Choose Psychiatry

In the UK in recent years, the Royal College of Psychiatrists (2023) launched its ‘Choose Psychiatry’ campaign to improve recruitment into psychiatry. Its answer as to why studentsshould consider psychiatry included having a huge impact on lives, working through new challenges every day as a team, working in a range of settings, having the ability to do part-time working, participating in growing scientific knowledge, and enjoying the high prestige associated with the profession.

In the last few decades, there has been a strong push to portray psychiatry as applied cutting-edge neuroscience (Insel and Quirion, Reference Insel and Quirion2005; Schildkrout et al., Reference Schildkrout, Niu and Cooper2023), often in the context of trying to improve recruitment and retention. In that vein, in the UK the Royal College of Psychiatrists’ Gatsby/Wellcome Neuroscience Project has been set up to carry out much-needed modernization and improvement of the neuroscience curriculum and to connect trainers with neuroscientists and the most recent developments in the field. Although this coincided with improved recruitment figures, it is hard to be certain as to what caused this. There were a number of other initiatives at the same time; for example, medical student psychiatry societies have sprung up in many medical schools (e.g. Pandian et al., Reference Pandian, Mohamedali, Chapman, Vinchenzo, Ahmed, Mulliez, Bruce, Burn, Korszun and Tracy2020). Regrettably, and in line with the general trend for decline of investment in the humanities and other non-STEM (science, technology, engineering, and mathematics) subjects worldwide (Goldstein, Reference Goldstein2021), we have seen much less of a similar, well-funded and centrally coordinated effort to improve the coverage of any of the other constituting elements of psychiatry, such as psychotherapy, social psychiatry, or the medical humanities, to name but a few. The social sciences, with their emphasis on phenomena above the individual level, help to anchor psychiatry in the right place in terms of its focus and prevent it from moving too far in the direction of neuroscience (especially parts that are irrelevant to psychiatry’s subject matter). The natural sciences, although clearly important, are but one pillar on which the clinical and academic branches of psychiatry rest. It is important to note that not everyone who is drawn to psychiatry is interested in genetics, molecular psychiatry, brain imaging, or computational psychiatry. Also, if we as a profession focus on attracting only those who are, we are inevitably going to steer the specialty into one arguably very narrow direction. This may risk not only seriously limiting the potential of our profession to advance our understanding of mental illness and developing treatments for it but also, crucially, losing our identity. Cogent criticism of overreliance on biomedicine and psychopharmacology in psychiatric training has been articulated, highlighting that ‘there is a real danger that psychiatric residents are being trained to become psychopharmacological technicians rather than humanistic physicians’ (Paris, Reference Paris2005, pp. 113–114).

Psychiatry – lying at the intersections of neuroscience, psychology, social care, sociology, anthropology, philosophy, and law – occupies a unique position in that it behaves in some respects as an exact science but in other respects as a so-called inexact science. Whilst in the exact sciences there is an expectation that a problem has one correct explanation or solution, in the inexact sciences this is not so, and multiple perspectives or interpretations are not just possible but often desirable or essential. In psychiatry, perhaps even more so than in other specialties, it is often the case that one can choose from a variety of clinical approaches which may all lead to the same outcome and it is difficult to say that one approach is better than the other. The preclinical science subjects, mainly including natural sciences as opposed to social science and humanities subjects, prepare medical students more for the ‘only one solution can be correct’ type of thinking. Clinical training primes students for some of the skills required for handling uncertainty and unpredictability, which is inherent in medicine, but these skills would be much less honed at that stage. This makes it less likely for students to choose psychiatry.

In the current climate, psychiatrists are increasingly under pressure to see patients only once (typically for an initial assessment) or infrequently (e.g. specifically for a medication review) and to adopt a multidisciplinary approach whereby much (if not most) of the contact is delegated to other professionals, most often psychiatric nurses or psychologists. This creates a problem for psychiatrists as seeing the patient only once or for a limited number of times offers only a cross-sectional view, a snapshot; at best they have a limited opportunity to get to know their patients as people, which was often why they came into this profession. It is also hard to remain part of the therapeutic dialogue with the patient this way. If this is the working mode that medical students and psychiatric trainees see, it can discourage them from choosing psychiatry, especially if developing a deeper understanding and building a therapeutic relationship with the patient was an important motivation for them to come into psychiatry.

