Abstract

In everyday mental health practice, clinicians are expected to assess and manage the risk of harm that may be caused by their patients to others. An informed approach to the activities of risk assessment and management should be grounded in a thorough understanding of the notion of risk. Whilst there are agreed definitions of risk, they do not do justice to the complexity of in-vivo representations of risk. Based on a review of the literature, an analysis of clinical guidelines, and practicing psychiatrists’ reflections on their own clinical experiences and sample vignettes, this article explores the varied subjective representations of risk in mental health practice. Of specific relevance to the possibility of an individual causing harm is the need to recognise that the causal agent of harm is an as-yet-unrealised state of consciousness, and that actions that may reduce risk are multiple and have effects that are difficult to define in advance. From an analysis of the semantic context of the use of the word ‘risk’ within practice guidance, the authors demonstrate a wide range of meanings (including harm, possibility of harm, characteristics of possible harm, a state with changeable potential for harm, and different states of potential harm) with different degrees of embodiment. With reference to clinical scenarios, the formation of individual subjective representations of risk are shown to vary not only in the way they can be characterised (e.g. likelihood, severity, and imminence), but also in the extent to which they come into subjective focus. Uncovering the different ways risk is represented in practice should allow a more refined approach to guiding and studying the process of risk assessment and management.

摘要

在日常心理健康实践中，临床医生应该评估和管理患者可能对其他人造成的伤害风险。风险评估和管理活动的知情方法应以对风险概念的透彻理解为基础。虽然对风险有一致的定义，但它们并没有对风险的体内表征的复杂性做出公正的判断。基于对文献的回顾、临床指南的分析以及执业精神科医生对他们自己的临床经验和样本小插曲的反思，本文探讨了心理健康实践中风险的各种主观表征。与个人造成伤害的可能性特别相关的是需要认识到伤害的原因是一种尚未实现的意识状态，并且可以降低风险的行动是多方面的，并且具有难以预先定义的效果。通过对实践指南中“风险”一词使用的语义上下文的分析，作者展示了广泛的含义（包括伤害、伤害的可能性、可能伤害的特征、具有可变伤害潜力的状态，以及潜在危害的不同状态）具有不同程度的体现。参考临床情景，个人主观风险表征的形成不仅在其表征方式（例如可能性、严重性和紧迫性）上有所不同，而且在它们成为主观焦点的程度上也有所不同。