From therapy to administration: deinstitutionalisation and the ascendancy of psychiatric 'risk thinking'.

ABSTRACT

Crisis Assessment and Treatment Teams (CAT Teams) were established in Victoria, Australia, in 1988 to provide crisis intervention and home treatment as an alternative to hospitalisation for the seriously mentally ill. These teams were set up to prepare for the closure of the large-scale, state-run psychiatric institutions over the following decade. Increasingly, concerns are being expressed in the media over the failure of the new community-based services to provide adequate care and protection to the mentally ill. This paper offers a preliminary attempt to make sociological sense of one such aspect of deinstitutionalisation, the major changes that have occurred in the practice and delivery of CAT Team services since inception. I suggest that a shift has taken place from a therapeutic consciousness, centred on providing home treatment, to a risk consciousness, centred on protocols to evaluate and document a client's 'risk factors'. Drawing on my personal experiences as a clinician in a Melbourne-based CAT Team since 1991, I probe these changes through the lens of sociology. In so doing, I utilise several insights from Nikolas Rose's (1998) analysis of risk as a foundation for social intervention.

KEY WORDS

Deinstitutionalisation; psychiatry; sociology; risk; therapy; administration

The argument

This paper examines the consequences of an intersection of several factors in Victorian psychiatric care over the past decade and a half. These include deinstitutionalisation, intensified risk management, 'New Public Management', public relations as a task of government departments, an apparent increase in the incidence of psychiatric distress, and the nature of the bureaucratic form.

Five central contentions are advanced in this paper. First, a shift has taken place from a therapeutic consciousness, centred on the provision of home treatment, to a risk consciousness, underscored by the development of protocols to evaluate a client's level of risk to self and others. When I joined the CAT Team in 1991, clients were discussed in terms of whether they were 'in crisis'. Several years later, the idea of whether they were 'at risk' began to take precedence in clinical discussions. The concept of being 'in crisis', I suggest, implies an inherently, or at least potentially, therapeutic response to a client, whereas assessing a client's level of risk is largely an administrative process.