Risk Managementin the Wild
Cultural Dynarllisrll against the Unknown
in the Ward Life of a A/1ental Hospitalin」

apan

14た rど な
qrノ cttι ね″″/シkぁ ピ
2/7ハ

̀7

2∂ οァ

FUKUSHIⅣm,Ⅳlasat。

lntroduction
Thc notion Of risk and risk managcmcnt is now spilling
Ovcr from acadcmic discourse to cvcryday cconOmic activitics.
Risk appcars to hidc at cvcry corncr of our socieり ちfrOm intcrnal

corruption of a privatc company to environmcntal hormOnes;and
we arc obliged to an■μc and managc it as PreCautiously7 as PoSSiblc.

Thc risc of thc notion Of risk managcment Partly derivcs frOmlarge scalc tcchn。 logical accidcnts such as Chcrn。 1ッ l or chcmicalplant accidents(cf Pcrrow 1984;Rcason 1997),and thc nOtion ofrisk managcmcnt has bccn dccply influcnccd by tht enginccring
deinition of it.Its basic tenet is that risk can bc ncutral,aSSessed

宙 th the usc of scicntinc t。 。ls of an狙"is,with
Which thetoprobabiliりOf the advcrsc cvent can bc cstiinatedquantitatively
bc thcnmanagcd in linc with such calculations(cf Golding 1992;Rcnn
1992;Funtowicz&Ravctz 1992)
Yct the nodon ofrisk managcmcntも neu廿 血りhaS bCCn seriOusヶchallengcdけ a numbCr of Pbnee五 ng works,such as Douglas andWildavsけ (1982)on cultural foundation of risk perception,and
Mrynnc(1987)on thc rcgulators'and scicntists'conision over thc
dcnnitlon of rlsk and its assessinent ln the casc of hazardOus、

vaste.

Bringing togcther thcsc criticisms against the enginccring notionof risk,JasanofF commcntcd on thc̀avo culmrcs'Of risk andysis ofcnginecring and social scicnce,and Proposed how to bridge themwith the cmphasis on thc possible contribution of anthropologicaland sociological approach for adding complex and contcxtual nuanccs
tO thc cngincering understanding ofrisk(JasanOf1993).
Turning Our cン ℃s tO｀ Vards public hcalth,similar trends towards

risk managcmcnt havc bccn prOpencd by diffcrcnt rcasons.Heycs
fOund an cxplosi■ 7c riSC of the notion of risk in Mcdline:frOm 1985

to 1991,100,898 refercnccs、 vcrc madc tO it,wllile in contrast it was
29,870 to ccrcbromscular disorder(Haン cS 1992).Asidc from conccrn

Risk Managementin thc VⅥ ld(FUKUSHIMA,MasatO)c riSkS tO pcrsonal health such

fOr risk in health care and for lifcstメ

as smoking(Lupton 1993;Haン ℃s1992),mcdicinc rclatcd litigation
has contributcd to thc rising risk cOnsciousness in mcdicinc(Hwman

1998:2,San■ 11lPoそ 史RObinson 2002)
A simllar trcnd is now underway also in Japan,WhCrc thc
numbcr Oflitigation in hcalth carc has doublcd frOm 352 in 1990 to

767 in 2000,and is increasing(Okada 2005).lllc ncws comeacal accidcnts are also higllヶrage of宙sお lC,and new acadcmic sodeties

rclatcd tO mcdical safc7 havc bCCn cstablished in recent vcars such as

JSHCM(JaPan SOdCり for HCalth Carc Managcmcnt)orJsQSH(Japancsc sOcicり fOr QualitV and SafcりofHCttth).

In ovcrwhelmingly quantitativc studics of risk in mcdicinc,
Heyman(1998)underlincd thc csscntial ambiguity of thc nOtionof risk in thc contcxt of rnedicine,、vherc risk has not bccn regarded

ncgati17cヶ a■ the dmc whcn padcnts wcrc conccrncd.Ъ

is rnost clcarly seen in thc balancc bc●

is ambiguiり

vecn the autonomy of thc

patients and thc stafFt eЯ ort for thcir saiり

(Hcyman&Hcnrikscn

1998:95;Corksh&Hcyman 1998:221)Heyman ct al pointed out
th lcarning difncultics oncc rcgardcd
that specialists on children、 ■〜五sk as濠、rablc and cven referred to it as̀thc digniりof五 Sだ (Hc)man,

Huclde&Handysidc,1998:211).
lhis papcr■ vill elaboratc thc vcry ambigui■r Ofthe notiOn Of riskin the contcxt of psychiatric、 vards in Japan during thc pcriOd justbcfOrc such notions ofrisk rnanagement started to nourish.Here thc
tcrm risk managcmcnt in the u7ild is tcmporariヶ dCincd as shO宙 ng

both thc ethnographic scnsc Of describing thc risk managcmcnt′′″,and thc namrc Ofthe observed practicc that was lesspracticcブ ″∫fOrmalizcd than thc subsequent introduction Of fOrmalizcd mcthOds
Of五 sk anaヶ siS・ TWisting a terminology of Goo〜 on litCraげ

(GOoψ

∫
′
ブ
ι
´′
グ
ο″ hcrc mcans the incrcasing influcncc Of thc
1977),″ ο″′cnginccring nodon ofrisk which has bccn promOted by gornmentp01ic"and this papcr tries to see ward lifcjust bcforc such systcmatic

domcstication began.

Thc oncc rich ethnographic studics on PsyChiatric wards,
PartiCularly in Post― war US(Stanton&Schwartz 1954;Caudill

1958,Goffman 1961;Perry 1966;Stotland&Koblcr 1965)h″e

fadcd largcly duc to thc transformation of Psychiatric P01iCy in

maiOr advanccd countrics(c■GrOb 1994;ル lanscl1 8t Ericsson

1996;Shotter1997).AlthOugh similar trcnds ha■ re been promoted
in Japanesc Public hettth,mcntal hosPitalS in Japan arc still playing

Rttk Managcmcntin thc Wlld(FUKUSHIMA,Masato)a pivotal r。 lc、vhcrc thc classical traditiOn Of ethnography onlps)℃ hiatric wards is an ongoing reali■ rl.Thc Purposc of this papcr

JapanCSC mcntal hcalth in thc

is to dcscribe non Anglo― Amcrican case studics in Psychiatricanthropolo〔 ヮ (cf Carpcntcr 2000;Come■ es 1991;Gaincs ed 1992,

esp.NOmura 1992)within the cOntcxt of risk analysis and risk

Asai cd 1996 rcvicws thc

intcrnational pcrsPcctiVC As tO
thc concisc histOっ ′OfpSychiatl■

and mcntal hcalth pOlicl scc
thc cditor's intrOductiOn(Asai

1996)In brict thc numbcr Of

management.

mcntal hosPitals and that Of

FOr this purposc,I宙 1lintroducc 6vO mutlla■ v related thcOrcdcal

inPatiCnts continuously grcw
frOna arOund 50t up t0 90も ,andframc、 vOrks.Thc flrst is the notiOn of distributcd cognition mOst

in 1993,mcntal hcalth P01icy

cloquently promotcd by Hutchins,in his seminal cthnOgraphyof nⅣal na■/igation(Hutchins 1995)Onc Ofthc main themes Of
his analysis、 vas thc socially and matcrially distributed naturc ofstartcd to shift tO cOmmunity

carc, accomPanicd ｀Vith thc
gradual dccrcasc of thc numbcr

of hOspitals and Paticnts

cognition,Ivhcrc thc crc、 vt cOnccti.7c activitics wcrc coordinated via

Attcntion shOuld bc Paid tO

a varicり ofnCtVOrks ofcOmmunic盤 lon,infOrmation and tool usc,inthc fact that thc mttOr17 0f thC

rcsponse to chanJng en宙 ronmcnts.

owncd sO that a nation― widc

Hal・ ing not cxPliciψ

underlined the nOtiOn Ofrisk management,
his casc studics lvcrc ncvcrtheless f11led■ vith such asPccts,1lke theshipも possibiliり

mcntal hosPitals arc privatcly

OfgrOunding On rOck,and hc dcscribed vi、

P01iCy to closc thcm dO、 vn likc
in Wcstcrn countrics、 vas hardto practicc

idヶ tl・ C

wり 。fmanaging riskグ ″∫グ′″,such as thc reco■ 7ering proccss■ Om thC
malftlnction of a certain tool by organizational rcdundancy wherc
each sections'overlapping arca could support thc other part in crisis(Hutchins 1990).