Importantly, both recruitment and later retention can be affected by what psychiatrists feel they are expected to manage. Most psychiatrists, for example, feel that it is their responsibility to prevent highly unpredictable events such as patient suicide and also feel pressured by others to do so whilst knowing that suicide is only preventable to some degree (Gibbons et al., Reference Gibbons, Brand, Carbonnier, Croft, Lascelles, Wolfart and Hawton2019).

But it seems that, at least for now, all is not lost. In the UK, it has been recognized at the highest levels that meeting future patient demand will require more psychiatrists (GMC, 2019) and that freshly graduated doctors need to have more exposure to the specialty at foundation year level if shortages are to be reduced (HEE, 2020). There are some positive signs that interest in psychiatry among medical graduates may be improving. The GMC Workforce Report described, ‘after years of stagnation and decline’ (GMC, 2019, p. 4), a small increase (2%) in the number of doctors in psychiatry training, and according to the Royal College of Psychiatrists (2019, n.p.), in 2019 the number of junior doctors choosing psychiatry was ‘at an all-time high’, with 92% of the training places filled, which they associated with an increase in public awareness owing to more investment into mental health services by the government and the College’s ‘Choose Psychiatry’ campaign.

Working in Psychiatry

The change over recent decades in how clinical psychiatry is done has been tremendous. In his editorial in the British Journal of Psychiatry, Martin Deahl laments the pressure from managers and the ‘veneer of quality improvement while at the same time witnessing services unravelling’ (Deahl, Reference Deahl2023, p. 2). Indeed, funding for core services becoming increasingly insufficient is a major obstacle to providing person-centred care. Today’s psychiatric trainees socialize into a profession struggling with underfunding and resultant supply–demand mismatch characterized by chronic staff shortages and long waiting lists (Punton et al., Reference Punton, Dodd and McNeill2022). With the reduction of inpatient bed numbers, it is now only the sickest who get admitted, if at all. Admitting patients for longitudinal assessment or for a change of environment has become a luxury hardly seen anymore. Patients nowadays can only spend a very short spell on the ward, sometimes as brief as a few days, before they are back in the community, often under the care of an extremely overstretched crisis resolution and home treatment team. Care is spread very thinly, allowing little time to really get to know the patient.

The way consultant psychiatrists work has changed tremendously too. Joel Paris (Reference Paris2005, p. 112) describes how Heinz Lehmann, whilst addressing the Canadian Psychiatric Association in a lecture in 1985, argued that psychiatrists ‘needed to change their role from that of expert psychotherapists to managers of acute and emergency care, and to carry out less direct treatment by becoming consultants to the mental-health community’. In Lehmann’s vision, psychiatrists would not need to have much knowledge about therapy but would have in-depth knowledge of psychiatric symptoms. Paris (Reference Paris2005, p. 112) wonders if the pendulum has swung too far and psychiatrists are becoming ‘DSM robots and pill-pushers’. This is not hugely dissimilar to the ethos of New Ways of Working (NWW; see CSIP and NIMHE, 2007, p. 12), described as ‘a cultural shift’ involving rethinking values, in that many of the psychiatrist’s roles would be taken over by other, non-medical members of the multidisciplinary team (MDT) and the psychiatrist’s involvement in the personal, daily therapy would be more light-touch. Unfortunately, the second half of Lehmann’s prediction may not have materialized so much. What appears to be required of the psychiatrist nowadays is not so much increasing diagnostic knowledge and skills; on a practical level, it is information technology (IT) and admin skills that seem more and more relevant. There is a conflict of values implicit in these new ways of working: primarily management values versus clinician values. The declared drivers of NWW include relieving the psychiatrists with very high workload (and reducing the need for a very expensive locum psychiatrist workforce) by shifting some of their tasks to non-medical colleagues, for whom these activities might represent development opportunities, and thereby improving the sustainability of already overstretched healthcare systems. Although psychiatrists are trained to be therapists (and therapy is meant to include a broader concept here than just psychotherapy), the implementation guide is clear about the expectation that ‘[a]ll consultant practitioners will have to prove they are worth the investment made in them, and they will need to be flexible and adaptable in their roles in order to achieve this’ (CSIP and NIMHE, 2007, p. 23).

