

Multiple regression was also carried out with the six risk factors again used as dependent variables. Dummy variables were established for a range of demographic predictor variables and the stepwise method of entering variables was used in multiple regression equations. Separate multiple regression analyses were carried out using each respondent group among the predictor variables. The predictor variables were explained independently of their association with other variables,

RESULTS

Results are presented in relation to each of the six risk factors identified from the factor analysis. It

Table 7. Dependency


Being dependent upon other people 0.43330 Being dependent upon mental health 0.44776 services Being overprotected by their family 0.42460

Cronbach's • = 0.6353.

is worth noting at this point that no significant difference was identified between the two research sites when a one-way ANOVA was undertaken using the locations as independent variables.

Underclass (factor 1)

Although the term underclass has its roots in the disadvantaged position of ethnic minorities within the labour market (Abercrombie et al., 1994) the term has become relevant to a range of other disadvantaged and rejected minority groups in society. Consequently it is of little surprise to find that rejection of one form or another features in at least six of the 13 risk items present in the factor. Additionally, lack of stable accommodation can be another feature of an underclass as can be the drift towards criminal activity caused by a lack of resources or unemployment. The general picture being painted by the group of risk items producing this factor is one of disadvantage and the conse- quences of being in such a position.

One-way ANOVA showed respondents over 60 rated the factor lower than all others (P < 0.001) as did females (P < 0.001). Multiple regression identified schizophrenia (P < 0.001) as the illness variable with the highest mean while general public respondents perceived the risk of this factor greater than other stakeholders (P < 0.05) and females higher than males (P < 0.001). Hospital workers perceived this factor to be greater than all other respondents (P < 0.005) while respondents aged between 21 and 30 (P < 0.001) and those over 50 (P < 0.05) perceived the factor lower than other age groups.

Medical disempowerment (factor 2)

Within the context of this research the term medical disempowerment is defined as a lack of, or re- duction in, control over health or related issues as a result of contact with medicine. Many of the items in this factor relate to the iatrogenic effects of psychiatry coupled with the need to control both symp- toms and behaviours potentially associated with mental illness. Most of the remaining items could be regarded as the effect of being labelled with a mental health problem. Both of these positions are directly or indirectly the result of being subordi- nated to the illness and its management.

From one-way ANOVA the general public rated the medical disempowerment factor higher than professionals and carers (P < 0.001) and community only professionals rating this factor higher than other professionals (P < 0.05). Professionals working between 1 and 3 years rated the factor lower than other professionals (P < 0.001). A difference was also identified between respondents under 21 years of age and all others (P < 0.01). Finally, female respondents perceived medical disempowerment higher than male respondents (P < 0.05).

292 Tony Ryan

Multiple regression showed that among the illness variables depression was perceived to be least associated with medical disempowerment (P < 0.001). Of the stakeholders professionals perceived the risk of this factor highest (P < 0.001) and carers lowest (P < 0.005). Professionals with over 10 years of experience perceived the factor lower than other professionals (P < 0.001) and even lower risk perceptions were held by non-professionals (P < 0.001). Professionals working in both hospital and community settings regarded the factor as a lower risk than all other stakeholder groups (P < 0.001). Respondents aged between 21 and 30 (P < 0.001) and over 60 years (P < 0.05) perceived the factor lower than other respondents.

Threat (factor 3)

Risk items in this factor are concerned with the danger a person may present to others. Although less obviously associated with a specific threat when compared with the other items "being involved in crime" fits within the factor if the view is taken that victimless crime is rare and most forms of criminal activity present a danger to individuals and society.

Oneway ANOVA showed that the general public rated the threat factor higher than other stakeholders (P < 0.001). Professionals working solely in hospital rated the factor higher than all others (P < 0.01). Stakeholders aged 20 and under rated the factor higher than other age groups (P < 0.05) while female respondents rated the factor higher than males (P < 0.05).