Howcvcr,in spite of the richness of material,Hutchins left
a couplc of qucstions unanswcrcd.AinOng thosc、

vas the natureof cOnstraints which innucnccs how the organizational scctiOns
c01labOrate 171a COgnitive tools.Ъ is l can thc Problcm Of cOgnitiOn/

1aw(Fukushima 2001;cf Bourricr 1999),and hcrc〜 /1a、 v mcans both
lcgal and sOcio― cultural cOnstraints such as regulatory constraints ofmanutts which may curb thc bcst pracdcc,or organizadonal culturc■
vhich restrains its rncmbcr frOm taking propcr dccisions.Ъ

is will bc

onc ofthc focal points Ofthis papc■

In compcnsating the、 veakncss of Hutchins'approach,thestudy of High Reliability Organizations(HRO)by the Berkeley
rcscarch tcam Of K.RObcrts,G.Rochlin,G.La Porte and othcrs w,狙be rcirrcd to.■■c HRO smdics wcrc a concction of quttitat市 e neld
studies of high risk organizations with high safcty pcrformancc,
such as air trafflc control towcrs,aircrai carricrs in thc Na、フЪand nuclcar pOwcr rcactors(Robcrts cd.1993;lVcick&Sutcliffc

2001;Rochlin 1989).Among impress市 e Andings,a distinct市 ccharactcrisdc was that thcsc OrganizatiOns arc vcry ncxible in shifting

the decision― making authority to adapt thcmsclvcs tO rapidly

Risk Managemcntin thc Wlld(FUKUSHIMA,MasatO)changing cnvironments.AnOthcr cxample is the redundant、 vay ofcommunication to scrutinizc ris,infOrmation multi dimcnsion山

ahn to Hutchins'casc(LaPorte&Conslini 1991)Furthcrmorc,
thc problcm of cognition/1aw was analyzcd in thc studics of
nuclcar reactors where thc staff wcrc forccd to balancc beaveen
the appropriatc lvay of managing risk and abiding by thc cOmplcx
rcgulations,which were in Placc to dctermine the levcl ofsafeりthere(Schulman 1989,1993;Bourricr 1996).
Ъ is paper tries to synthesize thcscれ vo apprOaches v7ith a caseStuウ Of pSrhiatric wards.■ hrcc points宙 狙bc focuscd upOn.「lrst,
thc wν 2y

thc stafFOfpsシ℃hiatric wards perceⅣ ed and idcntincd POssiblc

risks thtt should be managcd宙 1l be anaレ cd Cthnographicatt Hcrc

thc cmphasis宙 且be on thc anⅢ siS Ofthc distributcd and colcctiv℃
cd thc tacit

naturc of risk Pcrccption,esPccitt on hoW StafFpcrcc市
sign7als ofthc Patients(cf Polanyi 1966;Fukushima 2001).

Ъ c sccond POintis conccrncd with thc tools Ofrisk managcmentand its actllal cxccution.Oncc consensus on risks lvas rcachcd,thcrc
should bc tools and dc■rlccs wlth■ Vllich to eliminate thcm.lllere werc
a couple of such tools in thc facc of Pcrcci■ rcd risk,such as pOssiblc

violcnt behavior,yct in the contcxt of medicinc and psychiatrb
such measurcs can al■ vays bc contcsted as to thcir cfccti、 cncss andlC」 timacy(ciCutclifc&Barker 2002;MacKγ ct a12005).Further

rcsourccs of risk managemcnt were personal contact,medication,
and Particular placcs likc observation and isolation rooms.But thcsc

muldPle de宙 ccs had thcir intrinsic hmits in both tcchnical and mOral(or symb。 lic)senscs,and this would icad to prOblcms of thc acmal

application ofrisk managcmcnt which宙 ■bc anめ ced・ll■ cthird Point is thc blurrcd boundary of ncgatw℃

and Positl■ 7erisk,and its conscqucnce lor thc application ofrisk rnanagemcnt■ hepoint hcrc is that thc subtle balancc beれveen ncgativc and Positive

risk is aゥ namiC PrOCCSS WhCrC an cthnographic gazc is rcquircd forpropcr undcrstanding.qhis balancc is also rclatcd to thc cOgnition/

v problcm mentioned abovc,as optimal measurcs to prcvcnt risk

1a■in thc、 vard lifc、vcre not neccssarily carricd out due to the complex

rclation of rcstrictions on these mcasurcs.I will shoM′that thcorganizational ward culturc rcstricted thc stafF's decision makng in

the facc ofimpcnding risk in complcx ways.

Risk Managemcntin thc WⅥ ld(FUKUSHIMA,Masato)

Research sne and method

2 FOr transcribing andtranslating thc f。 110wing
SCPCntS OfConvcrsation,dctails

Ъ e setting for this rcscarch,HOspittt X inTOuЭ and has abOut

havc bccn changcd to avoid thc

500 bcds in closcd and OPcn wards.■ he rcscarch took Placc from theidcntiflcatiOn of thc paticnts

end Of 1994 fOr half aン ℃ar at an open ward,and from 1996 to 98 at

and thc stafF

both thc Opcn and closcd wards.I宙 sitcd thcsc wttdS m腱 maly once
orれ 、
icc a wcct mainly on thc dγ Ofthe■ vard mecdng.

―
At thc time,cach ward had abOut 10″ ″″′rOOms wherc 6
or 7 paticnts bcd tOgcthc■ At thc ccntcr of cach、 vard■vas a nurse

station,an obscrvatiOn room anncxcd to it,dOctOrt rOOms,a bath,and isOladOn Юoms in closcd wards qhc Patients'daiケ aCtMdes wercorganizcd according to a島 く
ed schcdllc and during the daytimc,a10t
Oftimc was sPcnt on OCCupadonal thcrapy in another building.

A weett Ward mccang ca■ edル グケ(frOm English conferencc)
was onc of the most important rcsources for this stu(与The ward

mcmbcrs,such as the ward dOctOr,nurses,a social wOrkcr,anoccupational therapist,a pharmacist,a diedtian and a clcrk gathered
togcther tO discuss thc PrOblems relatcd tO ward lifc.

Ъ e kanfa usuatt startcd宙 th thc introduction Of ncw patients.
Thcn rcports frOm paramcdicals were f0110wcd by reports form
nurses,cach of whOm was responsible for a r00m fOr appro対S破 Padents.lllere werc dittrcnccs in the sヴ

mateサ

e ofthe Lnas,bcttcen

doctOrs and bcれ vccn Opcn and closed wards.In thc latter,reports
tcndcd tO bc bricf and fOrmdized whilc in thc fOrmett the discussion

tendcd to bc long on a limitcd numbcr of chrOnic PatiCnts.Thc
fo■ Owing casc studics come from Obscrlrations from such wards.