Another important emerging issue is the strengths and weaknesses of IT. Notwithstanding the clear advantages when it comes to pulling out data for managers or researchers, most current electronic patient record systems are unnecessarily complicated, take longer to use, and offer few advantages over pen and paper. The change from paper notes to electronic could have freed up time if it had taken advantage of what cutting-edge IT can offer nowadays; instead, it often replicates and multiplies the admin burden. Unlike pen and paper, electronic patient record systems almost invariably require a lengthy approval procedure and a significant amount of extra training just to be able to use them. They often have so many functions that no one in the hospital really knows how to use all of them. Clinicians are routinely required to enter a lot of data that will hardly ever be used for anything. Whilst there is no scientific evidence for the clinician clicking away at a computer for long hours improving patients’ mental health, collectively we have allowed these record systems to take further time away from talking to patients or their relatives. What Deahl (Reference Deahl2023) calls the ‘functionalisation’ of care (i.e. splitting the patient’s journey within the healthcare system into many separate teams, such as inpatient, home treatment, community, primary care mental health) causes repeated unhelpful disruptions to continuity of care and the siloing of expertise and services. This type of division of labour increased productivity during the Industrial Revolution but doing it in psychiatry turns a blind eye to the important fact that human beings are very different from machines or other factory products that need to be assembled.

Another problem that psychiatrists acutely feel is the gradual, but by now almost complete, demolishment of the personal support we once had in our jobs. Most psychiatrists no longer have a medical secretary. People who used to provide this extremely important support have been huddled into impersonal ‘admin hubs’, often in geographical locations away from the team, expected to support many psychiatrists and therefore knowing none of them really well. In a clinical service dealing with people, this has had a devastating effect in many ways. Part of the problem is that the crucial contribution they provided, through talking to patients on the phone or on arrival at the clinic, helping the consultant sort out their busy timetable, taking care of annual and professional leave admin, and a myriad other things one needs in order to successfully function in a demanding person-centred job, is difficult to quantify or express in financial terms. The effect of taking them away is already reflected very visibly only a few years down the line in the plague-like retention problems in most systems.

In summary, clinical practice in psychiatry has changed very significantly over recent decades. Whilst some of these changes have been positive, an important lesson that can be distilled from a review of the values involved therein is that for any system to function well and in a sustainable way, there has to be some sort of alignment between the values of the stakeholders. Psychiatrists will be able to provide person-centred care only if their own needs, concerns, and preferences are also taken into consideration. The fact that it is when they are not that has the most important effect on recruitment and retention has been picked up by the Royal College of Psychiatrists, and it has now included well-being among the aspects it monitors when approving consultant job descriptions for the UK’s National Health Service (NHS). To create a healthy alignment will require continual, genuine, and intelligent dialogue with the general public.

‘Suicide Deaths Are Preventable’

The premise that suicide deaths are preventable is a statement of fact. It is worthwhile, therefore, examining the evidence that supports this statement.

People who are about to attempt suicide cannot be accurately identified: there is no single risk assessment tool that can accurately predict suicide (Lotito and Cook, Reference Lotito and Cook2015; Steeg et al., Reference Steeg, Quinlivan, Nowland, Carroll, Casey, Clements, Cooper, Davies, Knipe, Ness, O’Connor, Hawton, Gunnell and Kapur2018); some people who are going to die by suicide will not be identified and some who are not will be identified as high risk (Nielssen et al., Reference Nielssen, Wallace and Large2017). Suicide is not, therefore, completely preventable. This is acknowledged in Zero Suicide training materials: ‘It is critically important to design for zero even when it may not be theoretically possible. When you design for zero, you surface different ideas and approaches that if you’re only designing for 90 percent may not materialize’ (Education Development Center, 2018, n.p.).