Multiple regression showed that the general public respondent group perceived the overall risk associated with this factor to be higher than the three other respondent groups (P < 0.001). Across all stakeholders depression was perceived to be the lowest variable for the factor (P < 0.001). Female respondents perceived the factor higher than males (P < 0.01). Respondents aged between 21 and 30 years regarded threat lower (P < 0.01) than other age groups and those under 21 rated the risk higher (P < 0.05). Finally, hospital workers perceived risk of this factor was greater than all other stakeholders (P < 0.001).

Vulnerability (factor 4)

These risk items suggest naivety ("not getting benefit payments" or "being taken advantage of" in some way), being defenceless against abuse or exploitation and innocence ("catching the AIDS virus because of sleeping around" and "becoming addicted to illegal drugs").

Oneway ANOVA showed professionals and general public respondents rated the vulnerability factor higher than other stakeholders (P < 0.001). Professionals who worked exclusively in hospital rated the factor higher than other professionals (P < 0.01). Respondents aged over 60 years judged the factor lower than other respondents (P < 0.001)

while females perceived the factor higher than males (P < 0.001).

Multiple regression demonstrated that carers (P < 0.001) and service users (P < 0.005) perceived this factor lower than professionals and general public. Depression was perceived to have the lowest association with the factor among illness variables (P < 0.001). Fem~ile respondents perception of vulnerability was higher than males (P < 0.001). Respondents aged between 21 and 30 years (P < 0.001) and those over 50 (P < 0.05) perceived vulnerability lower than all other ages. Professionals with over 10 years experience rated the risk associated with this factor lower than other professionals (P < 0.05) while those who worked exclusively in hospital regarded the factor higher than all other stakeholders.

Self-harm (factor 5)

Most of the items here can easily be equated with injury inflicted by the person, whether purposefully or unintentionally. The item "becoming socially isolated" may not initially appear to be associated with the factor. However, if this is seen as a deliber- ate act on the part of the mentally ill person it becomes easier to consider it appropriate within the framework of self-harm.

Oneway ANOVA found professionals and the general public rated the self-harm factor higher than service users and carers (P < 0.001). Respondents aged over 60 years perceived the factor lower than all other ages (P < 0.001) while female respondents regarded the factor higher than males (P < 0.001).

Multiple regression showed that manic depression (P < 0.001) was the illness variable with the lowest mean associated with the factor. Service users (P < 0.001) and carers (P < 0.05) perceived the risk of self-harm lower than other stakeholders. Females perceived the factor higher than males (P < 0.005) while respondents over 60 years (P < 0.001) perceived self-harm lower than other ages. Professionals with more than 10 years experience perceived the factor lower (P < 0.05) than those with less experience. Those working in hospital settings perceived the risk to be greater than all other stakeholders (P < 0.05).

Dependen O, (factor 6)

The sixth and final factor consisted of three items and was given the name dependency because of the obvious association between the items.

A gender difference was the only variation identified in connection with the dependency factor as oneway ANOVA showed that female respondents rated the factor higher than males (P < 0.01). Multiple regression indicated that schizophrenia (P < 0.001) was perceived a higher risk for the dependency factor than depression or manie depression. Female respondents perceived the factor higher than males (P < 0.001) whereas respondents


over 60 years (P < 0.05) perceived dependency lower than all other respondents.

DISCUSSION

Factors of perceived risk

There are two indicators which are useful in gau- ging the quality of the results presented here. First the study has been grounded in data obtained from a considerable number of stakeholders (n = 87) in developing the questionnaire used to collect data on perceived risk. The second, which is discussed below, is that the results relate directly to existing bodies of knowledge in the mental health and risk literatures.