Case one: Everyday co‖ ective devices for perceiving
signs of possible risks
I bcgin my analysis with a possible casc of suicidal intention″ッο)Suicide was onc Of thc gravcst risks that thc ward
σな´ル ″′
staff、 vcrc facing,and the following record Of a kanfZa sho、

vs the、vay in which thc staff analyzed data and diagnoscd coHcctivelメ
Thc difflculり 。
f thiS Casc was that the patient,卜 lr.K,was POOr atcommunicadon so that starwere forced tO gucss frOm circumstantialc宙 dcncc whcthcr hc rcalヶ had suiCidal intentions2.

(26,Aug,94)① A,dOctor of the ward:

ⅣI■ K seems to be idgucd but l dort

Risk Managcmentin thc Wヽ

1ld(FUKUSHIMA,MasatO)

knOwぃ ̲As he cannOt dcscribc his condition through wOrds,wc
I IvOndcr ifhis bad condidon may dcri17c
have to guess ho、 v hcis n゛、

frOm thc fact that his imiヶt。

ld him that hc might ha■ 7e to leavethc hOspital.Wcll,I told him tO hang on tO that thOught,but l am
lvorried bccausc l saw him dashing to a、

vindo、v and t,■ ng to thro■ v

himsclf out and hc hllng On thc rall at thc宙 ndO、 1 0ccasiOnalヶ hc〜

acts impuls市 ely and itt scary② Nurse H:Last morning hc sttd that hc hatcd his hfc,and hc 100kcd
disccrnibけ dCiCCtCd・ So l once tried to put him in thc Obscrvation

room,but hc usualヶlea、CS thC rOOm within 5 minutcs.I am wOrried

about him too.

③ Dr.A: It's truc that hc hatcs the obscrvation room,but it's
impossiblc to watch him in an Ordinaγ r00m.

④ Hcad Ns:lVe■ ,his problcm is scrious.
⑤ NsH:His famlly said that hc had callcd thcm frcqucndy about
his ill hcalth.But it secms that thcy do not knOw that h/1r Iく met his

sister l am also lvondcring what hc shOuld dO abOut thc Occupation
thcrapy.

Then Ns S,、 vhO、vas in his chargc,gavc a crucial piece of
infOrmation which actllalけ dCtCrmincd thc causc ofthc disc■ lssiOn.

⑥ NsS:If l suggest him to havc a rcst,thcn hc answcrs̀well,no,″ ′α″ [Pittcr― PattCr]
I am not tircd'.[.… ….]His footstcps were′ ク
rhcn
hisfootstcps
arc′
Z,hC is in good condition.
as usual.ヽ
クス
ク クカ
〜

′

Actllatt when he■ vas h a bad condidon last dme,his f00tsteps ttК

″″″″[silcntヶ ],and I COuld not hcar thcm.SO I supposc hc is in
a gOOd cOndition.Actualヶ he sり S hC dOcs not fccl tircd.[.… …
]

likc∫

⑦ DrA: As hc claims he's been sleepル I have reduccd thc
mcdication l wondcr if his in condition mγ

havc dcriゃ ℃d from myrcduction Of medication last month.I am nOt quitc surc about thc
rcladOn.SO I wlll try to rcstorc that.

③ Hcad Nursc:WcⅡ I bc■ cvc hc has not been so ill.
As the head nursc ofthc ward concludcd that Mr K was not
so lll,thc scarch cOntinued on a difcrcnt track of thought;at irst it

lvas a sort ofsocioloy of iml,Aftcr talkng a bit about his fZamlしthc head nursc prcscntcd hcr interactional analysis of thc humanrelations in thc、 vard.

⑨ Hcad nurse:Wcl,I would say7 pcoplc mγpct,Or bu■ y or makc

in ofル lr K.If hc Pronounces a■ vord thcn other paticnts saỳShutuP'・

A/1rル l often complains thatル lr K is too noisy;he rcpcats thc

samc thing again and again and peOple feel he's annoying.But

Risk Managemcntin thcヽ41d(FUKUSHIMA,Masato)〜actutty heヽ not bullicd.Hc is simpヶ made in of⑩ NsI:When he was in chargc Ofthc mcal,hc had sOmcthing
going on lvlthン lr L IVas it thc rcasonP① Hcad Nurse:From the grOup of Mr L and Others,Mr K is
thOught tO bc a bit annoying.

⑫ D■ Wcll l suppOsc it will bc criticalお r him when he will nO
10ngcr bc loOkcd」 Rcr by Othcrs,then
Thc rccOrd shOws hOw the staff assessed the possiblc risk Of
suicidal intention collcctivc,ThC dOCtor was not quitc sure about

Ⅳlr.K's cOndition,sO that nurscs added vcrbal clues about his
dcsPcratiOn(② ),and his imiヶ 'S testimow OfhiS frequcnt Кtrcncc
tO his ill hcalth(()).′ rhc coursc of thc cOnvcrsation changed、vith

Ns S's sclFmadc diagnOstic criteria focusing on the sound Of thc
footsteps(⑥ ).物 ″ψ´″,an OnOmatopoeia,can be translatcd as pit
a Pat Or pittcr― pattcら in contrast with

ιクノ
クー
多ク′
αorグ ο
′
″―
〃ο
′
α,thc

lattcr vvith thc nuanccs of hca宙 cr sounds ofwalk.So′ α″ψ″″ iS an

expression of hght sound rcminding us of κlad17cサ Lght WCight.■ c″″uSutty shOws a quict rnOvcmcnt,sho、 ■ng that
Othcr cxprcssion∫ ″″〜hIIr K slided his feet along without li■ 7eliness Ns S concludcd that

Mr K宙 th hisお otsteps lvas in g00d health and this was acccPtCdけ
the other staF A nurse later explained to me that Mr K imprcsscd

the starけ banging the doors and the noisy sounds of his walk whenin good health,so this onomatopoeic diagnosis、

vas undcrstandablc

to thcm too.
If hc、 vas in good conditiOn,thcn■ vhat is thc causcP Rcducdon

Of thc mcdicadon(③ ),thc r。 lc Of his famiし and thcn camc social
interactionism(⑨ ―⑫ ).Thc hcad nursc susPcctcd the possible
intcrvcntionけ M■ L,who was thOught to bc manipulati,but thcrc

was no dccisiル ℃clue for that.In cOnclllsion,the stafF secmcd to asscss
that thc suicidc risk was nOt vcry high in this casc.

As thc rcsourccs for mcdical diagnosis、 vcrc limited,othervariOus sourccs wcrc fl11ly mObilizcd;ranging fronl mcdicinc tO
naI、 ℃―sociology ll■ csc dintrcnt pcrspccむ 、s wcrc accumulatcd rathcr

smoothし but thiS dmc could not draw a try focuscd PicturC Of his
rcccnt instability.Here one of the characteristics lvas the relativelack Oftcchnicaljargon.Nr SもaCCCPtCd as thc̀̀υ ,′̀77εonomatopoeic description were easiし̀'Of his bcing nOt quitc ill in cOntrast wlth

cascs in Amcrican mental hospital in 60も ‑70's where psrhoanaケ tiCiargOns callscd scriOus trOtlblc amOng thc stafF(Stanton&schwartz

1954;Stodand&KOblcr 1965).Thc heterogeneous judgments werc

Risk Managcmcntin thc Wlld(FUKUSHINIA,卜IasatO)smoothly combincd and such cOmmonscnsical descriptions wereseamlcss,intCravined with thc dOctorも mcdic7aljudgment.
So in concluslon,the risk of a suicide attcmpt did not sccm tobe impending,despitc his impulsN、

oudOOk.In fact it was only thistirnc that his scrious thrcat tO suicidc was discussed.But in terms ofrisk managemcnt,this discussion also rcvcalcd scriOus lack Of PrOper

t001s.His impulsivc bchaviOr nccdcd to bc observed cOntinuousl乃
but as G)shOws,thc star could not contain him in the Observation
roonl and the isoladon rooms later described wcrc nOt appropriatc for
prcvcnting suicidc.