The use of language such as the statement ‘suicide is preventable’ has rhetorical force. It encourages people to think of suicide as a socially embedded phenomenon rather than simply the choice of an individual (Durkheim, Reference Durkheim[1897] 1966) and to take responsibility for reducing suicide rates. Setting such an ambitious objective challenges psychiatric healthcare providers to find ways of improving suicide prevention. The benefit, if they are able to rise to this challenge, is fewer people dying in despair.

The risks associated with this position manifest when a suicide is not prevented: if suicide is preventable, but nonetheless occurs, blameworthiness may attach itself to everyone who failed to prevent it. People involved in adverse events in healthcare are now called ‘second victims’ (Scott, Reference Scott2019), referring to the impact of these events on healthcare workers. If a reduction in suicide rates is accompanied by an increase in the harm caused by the deaths that are not prevented, then the question of whether or not it is an acceptable risk to take is open for discussion. This is acknowledged in the Zero Suicide movement: whilst asserting that ‘if depression care were truly perfect, no patient would die from suicide’, Coffey and Coffey (Reference Coffey and Coffey2016, article subtitle) acknowledge that pursuing perfection is most successful within a just culture. A just culture is a systems approach to patient safety that does not seek to blame and punish individuals when mistakes happen but holds everyone working in an organization accountable for monitoring the system, reporting ‘near misses’, and making things safer for all (Boysen, Reference Boysen2013).

The second issue raised by the fact that suicide risk assessment is an imperfect process is the question of how to respond to people identified as being at high risk of attempting suicide. This is especially pertinent if they are reluctant to accept help.

‘Suicide Is a Form of Harm Equivalent to Other Patient Safety Errors’

Designing safer systems for psychiatric hospitals can be an effective means of reducing deaths from suicide. A well-known example is the reduction in rates of death by hanging among people receiving inpatient psychiatric care achieved by identifying and removing potential ligature points from psychiatric wards (Hunt et al., Reference Hunt, Windfuhr, Shaw, Appleby and Kapur2012).

The Zero Suicide movement has issued a call to action to improve safety and the quality of suicide care in psychiatric systems. One can think of this approach as the modern-day manifestation of one of the oldest values of medicine: ‘First, do no harm’ (Hippocrates of Cos, 1923).¹ However, some factors that place patient safety at risk in psychiatric units (e.g. self-inflicted harm, the use of physical restraint to prevent self-harm) differ from the kind of errors that lead to harm in the general hospital setting, creating a tension between maximizing patient safety and maintaining patient autonomy (Thibaut et al., Reference Thibaut, Dewa, Ramtale, D’Lima, Adam, Ashrafian, Darzi and Archer2019).

Prevention of hospital-acquired infections, medication errors, and wrong-site surgery is achievable through the design of safer systems and the training and management of staff to reduce human error, assisted by the fact that patients themselves do not want these events to occur. Inpatient self-harm and suicide differ from other patient safety issues in that they involve events that the patient (albeit in the context of disturbed mental state) wills and brings about through their own actions. Prevention of these critical incidents usually involves some degree of coercion, justified by the intention to protect patients from harm. Whether or not such paternalism is justifiable is a question of the relative value placed on the prevention of (self-inflicted) harm and on individual liberty. Furthermore, given that suicide risk assessment is imperfect and some people identified as high risk would not have gone on to die by suicide, some people will be deprived of their liberty in order to prevent a suicide that was never going to happen. The question of how many people it is acceptable to detain in order to prevent one suicide is a question of values, not fact (Szmukler, Reference Szmukler2003), and is open to legitimate disagreement.