It should be no surprise that the underclass factor is a major dimension within respondents' perception of risk. It has been suggested for some time that people who experience serious mental health problems are also prone to a downward drift in social status (Hollingshead and Redlich, 1958; Goldberg and Morrison, 1963; Dohrenwend and Dohrenwend, 1969). Mental illness appears to increase the possibility of a person becoming homeless (Scott, 1993; Left, 1993; Timms and Fry, 1989) or involved in the criminal justice system (Gunn et al., 1991) which are associated problems of underclass membership. Whether people experience social drift as a cause or an effect of mental illness is moot but the two are certainly linked, not just in perception but in actuality.

The debilitating nature of many forms of mental illness, whether transient or enduring, often limit the abilities and independence of service users and those close to them. Recently questions have been asked of medicine and its allied professions about the coercive nature of their work when dealing with this client group (Rogers, 1993; Sines, 1994; Szasz, 1991). Today, awareness by professionals of their entrusted position is no doubt greater than it was at the time of the anti-psychiatry movement (Cooper, 1968; Szasz, 1961) which can partly be attributed to the rise of the user movement and the development of health and social care markets with their consu- mer emphasis. It may also be due to the theme of empowerment running through the training of health and social care professionals in recent years resulting from a right wing political ideology of self-responsibility. Therefore, the presence of medical disempowerment as a factor of perceived risk seems applicable to the current climate within this field.

Mentally ill people have been defenceless against sections of society for a long time. Not only have they been mistreated within communities but they have been abused by those who have been paid to take care of them (DHSS, 1972, 1980; HAS and DHSS, 1987; Do l l and SHSA, 1992). Therefore, it is probably true that the vulnerability and threat

factors have been dimensions within risk perceptions concerning people with mental illness for a long time.

It has been suggested that mentally ill people are a greater danger to themselves than they are to others (Prins, 1990) which is a view supported by policy targets to reduce the number of suicides (Doll , 1992). Recent research into illnesses such as schizophrenia (Hogman and Meier, 1995) and depression (Barraclough and Hughes, 1987) and their relationship with suicide confirms this viewpoint is valid. The dimension of self-harm as a perceived risk is therefore consistent with existing knowledge.

The dependency factor is no doubt related to the chronic and debilitating nature of various forms of mental illness. The person can become dependent upon medication, services, carers or the state to varying degrees.

Variations between stakeholder groups and the risk factors

There was significant agreement between each of the four respondent groups and their perception of the association between illnesses and the six risk factors. Each of the respondent groups when analysed separately perceived depression as the illness significantly less likely to be associated with the underclass, medical disempowerment, threat and vulnerability factors. One reason for this could be that depression is less likely to impair cognitive functioning than the other two illnesses and the cognitive ability of a person could be regarded as important in determining the risk associated with these factors.

Professionals perceived manic depression as a lower risk variable for the underclass factor which could be explained by the fluctuating nature of this condition and the good prognosis associated with lithium carbonate treatment. During a manic epi- sode a service user is likely to experience impaired cognitive functioning but this is likely to be short lived in comparison with many depressive illnesses or chronic schizophrenia (Goldberg et al., 1987). All respondent groups perceived manic depression as a lower risk variable for the self-harm factor than the other illnesses which could be for similar reasons.

The professionals and general public perceived the vulnerability factor significantly higher than service users and carers. In the case of professionals this may be related to their role as paid carers and as such can be held accountable for their actions. It may also be associated with the fear that they may be scapegoated should anything go wrong. In the case of the general public the one obvious reason for a similar high perception may be that they want mentally ill people to be protected (Hall et al., 1993).

Schizophrenia was perceived to be a higher risk variable for the dependency factor by all of the

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respondent groups. This may be the result of it being regarded as a chronic debilitating illness.

Demographic differences in the perception of risk

Probably the most important finding of the study was that the gender of respondents played a significant part in the perception of risk associated with each factor. Female respondents perceived the risk associated with all factors greater than males irrespective of stakeholder group. This confirms findings in other fields where it has been demonstrated that women perceive risks greater than men (Greenberg and Schneider, 1995).