Case twoi the shifting nature of risk rnanagement andrisk taking■hc sccOnd case w11l show a diferent typc of risk managemcnt
in1701■ 7ing

a paticnt,M■ M,whO had drastic狙,10St Wcigllt.Just likC

the cascあ ove,it was amcultt。 ■nd Кasons for hs wclght dccК ase
At flrst thc causc was thought tO bc purcly mcdical,and the staff
treated it as such ■hcn thcy gradually changed their diagnOsis andthe inltlatlvc was transfcrrcd tO nurscs and thus thc naturc of rlsk

managcmcnt also changed diachronica与At irst,thc starpragmatictty tricd t。 lct him cat.lllis stratc,ちhO、vcvcち collapsed whcn he started to reiCCt medication.Thc ward

dOctOrs admittcd that thcy nccdcd to ovcrhaul thc trcatment p01icy
c Othcr stafF did
け StOpping all the mcdication pro宙 dcd tO him.■ ■not comment rnuch on the change of strategン

1■he radica1 0verhaul

appeared to work and thc paticnt subscqucntly started to regain
lveight.lhc pcak ofthc crisis sccmcd to havc passcd.Yct his strangc
beha、 lor continued and thc stafF startcd to think that thcre nlight bc

somcthing more than the p,sio10glCal reasons behind it Hお由ange

beha■ 7ior pcrsistcd and includcd acts such as cntcring the isolatiOnroom with his undenvcar doM′ n to his knccs.

At■ rst,the star suspCCted that his bchaviOr had an element of

けStCria,a rarc diagnOsis ofwhich thッ

w℃ re not quite certain.As thc

fou。 、
ving Convcrsadon shows,after the impending risk ofwcight loss,

a new theme camc to thc surfacc.
Ъ c、 vard stardiscussed]ν l■ h/1も diaper and the doctor suggcstcd
that he should bc out ofthc、

1997)

Risk Managcmcntin thc VⅥ ld(FUKUSHIMA,Masato)唸rd whcn hc had cnough timc.(5,Feb,〜

3 /″ ′′as adlcct市 c means① DrB:Hc has bccOmc a bit hkc a baby rcccndy
ο
″―
′
′
え
② NsF:Hct dependent(′ χの③ NsD:Yes,Indeed.

sweet in tcrms of tastc,and.

④

PCrmiSSiVe in tcrms Of Onc's
attitude ン ク′ls a nOun and

DrB:We■ ,then he wil grow uP,I supposc(laughtcr).You knoL

if hc is a baby and dcpcndcnt,naturalけwc宙 Sh he宙 1l grOw up

dcscribcs̀″a mental statc
Of dcpcndency,unrcalistic―
CXPCCtation and s0 0n/″ ′θ(laughtcr).Well,we havc tO acccpt his´ ″″′to a ccrtain dcgrec,Andγ″ as a vcrb means to bc

thcn gradutty wc waitお r his ill grOwth(laughtCr).

dcpcndcnt,but rathcr Posit競 与⑤ NsF:Butthc dimcuり is to what dcgrcc[wc acccpt]″degrecP⑥ NsD:To a″ 物 グ■■
c ncw thcmc was his´ ″″′./″ ク′is aJapancsc tcrm ofPsychO―
cmotion whた h bccamc wcl knOwn thrOugh thc cxtcns市 c semandc
hiatrist Doち whO Cmphasizcd that thisanttysis by the JaPanesC psン ℃

tcrm shows onc of thc kcy clcmcnts ofJapanCSC mcntality./″ク′

can be looseけ tranSlated as dependenc"but as Doi showed,this has

morc positivc connotation unlikc its corrcsponding English word,

dcpcndcnt(DOi 1973)3.
qhe stafFbcgan to rcgard″
ⅣIrル l as″ ″″ ー′″(showing tendency
̀ル′″″usuall1/has aOf´ ″´).Describing someone's behMor as´ ″″凌 ―critic・ al

L/1■οοdcPendent ctc.

nuance,as in thc pcrson bchavcs childish,′

ン1も behavlor was thought to be a sort of regression to that of aspo■ cd child who sought to be cuddled like a baけ

(① ④

)・

■he stF

accepted this framcwork and thc trcatmcnt stratcgy changcd fromrisk management to that wllich was simllar to disciplining a spoilcd
child.

Bcing susPcCtCd as amac,his unintclligiblc bcha、■or kcpt On andthc、 vard dOctor Opcnly confessed that he did not understand thepatientも motivc.■hcお llowlng rccOrd shows how the stafF was at a

10ss abOut his intentions.(25,ル laら 1998)⑦ l)rB:itt good that het in good condition.Has he been eating
thcsc daysP③ NsF:Todり hc t00k orangcjuicc.
⑨ NsI:We■ ,he does not particiPatC[in ward actMtics].ヽ Vhcn hc
comes hcrc[to thc nursc station]hc simpケ lies down...
⑩ DrB:Hc was sprawled out here(lallghter)① Hcad Nurse:Yes,he was down hcrc cvcn todγ!

⑫ Ns.■ Wen,he was appealing to somcthing but l dod knOw what
it was.

⑬ DrB:If he docs not bothcr othcrs,It may bc bcttcr lctting him
down hcrc.
⑭ NsF:Hc is down where it bothers people.

Risk Managementin theヽ1ld(FUKUSHINIA,卜 lasatO)〜

⑮ DrC:Didtt hc gct up again whcn pu did notsγ gCt OutP
⑩ Head Nursc Yes,indecd,hc wOuld get upけ himSClf⑫ DrC:I watched him going to to■ ct and his footsteps wcre■ rm.
⑬ NsI:lVc arc at his beck and call.

駈 cr thc宙 siblc risk Of wcight loss managcd,the dOCtOち

tllC

staff had gradually come tO undcrstand that there was something
more bchind this,whcn his strangc bchaviors camc to the surfacc
of the stafも concern,which、 vas dubbed as α″′′.COmpared tO thc
Flrst casc、 vhcrc thc mobilization Of all thc possible resOurccs、 vas

simultaneous,h ths caseれ vO difcК nt wa17cs ofthought came to thesurfacc One after anOthcr in linc、 vith thc change Of thc perception
Of thc naturc of the risk.In thc■ rst casc,thc vcry naturc Of suicidZal

intcntion was the focus Of thc mystcry story(Brown 1993)whilein thc sccOnd,thc 10ss Of wcight、

vas such an evidcnt symptom thatthe stttF could cOncentratc on its。 たグ
ιル ″′
ク∫
″πιグ
ルク,with risk
managcmcnt policy con■ ncd to mcdicinc and nutrition.
lllings got complicated whcn his strange behavior bccame thefOcus Of c。 1lcctivc diagnOsis.Then the new idca ofク″´′camc to

the surf7ace with the initiativc Of thc nurscs'more cominonsensicaljudgmcnt.As thc dOctOrtiokc On hsク ″α
a fOuowed by an cxplosbnof laughtcr shOws,describing him in tcrms ofク″´′had a very

cynical connotation,compared to describing his casc technica1ly as
regression in psン choanalン tic scnsc.ll■ is is an intcrcsting casc■ vhcrc
thc ambigttilァ

ofthc nOdon ofrisk is bccoming宙 siblc,Ivhich wvill be

discussed irther belo、 、L

Meaning oftools in the face ofthe risk of violence
No、v、 vC■ Vill fbcus mOrc on thc sccond Point,i.e.,tool usc in thecontext of risk managcment.In the、

vard lifc,thcrc arc a couple ofobscrvablc advcrsc events that can bc labclcd as risk,1lke cruptions
Of vi。 lcncc,squabblcs amOng thc inmatcs,attempts of assault On

thc stafF and s0 0n Aside frOm thc cascs shou7n above,the catcgoryof high risk patients could overlap、 vith that of difflcult patients,
including criminal patients AInong thenl,thc stafwcrc aware ofthc
condition Ofthose related to vi。 lcnt behaviOt As thc cOndition lc、 clsof the paticnts could not bc quantincd like宙 tal indexcs,crメ リ

obscrvatiOn of thcir behavior was rcquircd to alroid an undesirablc
incidcnt.

