Thus far, much attention has been paid to the contexts of vulnerability anduncertainty that make trust relevant and salient for service users. We havebriefly noted in earlier chapters that mental health professionals deal withmanifold uncertainties, though the ways in which these uncertainties areintertwined with high levels of vulnerability have not been discussed in anysignificant depth up to this point. This chapter begins by noting howprofessionals respond to vulnerability and how these responses are shaped byinstitutional and policy contexts. We assess the format of risk approachesthat aims at control and explore the ‘trust–controldialectic’ (Gallivan and Depledge, 2003; Brown, 2008a) that resultswithin mental health contexts. This provides one useful basis forconsidering the interrelatedness of different levels of trust:manager–professional, inter-professional andprofessional–service user. Drawing on our data, we go on to considerthe appearance of virtuous or vicious circles of trust, and the way thesecyclical patterns are rooted in institutional policy formats on the onehand, and the social contexts of service users on the other. The chapterwill close with some initial policy recommendations, drawing on some of thenotions of transaction cost economics touched upon in earlier chapters,which will lay the basis for certain discussions that will be pursued in thefinal chapter of this book.

Professionals in the midst of vulnerability

The preceding chapter explored various features of the responses of serviceusers, in many cases leaning towards trust, which were understood withinsocial contexts of vulnerability and the needs of service users to cope withthis. Mental health service users, especially those with diagnoses ofpsychosis, are often characterised as a vulnerable group, but less attentionis paid to the vulnerability experienced by professionals. Earlier chaptersreferred to the close linkages between risk and blame (following Douglas,1992) and, moreover, the way risk has become a defining concept of recentmental health policy in England (Pilgrim, 2007). In contrast to neighbouringpolicy contexts, Scotland being one notable example (Darjee and Crichton,2004), significant emphasis has been especially placed upon certain forms ofrisk management within English mental health services (Langan, 2010).

The very nature of risk, especially in terms of its application within modernorganisation contexts, is to apportion blame (Douglas, 1992), often onto theshoulders of experts (Luhmann, 1993). Risk was a significant theme inprofessionals’ accounts of their day-to-day work.