A further important finding relates to differences between the professional groups and their risk perceptions. The main differences exist between psychiatrists and the other professional groups. For the underclass, medical disempowerment, threat and vulnerability factors psychiatrists perceived the risks significantly lower than the other professional groups. Although the concepts of risk and dangerousness are very different this finding is interesting considering that a WHO study of assessments of dangerousness found that psychiatrists were prone to rate dangerousness higher than other professional groups (Montandon and Harding, 1984). This outcome is all the more interesting considering that in most of the recent policy initiatives psychiatrists have been given a central position in risk assessment and management which places them in the prime position to be scapegoated should things go wrong (Doll , 1990, 1993; National Health Service Executive, 1994). Social workers also perceived the threat factor significantly lower than other professional groups but not as low as the psychiatrists. Nurses' perceptions were lower in connection to the medical disempowerment factor but higher than the psychiatrists which may be due to their particularly close ties with medicine.

Professionals rated risk of medical disempowerment higher than the other stakeholder groups. This may be due to an increasing awareness of their position as potential agents of social control and an acknowledgement of the stigmatising effect of contact with mental health services. It may also be associated with an awareness that they are working with people who, at times, may not be competent to make decisions regarding their care and treatment (Grisso and Appelbaum, 1995).

Finally, in the threat factor hospital workers perceived this risk to be significantly greater than other professionals. A possible explanation here is that by the time people with mental health needs are admitted to hospital they are more acutely ill than when they are being dealt with on an ongoing basis outside hospital. Therefore the threat perceived by this group may be greater as a result of the increased contact with people who are acutely ill. Many people are admitted to hospital because they present a danger to themselves or others and this is

a basic criterion for hospital detention under the 1983 Mental Health Act, therefore the perception of this professional group is probably an accurate one. Furthermore there is evidence to suggest that violence by hospital inpatients presents a very real threat to those who work closely with them. A review of 12 studies of psychiatric inpatient violence concluded that around 90% of mental health professionals have been assaulted at some time when working in acute inpatient settings and that the majority of these are nurses (Whittington, 1994). It has also been suggested that a quarter of nurses in mental health settings are physically injured by patients during any 12 month period (Health Services Advisory Committee, 1987). Professionals in hospital also rated the vulnerability factor higher than other professionals which again may be because they see people when they are particularly ill and at their most defenceless.

CONCLUSIONS

There are several points which can be made with reasonable confidence as a result of this work. Firstly, risk in connection with mental illness is a multidimensional concept which covers both risks faced as well as those posed by mentally ill people. Five of the six factors identified from this study relate to risks faced rather than risks posed. The second issue is that females, irrespective of respondent group, perceive each of the six factors of risk higher than those of male respondents. Thirdly, there are significant differences between some of the professional groups, in particular between the psychiatrists and the other professionals in four of the six factors. Finally, although small in numbers, and therefore possibly an artefact of the data, it is interesting that the respondents over 60, irrespective of respondent group, perceive each of the six factors of risk significantly lower than all other groups.

The significance of these findings can be highlighted in several ways. Firstly, in relation to the risk factors themselves the research identified that there are significant dimensions to perceived risk other than those identified in recent policy: harm to others, harm to self and severe self-neglect (Doll , 1993). This suggests that current policy definitions of risk are concentrated too narrowly in the eyes of the stakeholders who participated in the study. The question this poses is whether the factors of perceived risk identified here are those which efforts should be focused upon. If the prime concern is with high consequence/low frequency events and resources are specifically targeted toward this area it could mean that the majority of people with mental health needs are given less support from services. The consequence of shifting the attention to high consequence/low frequency events is that everyday risk events receive less attention as a disproportion- ate amount of resources are targeted at risk elimin-


ation. Therefore, as already argued by one user movement (MIND, 1994), everyday risks are likely to become even more frequent as risk assessment is given such a narrow focus. There is also the possibility that people who use services are given a per- verse incentive to be a greater risk to self or others if this becomes the criteria for getting a service.