Risk Managcmcntin thc Wlld(FUKUSHIMA,MasatO)

One ofthe maior to。 lS fOr mana」 ng thC risk Ofsuch prOblematicbcha、 iors could bc mcdication.If these problems are diagnoscd as

causcd by thc lvorscning condition of a patient,these shOuld bc dcalt

lvlth changcs of drllgs both in knd and amOunt But in this cOntcxt,
tacit organizational culturc Of a、vard cxcrtcd influencc upOn its
gener7al policyン ledication could bc a tool uscd as a sOrt Of chcmicalstraitiacketけ tranquilizing thc paticntt bchaviOr.But ho、 v far thestaff should treat a paticnt in terms of risk managemcnt dcPcndcd
upon thc situation and thc、 vard policy ttor treatment.

■he dOminant understanding of the stal:either said or unsaid,
was to avoid PaticntS frOm bcing drOwsy duc tO maior tranquilizers

HcDwevet this shared understanding,while certain,COmmcndablc as
a basic P。 11%had its o■ vn dravlbacks.AlthOugll it was truc that the
stafFdid nOt likc

ο ″tranquilizatiOn,what cxactt it mcant to bèo■ rcr'

was in fact situationally determincd.As tl■ c following casc will shO、
whcn a paticnt sho■ vcd cxccpdonal scnsit市i7to thC nOrrnal dosc Of
Psシ chotropic

drugs,thc mcaning of̀Ovcr'bccamc quitc problcmatic.

Hcrc thc tacit assumption about the desired condition Of a paticnt
bcgan to cxcrt its innllcncc on risk managcmcnt policy.

The sccOnd maior rCSOrt for risk managcmcnt was isolationrOOms.A c10scd ward had 5 isolatiOn rooms,which in Japancsc arc

ο―
∫
力
′
′
″(litcr州 け:prOtCCtion room),or in Japancsc mcdicalca■ cdら gο

iargOn,z′ //F(from Gcrman,mcaning thc ccll).Thc star usually
paid scriOus attention to violent behavlors giving allnost uni【ormtrcatmcnt to PatiCnts rcsPonSiblCお r such acts by putting thcm into
an isOlation room immediate与I witnessed a numbcr of occasions whcn thc staff rushcd tothe place■ vllcrc a violcnt act,usually a small quarrcl,occurrcd.In
the worst sittlations,to avoid Possiblc risk,usualけ

malc nurscs wcre

summoncd to the scene Arr、 ■ng at the scene,qucstions、 vere asked
in a brief but stcrn、唸らand thc pcrsOn in question was rcqucstcd to〜ン

go to an isolation room.Thc entire proccdurc wOuld rcscmblc that
Of an arrcst of an oЯ endcr by the policc,if it lvcrc、 vitncsscd without
kno■vlng hs background.

The omcial discOursc Of thc staff at this Point,however9 was、aried and a bit con■ lscd.Onc Ofthc most o■ en stated̀reasor to put咀a宙 olcnt padcnt into an isolation room lvas to calm thc paticnt do、 〜.

But things bccamc lcss pcrsuading in the quite frequent case of、■olcnt quarrels,Ivhen thc stafFrcachcd thc sccnc and thc disputc had
狙κaウ been scttlcd and thc ptticnt had rettlrned to a state of dm.

Risk Managementin the Wlld(FUKUSHIMA,MasatO)Bchind this dctcrmincd attitudc of thc stafF cOnccalcd the inessage
that宙 olence was not a■ owcd in thc hosPital SO this swift procedure、
vas intcndcd for thc Patient to learn the lesson against v■ olcncc inthc hosPital,0ちmOre fonvardヶ put,tO punish them.

Thc very ambiguiり liCS at this pOint.FOr thc is。 latiOn room tofunctiOn as a risk managing dc宙 cc,it should wOrk as a lcarning tool
for patients to undcrstand̀why'thcy wcrc put thcrc.Ъ

c f0110wing

cases wi■ show tllat this is far frOm rcaliり ;and thiS als0 1cads to show

thc ambivalcnt nature ofthese risk managing de宙 ccs.

Case three:a difficult patient and the linnit of tools.

■■
crc were a couplc of cascs thOught tO bc difncult by the star
where this dilcmina camc to thc surface.Mr N was Onc ofthcsc
cases:when hc was frantic,no bundle ofrnalc nurscs could stoP him・

■ c grcatest worry of thc staf was the securi7 during thc night as
マl His symptoms
thc numbcr of thc nurscs on night shift、vas tOo■ 、also drcw cOncern for thc staff as his delusion seemed to dcvc10p
stcadiけ and he。

■en claimcd that mcmbcrs ofstafFhad atackcd him.

This cOuld provoke a dcfcnsivc rcaction on his part and hc、

vOuld

attack stafF in rctaliatiOn.So the stafFwas usualけ 負野 alert as to his
rcactlons

Yct his casc,as well as other examplcs not shown hcrc,rcvealed
thc limitcd a■ 7allabiliり of thC practical tools of risk managemcnt.In

偽ct sOmc of thcsc paticnts had a rathcr idiosyncratic scnsitivity to
mttOr tranquilizcrs so that the standard dosc madc thcm dr、 w andinacti■ 7c.Herethe risk managcmcnt pol19 was cOnfronted dircc寺

宙 th thc organizadonal culturc which tacl寺 pre■ 7ented the staffrOm
overdodn3 aS thC Stardid notlikc such drO、 ■incss,thOugh,in tcrms
ofdosage,thcirs was thc a、 crage dose for othcr paticnts.

Without medication,thc staff realized that there、

vas notmuch to bc done tO control such violcnt tcndencics fOr thc
riskicst.Therapies,cithcr rccrcational or occupational,wcre
mainly for rcinvigorating inactive paticnts and not cffcctive forcurbing dcveloping dclusiOns The ward doctor's mcdical in―

depth

consultatiOn did not sccm to bc success■ 1l at all At the kanll,thedOctOrs Often rcportcd hav they avoidcd rcqucsts frOm such PaticntStO be discharged from thc hosPit狙.

Nurscs also found thcm hard to communicatc with.A nurse

Risk Managcmcntin the lVlld(FUKUSHIT4A,Masato)

in chargc of Ⅳl■ N witncsscd that this techniquc Of cOnvcrsationalsoothing did not work wcll with Paticnts of his ilk,

becausc themore l tヮ to s00the himけ talkng c・ alml17 and paticntし thC moreagitated hc gcts,and his Own excitcmcnt further stirs the cmOtiOn.
Itヽlikc a viciOus circlc''.qllus Oncc in a kanfa,thc dOctOr wanted thc

occupational therapist to trcat thc paticnt,but thc latter talkcd backSγ ing not to expect too much frOm the therapy As a result,the stF
adOptcd the strategy of changing the level ofthc PatiCntt rcstrictionof beha宙 or to crcate thc impression that thc paticnt was gradualヶfrccd frOm thc ward.

