What a relief to hear Chris Whitty and others finally start to talk about the balance of risk. This concept seems to have been sadly lacking from the public discourse over the last few months when it should have been fundamental to our understanding and strategy. Bear with me as I use an example from my professional career.
As a psychiatrist, I had to make difficult decisions about detaining individuals’ liberty under the Mental Health Act – a process commonly referred to as ‘sectioning’. This decision is taken very seriously, with many safeguards in place to protect the individual. Voluntary admission is always encouraged if at all possible. Patients are discharged from the ‘section’ as soon as it is considered safe to do so. There are appeal processes at every stage and prolonged detention involves a Mental Health Review Tribunal. Removing an individual’s freedom, in the first place, feels like a weighty responsibility, but the hardest part is deciding when to release the patient from legal detention. For some patients, the decision is easy, as the boundary between being ill and being well is obvious. But, for most, this is much less clear cut. Psychosis, mood disturbance, dangerousness and insight are difficult to assess and can change very quickly.
Risk in mental health patients is never eradicated. But the long-term social and psychological consequences of ongoing detention in an institution have to be weighed against the risks of allowing someone to walk free. Some patients react particularly badly to having their liberty curtailed and become more dangerous in hospital. With these patients it is too easy to respond with ever increasing levels of security, creating a vicious circle that is difficult to break.
Sadly, of course, a minority of patients with very severe illness need long-term detention, but most will be able to pick-up their lives and carry on more or less as normal. Such an outcome is enabled by modern treatments but also a positive attitude towards recovery that was absent in the past. The history of psychiatric institutions, where individuals admitted rarely regained their liberty and became progressively institutionalised, serves as a warning about what happens when there isn’t a strategy to get back to normal. Good mental health teams will start to plan towards recovery early on in an admission. This – getting back to normal – requires imagination, vision, experience, skill and hard work on the part of everyone involved. It also requires a certain amount of courage and the capacity to hold one’s nerve. It doesn’t just happen.
Without the will to focus on healthy functioning rather than just pathology, things can move rapidly in the wrong direction. Without a strategy, the mental health team becomes simply reactive and risk averse. Vitally important therapeutic risk-taking will not happen. The ‘command and control’ leadership, often essential in the eye of the storm, has to change to a more consensual style of authority, where power relations are made explicit, recognised as dynamic and re-negotiated. A shared understanding of responsibility and accountability are all important in this difficult conversation between patient and clinician. Some patients are left feeling mistrustful towards the team who ordered their incarceration and reparative work may be needed. Others will be resistant to taking back responsibility for their lives and a program of encouraging, facilitative work, breaking down the process into small manageable steps, will be necessary.
Back to the pandemic. Like John in his last blog post, I worry that there is too little understanding of the need for such a recovery process at the higher echelons of Government. There is little evidence of a strategy based on balancing risk to take us forward, and numerous examples of reactive, knee-jerk responses to the latest ‘crisis’ running in parallel to gung-ho attempts to pretend things are back to normal. The fear engendered back in March/April may have been appropriate at the time, but fear only works as a constructive prompt in the short-term. There seems to have been an absence of sensible thinking about how to move the country forward, and if there is a strategy at all, it clearly lacks any thinking about how to repair the psychological and social problems that are part of the lock-down legacy. True, there have been some somewhat ad hoc economic incentives, but these have little chance of making an impact unless the social and psychological issues are addressed. Crucially, we are now at a point where we need to be encouraged to use our intelligence to think sensibly together about balancing risks in our own communities and institutions. This would be a better contribution to recovery than anxiously trying to get our heads around the latest command from a government seemingly detached and worryingly unaware of our experience and concerns.
Penny
Intelligent Kindness 
Thank you for this Penny, but, prompted by my own reaction to Whitty’s statement, allow me to take it in a slightly different direction. I read Whitty as making a political intervention that reflects his subordination to his official position. The balance of risk referred to his probably correct assessment that “the chances of children dying from Covid-19 are incredibly small”, versus the damage caused when children do not attend school which is “incredibly clear”. Not, it would seem, a difficult judgement. What is significant, however, is what is left out of the balancing factors.
Looked at more holistically, there should be included other concerns. Somewhat surprisingly for the government, adults work in schools and may be vulnerable to infection. Children also have parents and grandparents (and not just nannies and au pairs) who may have co-morbidities. They do not figure in the balance. According to a recent US study (see
https://www.mirror.co.uk/science/children-carry-higher-loads-coronavirus-22546624)
Children can carry larger amounts of the virus than adults left fighting for their lives – yet show no symptoms.
But as asymptomatic carriers attending school, they can spread infection and bring the virus into their homes.
This is a particular concern for families in certain socio-economic groups, which have been harder hit in the pandemic.
Recommendations from their study include not relying on body temperature or symptom monitoring to identify infection in the school setting.
They underline the importance of social distancing, universal mask use, effective hand-washing protocols and a combination of remote and in-person learning.
They said routine and continued screening of all students with timely reporting of the results are an imperative part of a safe return-to-school policy.
In your reflections on psychiatric work you point out it is possible that ‘Without a strategy, the mental health team becomes simply reactive and risk averse. Might it not also be possible to become reckless? What will children return to? Headteachers are currently complaining that they have little or no support and guidance and there is an absence of contingency plans for if (when) there are outbreaks at schools. In short you are right to emphasise that ‘There is little evidence of a strategy based on balancing risk to take us forward, and numerous examples of reactive, knee-jerk responses to the latest ‘crisis’ running in parallel to gung-ho attempts to pretend things are back to normal’. Whitty has made no contribution to this strategic gap – it is merely the latest part of the intervention to undermine the demands of the teachers’ unions and a large number of parents to be consulted about the conditions they work in and their children are taught in.
So, while we do need as individuals to shed any faith in the authority and wisdom of a particularly partial and incompetent government and to plot a sensible way through the risks our own lives, this strategy is no solution for those in imperatively controlled workplaces.
(Sorry for the length).
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Don’t apologise for the length, it’s good to get some debate going! I guess there are two levels of balancing risks. One is just acknowledging that there are other important risks around, some of them life threatening, not just the dangers of catching Covid19. Although there is recognition of this in terms of the economy, the government has been very slow to acknowledge the rising tide of social and psychological problems and often talks as if the pandemic is the only show in town. Hence my relief at hearing the CMO simply use the phrase, though I agree with you that it came across as an over-simplistic assessment.
But you’re right: the next step is getting into the complex detail of genuine risk assessment and the tricky business of weighing very different risks against each other. There is lots of expertise to help with this, but you wouldn’t think so from listening to this government. It’s also vitally important to involve stakeholders in the process in a meaningful way and this seems to have been particularly badly managed in relation to teachers. It might even be that some of them would have been reassured had they had more sense of agency and been more engaged in the debate around the available evidence.
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Thank you Penny for a thought provoking piece, and for your ideas for going forwards based on assessing risks and choosing to take some sensible ones. It linked in my mind to the article ‘Missed Connections’, New Scientist , 15 August 2020, which is about the erosion of social capital. We have been starved during lockdown of: shared experiences with friends and families; daily interactions with average of 11 to 16 people who are casual acquaintances eg bus driver, barista, somebody in a queue with you, neighbour, shop assistant etc; touch as we greet or say farewell or empathise with friends and family – all these increase our feelings of happiness. We need to rebuild and increase our human interactions, as not having them is a significant risk to our wellbeing and mental health.
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