Trusting on the Edge: Managing Uncertainty and Vulnerability in the Midst of Serious Mental Health Problems


Brown, P. and Calnan, M. Trusting on the Edge: Managing Uncertainty and Vulnerability in the Midst of Serious Mental Health Problems . 2012 144 pp £56.00 (hbk ) ISBN: 9781847428899

The shift towards risk management, an audit culture and other elements of the New Public Management have received a great deal of attention over the past twenty years. This short book brings a sideways perspective to bear on them, through an extended theoretical and empirical exposition of the concept of trust in healthcare settings. In it, Brown and Calnan provide a sharp critique of the undue reliance now being placed on calculative, control orientated ways of managing uncertainty within the English mental health sector.

Brown and Calnan have chosen mental health as a setting for their case study on trust, because it is a context in which diagnoses and treatment plans are uncertain, service users and clinicians can be quite vulnerable, processes undermining trust are very evident, and a tension is thus created. Trust is exceptionally necessary in this context, even while it is particularly hard to achieve. Their reason for focusing on mental health was thus to find the right social space to engage in a theoretical development of the concept of trust. My interest in this book, by contrast, came from an intensely practical concern with mental health practices and systems. I wanted to know how a more effective and less damaging mental health system can be achieved. I found that while this book did an excellent job of meeting Brown and Calnan’s aims, my interests in a focus on the practicalities of the mental health context were only partially satisfied.

The bulk of the book includes a deeply theoretical engagement with the concept of trust in a context of heightened vulnerability and uncertainty; Brown and Calnan provide a model which develops a complex linkage between these three concepts. Trust is one response to uncertainty about the future, and the vulnerability associated with that uncertainty. Vulnerability is both a precursor to the action of trusting, and an outcome of placing one’s trust in another person. They work from a Schutzian phenomenological framework to develop a trialectic model of three types of experiential knowledge that can lead to trust, even in contexts that don’t seem conducive to it. The most important of these are private interactive experiences, which are located in the everyday experiences of empathy, body language and communication that are most difficult to capture in quality assurance and performance indicators.

A weakness of this book is its light empirical grounding. Its empirical data is based on only 23 semi-structured interviews, of which only eight were with service users. This in itself is evidence of the importance of the topic, as the authors state that 158 approaches to service users garnered only their eight participants; this suggests to me that trust may indeed be fragile within the English mental health system. Quotations are lightly sprinkled through a book which is primarily theoretical in orientation. However, the quotations that are used are very well placed, and illustrate well the points being made.

The book really comes into its own in the two final chapters. Brown and Calnan describe what they call virtuous circles where trust is encouraged through a complex layering of policy environments, local organisational cultures, and the everyday interactions of professionals and service users. This is contrasted with the vicious circles created by instrumental, bureaucratic policy and organisational contexts, which in turn generate defensive and procedurally focused practice, leading to a lack of trust addressed by further measures focused on control rather than relationship building. I was pleased to see this written exposition of the ‘trust-control dialectic’. Brown and Calnan’s careful exposition of this dialectic is important material, as it creates a sound argument for moving the mental health system towards relationship and trust building, rather than towards systems of risk management, calculation and control. By making the argument that any moves towards bureaucratic and calculative control can be antithetical to trust, the authors have made a useful contribution to the health policy literature.