Case four:the rnoral basis ofisolation rooms■he ve7 1ast rcsOurce of managing the risk Of vi01ent acts、 vas
thc is。 lation room■hc multiple uscs Of the isolatiOn r00ms arc wcll

documented in Uchimura&Yoshizumi(2002)and in HosPital
X,similar prOblems、 vcrc obscr■ /ed.Thcsc rOOms wcrc usually■ lヶOCCuPied by hcavily lll(and Oftcn dittcult)paticnts,stγ

ing thcrc fOr

a10ng timc.Ⅳ lanaging thcsc r00ms in ordcr tO have a spacc for acutc
padcnts was onc ofthe d猛 ヶ chOreS Ofthe ward st証
lhe ambiguOus nature ofthc role ofisolatiOn rOOms can bc sccn
from its vcヮ

namc.π ?″ ―勁竹″(lit protection roOm)is ambivalent

in thc sense ofwho is protected from whOm.■ he fOl10wing case thus
revcals this prOblcmatic aspcct of it as a maior riSk managing tool
MiC)was Often Put into an isolatiOn room bccausc of his repeatedviolent behavi。 ■Hc exPloded again and this timc hc hit a cOuplc

Ofinmatcs so strongly that one Of them had thcir teeth brOkcn.In a
kanfa,thc ward doctOr cxprcsscd his doubt if thc patient undcrstoodthc meaning of bcing put there,tO which nurses agrccd.(3,ScP,
1997)① DrB: AbOut Mr.0,yOu knOち hOw many times in this year
」reaⅢ …
② NsT HchitⅣ I二 A and MI B and.¨③ NsS:What shall we dO ifhct out ofthc is。

latiOn roOmP④ DrB:Wc have to Put him backin,thcn.
⑤ NsS: Wcll hc 10st memory and now again hc's got mOrc
distanccd from his ttmilン We cannot ask thcm to acccpt him.

We cannOt rcqucst too much of his famlly[followcd by minutc
cxPlanation ofwhat hc did to his inmates]

Rttk Managcmcntin thc Wild(FUKUSHIMA,MasatO)

⑥ DrB: Next timc wc should PrcscribC a dcposit illliectiOn or
somcthing.But wc cannOt control him with il■

icCtiOns On与

[・

……・

this、 vas followcd by a discussion on how long he would bc putin thc

isolation room]⑦ Ns T Shall wc say to him that as his stりin thC isolation room

w11l be long,hc shOuld takc carc Of the laundryP(laughtcr)Hc lvill
hit me(laughter).You said it,hc wOuld say.I am scarcd.

③ DrB:lmcn l wil say lttO him this week.
⑨ NsT OK.

⑩ DrB:「Lc rcason wけ he宙 Ⅱhave to stγ for a long dmc is thc
protcction ofothcrs.It is not rcally to curc his Own illncss.TO prcvcnt

others from bcing damaged.

⑪ NsB:Wcll,pu knOw91 wOuld sγ that he cannot rencct on his
acdons,or itt his symptom⑫ DrB:Itt his 11lncss..
In this fragmcnt of conversation at the kanfa,the stafF discusscd

thc pOssible mcasurcs against his violcnce.TIvO possibilitics,such

as scnding him back to his imily(⑤ )and mcdicatiOn― deposit
itteCtiOn― (⑥ )■vcr thought tO bc inerecい に so the isoladOn room

wOuld bc the last resort and thc paticnt、vas cxpected tO stay thcrc

fOr a 10ng time(⑦ ).■ om ⑩ to ⑫ ,this is a rather rarc,but blunt
discussion of thc rolc of thc is。 lation room,not for treatment but

fOr sccur17 0f Othcrs.I bclict that these statements rather Openヶadmitted thc ambiguOus nature of thc isOlatiOn rOOm as thc lcarningdc宙 cc for patients.It is truc that in somc cascs,it was reportcd thtt apatient lcarncd thc lesson ofbcing thcrc,but in this casc,this did nOt

happen.

Case fivei the reflected rneaning of the isolation roomln contrast to thc casc abolrc in which the role ofisoladon rooms、
vas concci■7cd ofas risk managing and disciplinary tool,thc fOl10■ ving
discussion■ v11l sho、 v thc stafF's rcaction to such a formulation.■ his、
vas the year whcn a series of violent ro、vs in thc、 vh。 lc hOspitaloccurrcd and subscqucntly long discussions on how to dc・

al with suchsituations lvcrc hcld.lllc dOctOr rcpcatedly emphasizcd that the staf

had to dcmOnstratc to the patients that宙 olcnt acts wcrc absolutcけ
forbiddcn.But the ambigui7 of thC use of the isolation foom宙宙s this mOtto was clarincd in thc case below(7,Oct,1997)

Risk Managcmcntin the VⅥ ld(FUKUSHI14A,Masato)s― a―① Hcad Nurse:What should thc nursing stafFdo about this[casc of
宙。lcncc]P A dtlり dOCtOr mげ ask,̀usuatt what、 vOuld Pu do in thiscasc on this wardP',Sometimes l feel like ans、 vering,̀wcn,if he is insuch a condidon nowЪ itも OK[not tO put him in an is。 lation room]ちbut atthc samc dmc l think itt vcヮ impOrtant to ttκ the framcwork

notof̀宙 olence is absolute forbiddcr,and l bclicvc,in any case,itもacceptablc to resort to violcncc.It is not that、 vc punish,but at least、ve have to make it clcar that wc thc ward stafthink like tllat.[..]② NsF:Itt tnlc that wc dott like to usc is01ation rOOms cxccPt fOr
the worst cases.… V/ell,but vi。 lcncc Or Othcr things arc absolutely¨.If wc havc uscd mcasurcs llkc inicCtiOns or straittaCkets in thc
obscrvation room,and、 vc havc succccdcd to a ccrtain lcvcl ofmanagcmcnt,but if a rctt flght Occurs,and if both arc rcsPonSible,
thcn l bclicvc thcy shOuld be put in an isolation room even for a
wcck.Thc point that l likc tO strcss is that in thc casc ofン lr R I
cannot caslケ sγ tl・ at hc should bc in thc is01atiOn rOOm.

③ D■ A:Wcll,pu kl■ o、 thcsc du7 doctOrs changc c17c"辱

andcach doctor has his own standard ofjudgmcnt,and wc cannot sりthat̀if thcrc is a quarrcl,cvcryonc should bc put in the isolationroom④

Hcad Ns: N。 ,wc can't Say that.But at lcast it should bedcmonstratcd that in this ward宙 01cncc is absOlutcヶ fOrbiddcn.

This is a fragmcnt of a mcandcrcd discussiOn on thc dilcmma

bc印、cn the motto of anti― wiolencc in the ward and the hcsitadon ofusing the isolation roonl as a punishing t001.Evcn thOugh the doctOr

rcsistcd the idea of putting someOne into the isolation rOOm in aquasi‑lcgal rcspOnse to violencc in this discussion,in othcr cascs thc

same doctor、vas rcported to order to put vlolent paticnts a、

vay almost

グ
″″′
グ′
ク″ク a■ er a squZabble.
In comparison lvith Dr B in case four tvherc he statcd so dcarけthat isolation■ ooms、 vcrc for prcvcnting fllrthcr victimization of

Othcr inmates,IDr A abOvc did not likc such blunt formulations,at

thc samc dmc,he did not deny the disciplina7 inction ofthem forcominunicating the message that violcnce was not auo、 ved ln fact,
the inction of an isolation roOnl、 vas dclicatcly balanccd bctvccn
a to01 of isolation for trcatincnt and onc of cxPlicit punishmcnt
likc a prison ccll.It is here that the ideal of treatment and、 vard
culture sho■ vn abolrc prcК ntcd tllc staf frOm a sOrt Of i■

scalc risk

managcmcnt,as sho、 vn in the case nve,the very mcaning of isolation
room was occasionally under renectivc scrutiny2 thrOugh、 vhich thc

Risk ⅣIanagcmcntin thcヽ41d(FUKUSHINIA,MasatO)〜4 For descrlbing Patlcnts
worscning condition closc to a

PoLcy intendcd for maximum sccuri7 was aCtllalケ

not a■ 。
.ved.