Secondly, in connection with the gender differen- tiated perception of risk there are several points which need to be emphasised. Given that what we perceive often governs what we do, sometimes in the face of evidence to the contrary, as in the case of smoking cigarettes, this is probably the most significant finding of the study. If female professionals perceive risks to be greater than do their male counterparts then they may be prone to adopt more conservative approaches to their work. This has important implications for how, and by whom, mental health services are organised. It may be that services which are primarily concerned with safety for the mentally ill person or other people, such as acute inpatient units or forensic services, should have significant input from female staff. If not managed by women then they should at least place women at the key decision making points because of the gender differences in perceived risk. Conversely services which require some degree of risk taking, such as rehabilitation services, may be better run by men because of their lower perception of risk. This is not to say that women should not be involved in these services but merely to highlight the particular roles which gender may play within multidisciplin- ary team working. Given that many mental health services are male dominated in key areas of responsibility these findings suggest that more women managers should work alongside their male counterparts in order to balance various perceptions of risk. The question which arises from this gender differentiation in risk perception is whose perception is more accurate. Until we know more about the accuracy of risk perceptions in this area it would appear logical to take a balancing approach by readjusting the gender balance in key positions.

While these comments can be made with a fair degree of confidence it should also be noted that there are inevitable technical and interpretative limi- tations in a study of this kind. The number of respondents (n = 550) and their sets of responses (n = 1076) were fairly high. However, they were not large enough in some of the subpopulations to permit more sophisticated analyses of the data. Additionally biases within the sample may have occurred since information on non-respondents was not available. While precise definitions similar to those used in clinical settings (American Psychiatric Association, 1987; World Health Organisation, 1989) could have been used to define mental illness a compromise had to be made as such definitions could have been too technical for all stakeholders. Given that respondents are likely to interpret ques-

tionnaires in the context of their own experiences (Foddy, 1993) this would have meant that precise definitions would have been open to self-interpret- ation regardless of such definitions. Finally, although the exercise of extracting factors is statistical the task of naming them is qualitative and can be very individualistic (Alt, 1990). Thus, the name that one researcher gives a factor may be quite different to that used by another.

In conclusion, it appears that this research broad- ens the concept of risk in the mental health field. Policy and media attention have focused upon a narrow definition of risk and have to some extent driven practice towards a potential overemphasis upon high consequence/low frequency events such as homicide and suicide. It is clear from this research that what underpins perceptions of risk is significantly different and much wider. On one hand, it is right to ensure the safety of the public against homicides by mentally ill people even though they are small in number. This is partly for public safety reasons but also for those people who are mentally ill who do not pose any threat to society yet are perceived to be so simply because they are mentally ill. Similarly attention upon the threat that mentally ill people pose to themselves through suicide is also worthy as the risk here is much greater than that of homicide (Steering Committee of the Confidential Inquiry into Homicides and Suicides by Mentally II1 People, 1996). However, while it appears that policy makers currently have a narrow perception of risk in connection with mentally ill people, each of the four respondent groups participating in this study have a broader multidimensional concept of risk.

Acknowledgements--I am grateful to Professor Keith Soothill (Department of Applied Social Science, Lancaster) and Dr Janis WiUiamson (Department of Psychology, Bolton) for their advice and support throughout this research and Mr Brian Francis (Centre for Applied Statistics, Lancaster) for his guidance during the analysis of data. I am also indebted to Professor Roger Clough (Department of Applied Social Science, Lancaster University) and Professor Keith Cash (Department of Nursing, Leeds Metropolitan University) for their helpful comments on an earlier draft of the paper. Further, I wish to thank Professor John Monahan, Director of the MacArthur Studies, Virginia, for his interest and encour- agement in the study. Finally, I am indebted to those who participated and to those who provided access at both research sites.

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Perceived risks associated with mental illness: Beyond homicide and suicide

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