℃rc
ν
■
olcnt outbreak,elc looks、 マ
oftcn Pickcd up and dcscribcd

之′′ えο
っ′′(scary eras″ あ ″
αえ″(cyCS
100ks)or″ ′g″ ∫′ηえDiscussion and concluding remarks

arc triangular)in linc withthe above mcntloncd footstcp
diagnosis

Assessing and managing risk is a vc[/COmplcx cultural bchavio■

The pOints Of this PaPcr arc conccrncd with analyzing it in theeVerメ リ COnteXt Of ward lifc.COnccrning thc Arst point of the
distributcd and collective nature of risk perception,I havc shOwn inthe■ rst and sccOnd case a couplc of difFerent patterns Of rnobilizing

possible informatiOn to analyzc thc distributcd naturc Of risk
PCrCCption,thc rangc of its mObilizatiOn,and its relation with group

ウ namiCS among stafFmcmbcrs.
Attcntion should bc Paid tO thc importancc of the situational

diagnostic critcria in thc form Of OnomatopOcic mimicry of thefootsteps,facial cxpression and eye looks4 shared and undcrstOOd
by staff of differcnt profcssiOns,in contrast with,saン

ちsOmc ofthc

troublcs with thc isolationist naturc of thc Psン ℃hoanalytic languagc

obscrved in classical mOnOgraphs on mental hospittts in posれvar US(Stanton&schlvartz 1954;Caudil1 1958;Stodand&Koblcr 1965),
In this cOntext,Bare■ ヽcthnographic account Ofthc languagc used,
the psン chiatric tcam in an Australian menttt hospitral showed a richrcpcrtoirc ofsimilar colloquial cxprcssions such as̀nOtッ vith ittbut of
his trcc',̀high Lkc a kite',̀o∬ ',お r dcscribing thc dcgrcc of Patients'

conditions(Barrett 1996:147‑8)or̀stropFy',̀quiet',̀iagilc'abOut togO Of'in cascs of宙olcncc(Barrctt 1996:82).
A large amOunt ofthese expressions is intercultur」

販 translatableーand Barrctt tended to cmphasizc thcir solidariリ makng function
among thc team(Barrctt 1996:167).As it is hard to dcny such àfunction′ ,I vvill add emphasis to thcir cognitivc,situatcd naturc,

which is esscntially parallel to the cascs studicd by rcsearchers On

situatcd cognition,such as strcct mathcmatics in Brazilian child
traders or arithmctic in grocerv shopping,Ivhich wcrc far fronl theorthodox arithmetic PrinciPles taught in scho。
vc7 crcctive for practical purposesグ

1,ン℃t were shown tO bc″∫
グ′″(Nunes ct al.1993;Lave

1988).Risk percepdon in thc、 唸rds was deepケ based on this simatcd
naturc ofcognitive activitics.

Thc second Point Of tool usc was most clcarly pointed in thecase of■ 71olcnt bchavlor ofpaticnts.,A cOuplc of preventiゃ℃mcasurcs

could bc mobilized against vlolcncc in the wards,such as medication,

Risk卜 Ianagcmcntin the WVlld(FUKUSHIT4A,Masato)therap乃 observation and isolatiOn rooms,but in cach case there
was a sort of ambiguity in the scnse Of its Practical cffcctivcncss
and cthical lcgitimacメ I fOund that the veっ′use Of thCsc tO。 ls was

decPly restricted by the background hypotheses of thc ward staras to thc cxpcctcd condition Of Paticnts.To articulatc this POint,Iwill cite an interesting dialoguc bcavecn thc hcads ofれ v01cading
rcfOrmist hOspitals in Japan in thc 60も(Scnba&Ishikawa 1983).In

this dittOguc an intcrcsing cpisodc■ vas introduccd:thc stafF of cachhosPltal mutu山 宙sited and obseAred everメ リpractiCes in thc Othcr
and found they Werc quite difcrcnt.In onc hOsPital,it sccmcd that
too much cmphasis was put on insPiring Paticnts'PartiCipation for
cvcnts in hospit狙 ,which theャ isitOrs lound t00 artincial.In rcturn,thc othcr hospittt was fOund to bc too quict.GrOup activitics of thepatients wcrc minimal as comparcd to thc■ rst hosPital,and genertty
thc imprcssion was Onc Ofstagnation.

Thc diffcrcnccs came frOm thc background hypothcscs hcld
by thc staff about thc idcal imagc of thc paticnts,which can bc
tcntativcly labeled as the organizational culture of a ward Or a
hosPital.In this scnsc,thc staff Of HOsPital X largcly sharcd thc
former's understanding,1.e.,preferring reinvlgorating the patients toletting them rest.In the context of cognition/1aw7 it was not exPliCit
rulcs or manuals but this organizational culturc that cxcrtcd in■ ucncc

upon the、 喰y thc various tools of risk lnanagcmcnt lvcrc used.In the〜cascs shown abOve,thc use of rncdication and isolation rooms wasКpcatcdケ prOblCmadzcd in linc宙 th such tacit undcrstanang。
■ is cOmplex restriction to the tool use is dccpヶ

related to thethird Point Of thC dual aspccts of thc mcaning of risk.As has bccn

POintCd Out,risk taking rather than risk managcmcnt、

vas once

thOugllt to be moК important in the areas relatcd to educadon andwcrarc.E17cn in thc case of宙 。lencc,maximal risk management was
not retty thc option of thc ward stac and thc usc of thc is01atiOnroom lvas tainted wlth ambiguit′as tO Wllcthcr it■vas for punishmcnt

or cducation.

Thc second case was a good example to shcd light on thc
JanuS‑1lke aspect of thc nOtion of risk.Judging somconc cithcr
to bc medically ill or to bc″″″′makcs a diffcrcncc in thc staff's

understanding of thc naturc of risk.Diagnoscd as thc fOrmcr,
thc staff would tend to a17old negativc risk,but as thc lattct thcy
would cncouragc thc paticnts to′

クえ′risk for icarning to be moreautonomous(mcaning mOre adult).In f7act,thc sitllatiOn rcsemblcs

Risk卜 lanagemcntin thc VⅥ

ld(FUKUSHI14A,MasatO)the cases of chidrcn宙 th LD(Hcyman,Hucklc&Hanゥ sidC 1998:

211,Corksh 8c Hcyman 1998:221).Ъ c difFcrcncc,thcn,is that inthc casc Of my studtt the change Of the undcrstanding Of ncgativeand POsitlve risk was applied to the same person and organization狙

ψnamiCS Ofthc starchangcd diachronictty ln linc宙 th th changc
OfdiagnOsls.

Such complcx rclatiOn bcれvccn cognition and Organizational
dynamics in thc ward lifc invitcs us to comparc this case study
with thcsc of HROt with high safcty pcrformance.Onc Of thcir
important nndings was that a smOoth shift Of Organizational stメ

efrom a rigid hicrarchy during ordinary pcriods to thc tcmporary
dclcgatiOn of authOriサ tO the bottom that actual,perfOrmcd thc
riSけ task occllrrcd in times Ofcrisis Ъe Berkclッ team bCliCvcd that
it was such smooth shift of organizational structurc that was thought

to be onc ofthc mOstimportant souКes oftl■ c high rehabili7 0fSuch

organizatiOns(LaPorte&Consolini 1991).

■his kind Of shift can bc also observed in thc wards,cspccialけin the flrst and second casc,whcrc thc changc of thc diagnosis on

thc Paticnt from a medical to a more psychological pcrsPcctiVCcorresPondCd With thc way thc collcctivc wcb Of diagnOsis、 vas
mobilized,and、 vith thc shifting of the initiativc fron■thc doctors

to nurscs or ParamediCals lllis nexible shift was one of the featurcs
that allo、 vcd ward staff to collaborate smoothly according tO thcchanging conditions.But as l havc tO point out,this sm00th shift

was not always guarantccd and in sOme cases,such a shift cOuld
develoP intO a rathcr clcar confrontation bcれAs far as l obser

vccn thcsc Lvo modcs.

d thc act市 itics of thc ward statt noticcable rifts

among thc staff、 vcrc vcry limitcd in number,M/hile mcdical andmore commonscnsicaljudgmcnt on a certain patient difFered sharpケ
among the doctors and thc paramcdictts
SO it is nOt the smooth shift of Organizational c01laborationthat makes a difFcrcnce beaveen the HRO cases and the Psシ

chiatric

ward,but is the vcry undcrstanding of risk and safety that diffcrs
substantially′「

his is lvhere the wisdom of the■ IR()studies is notdircctly translatable to thc rcscarch in mcdical anthrOpology■
thc vcry notion of safeサ

1・

vhcrc

e.,low frcqucncy of accidcnts,should bc

counterbalanccd with the contestablc natllrc ofthc̀risだ

ln other words,thc HROも

Ofthe、 vard

madc it a rulc to search intcnslvcヶfor thècausc of the possible accidenピ、
ヮ
ithOut much scl「 reflect市cregarding on thc meaning of risk bccausc it、 vas so scl「 cvidcnt,whilc

Risk Managcmcntin thc Wild(FUKUSHIMA,Masato)

in thc psン ℃hiatric ward,thc scarch of thc̀causc'、 vas morc liinitcd,

accompanicd、 vith occasiOnal scl← rcncction on thc meaning of riskin the ward.This is prObably the very nature of risk managementin mcdicinc at largc and Psychiatry in particular,、 vhich requires
both the intensive search of thc causc of the troublcs´″″sclf―rcncctN、 scarch of thc situated mcaning of risk as such.Ъ is dOublc

requirement,howeveち may causc continuous dil五 culサ in practicing
risk management in such cOntcxts,as the vcry strategy itself inay
mcandcr according to thc change of the mcaning of thc targct itsclf
causcd by thc continuous self― rencction ofits sitllatcd mcaning.

Now the meaning of risk managcmcntグ η′″ is rcady
み′リグ
tO bc clabOratcd.Hcrc励 ′ωグ〃 mcans̀lcss domcsticatcd'by thc
cngincering notion of risk and risk managcmcnt,which seems toexert more and morc innucncc upon thc exPanding empirc of risk
analysis.The period of my rcscarch was appropriatc to observe thelcss domesticatcd form of risk managcmcnt as thc t001s of risk

managerana,SiS and specializcd staff llkc fOr cxamplc thc safeサwas yct to bc introduccd tO ward lifc.In part,効 ιω′″ mcans a
sort of impressionistic and c。

110qulal way of risk pcrception andcommunication、 vhich、 vas rathcr smoothly amalgamated with thc
morc prOfcssiOnal,mcdicaljudgmcnt and discoursc.

The Other aspect of the risk managcmcnt in thc、 vild is theindamcntal ambi2vitv ofthC natllrc ofrisk and risk managing tools
in PSrhiatric contcxt.Unlikc the enJncering notion ofrisk in which
the target is clearly dcflnablc in thc casc Of thc HR()'s,thc vcry
notion of risk and t001s in ward lifc is al■ vays cOntcstable in practicc.

Furthermore,the second― order renection upon the meaning of risk
might jcopardizc thc nrst ordcr practicc of risk management,as the

おrmcr could dcstabilizc thc vcry targct of risk control,and mightparadoxiぬ 野 Clrcn incrcasc thc 17cry risk through sclFrcnection.

グσ´万οπcan be deined in a cOuplc Of ways.
Consequentし あ″ ′SuPcrflcialltt it signiflcs thc intrOduction Of a quantiflcd notion ofrisk calculadon、 vith risk analysis tools lt is stil uncertain ifthis leads
to thc climination Of thc imprcssionistic and colloquial、

vay of risk

perccPtion and communication,but one of the imaginablc changcs

mγ bc that thc esscntial ambiglliり 。f risk in thc mcdical icld mり
bc rcplaccd with nOn― cOntcstablc,Inanualizcd nOtiOn Of risk andSafCり Where the instabiliり of Situational deflnition of risk can bc
climinatcd.

■hc sign Of such a dOmcsticating proccss is rcportcd clscn7hcrc

Risk Managcmcntin thc VⅥ ld(FUKUSH114A,MasatO)

5 Such a tcndcncy iS mostclcarly sccn both in thc
Govcrnmcnt policy and thc

in rcscarches on mcdicinc.A cOuplc Of cthnOgraphic accounts ofdcvcloPment Of thc societies

impact of managcd care(Robins 2001,Kirschner 8c Lachicotte 2001)

conccrncd with mcdical safcリOnc Of thc oftcn Obscrved
scencs at thc confcrcnccs ofrecent developmcnt in American ps)chiatry showed the undcniablc
or even Wal卜4arting process where thc prcssure for OTPs(OPdmal
Trcatmcnt Plans)and stratcgics of rcsistancc by thc staff wassuch socictics is thc lccttlrcs of

dcscribed(Donald 2001).lhis prOcess of standardization has bcgun

thc spccialists of risk analysis

tO shOw both simllar and difFcrcnt cgects on thc scene ofJapancsc

and safcty mainly from suchindustrics,usually bclicvcd tohⅣ c dcК lopcd morc srtCmatiC

mcthods of risk managcmcnt.

Simllar prOccsses in Japanese mcdicinc arc oftcn regarded
Publicヶ as prOmising,bccallsc if the risk managing process is more宙sa宙 s hcalth carc
6

mcdicine and Psrhiatrプ

rationdizcd,it is thought that paticntt satり 宙I be incrcascd.But■s suPPOrtcd]his rcscarch、 マby G10bal Communication
Centcr Of thc lnternational

thiSり pe Ofundcrstanding clearヶ miSSCS tllc impOrtant aspcct ofrisk

managcment in mcdicinc and psン chiatr"which is thc fundamental

Univcrsity of Japan and thc

ambiguity of the situatcd mcaning of risk in such a contcxt,and

dcpartmcnt of nursing of thc

thc possible dangcr if that was substituted with thc simplifled andHospital X ⅣIy thanks arc to

fOrmalized dcflnition of risk borrowcd from airlinc or nuclcar

the paticnts and thc ward sta二cspccialけ●VO HCad Nurscs ofcommcnts,to Fabio Gtti Oftl■

industryln this scnsc,how far and what kind Of cOnflicts emcrgcs inthc wards for their suPPOrt ande

Un市 ersitv Collcgc of London

thc proccss Of the domcstication of risk managcmcnt in the wildけ

for his hclpful commcnts,andthe cnginccring notion of risk rcmainsシ ℃t tO be seen.But l dOrt

tO Toby ⅣIosclcy for kindly

bclicvc that it、 vill bc a sort of uniliniar process of rationalization,corrccting English

as thc task of domcstication requires to translatc thc sclf―

rcncctivc

t′z into the form of manuals andpracticc on the meaning of risk′ ″∫anttμ iCal tools.I am nOt quitc surc■ vllcthcr this is a simplc casc Of

ι″管
contradiction in terms,or a case of succcssil dmcctica1/ψ ′of contradiction.But at lcast l like to underline that the very
ambiguiり of thC nOtion of risk in thc ward lifc is at the samc timc
the vcry strcngtll of thc Psrhiatric PractiCe,as it rclcndcssヶ requests
reflcction of the practitioncrs about the very meaning of、vhat they

are doing,Ivhich l havc tricd to dcscribe in this papcr6.

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