The Rotterdam Declaration sets a vision for Zero Suicide Healthcare where people who seek psychiatric treatment ‘will experience that suicidality can be discussed openly, is treated directly and managed in a least restrictive, recovery-oriented way’ (Zero Suicide International 4, 2018, p. 3). Nonetheless, a values-based decision to focus on inpatient safety may have unintended adverse consequences: creating a restrictive and ‘clinical’ environment in which people are reluctant to stay to receive treatment (potentially leading to increased rates of psychiatric detention); increasing use of sedation and restraint to prevent self-harm (potentially leading to increased rates of physical injury, increased psychological trauma in patients, and increased moral injury in staff); and fostering a risk-averse culture where inpatients are protected from death by suicide in the short term but may not learn the psychological coping strategies needed to resist suicidal ideation once they are re-exposed to access to lethal means in the community.

‘Suicide Should Be Eliminated’

This is the most obviously value-laden premise in the argument for suicide elimination. Adoption of the goal of suicide elimination implies that (1) suicide is always a form of harm and that (2) it is a form of harm that outweighs the potential adverse consequences of its successful elimination. In other words, suicide is not only a tragedy but also the worst possible outcome, whatever the circumstances. If this reflects the values of everyone who will be affected, this is perhaps unproblematic. However, if suicide elimination imposes the values of one set of people onto another, it risks causing moral harm and undermining its own legitimacy.

The question of whether suicide is sometimes a legitimate response to a tragic conflict has been addressed in a variety of ways. In the non-Western traditions, a diversity of positions regarding the moral permissibility of suicide exists (Battin and Mayo, Reference Battin and Mayo1981). Ancient and Classical Western thinkers also differed in their views. Plato claimed that suicide is disgraceful and that those who die this way should be buried in unmarked graves. Aristotle argued that self-killing does not treat oneself unjustly so long as it is done voluntarily, but concluded that suicide is somehow a wrong to the state or the community. The Stoics argued that, in the absence of the ‘natural advantages’, such as health, considered necessary for flourishing and living a good life, it can be wise and appropriate to end one’s own life (Cholbi, Reference Cholbi and Zalta2017). Early Christian thinkers opposed suicide, as a natural extension of the fifth commandment, ‘Thou shalt not kill’, and this became part of Christian doctrine and canon law – a ban on funerals for people who died by suicide was part of the legal code of the Catholic Church until the 1980s (Dine, Reference Dine2020). Suicide was a criminal offence in many Western countries until liberalization in the modern era.

In recent years much work has been undertaken to de-stigmatize suicidality and mental ill-health (including the work of the Zero Suicide Alliance in the UK). People are encouraged to reach out to others if they experience suicidal ideas, and to access help and support, including psychiatric treatment for any underlying mental illness. Despite the lingering use of language such as the phrase ‘commit suicide’, suicide is no longer unlawful in the UK and people are free to end their own lives (Suicide Act 1961). In a democratic, pluralistic society, is it legitimate to aim to eliminate a lawful act?

There are numerous reasons why suicide may be evaluated as a serious harm which should be prevented, even if it is not criminalized: its irreversibility and the complete loss of potential for flourishing, especially in the context of disordered mental state; the grief of bereaved loved ones; the traumatization of witnesses; and the potential for increasing the likelihood that others will act on suicidal ideas.² However, there are also legitimate reasons why some deaths by suicide may be evaluated differently: as rational choices to escape unbearable suffering (physical or psychological) or simply as a response to life carrying on after the ‘good life’ has ended.

Given this plurality of values, the aim of eliminating suicide completely could be criticized for failing to recognize that it is value-laden – ‘values blindness’ (Fulford, Reference Fulford and Radden2007) – or that it is based on values that are not necessarily shared by others – ‘values myopia’ (Fulford, Reference Fulford and Radden2007).

In summary, the lens of VBM reveals that the fundamental principles on which Zero Suicide is based are not value-neutral. The values of Zero Suicide, some explicit and some hidden, may not be sufficiently widely shared to justify a universal goal of suicide elimination. Furthermore, a decision to prioritize suicide prevention over other activities could potentially reduce patient autonomy, prolong suffering, and impede recovery. Where a policy creates conflict between values, or where there is plurality of values held by those who will be affected by a policy, VBP suggests an alternative approach.

The Case for a Values-Aware Approach to Suicide Reduction

Target-driven approaches in healthcare management are widespread and bring with them both advantages and disadvantages. The old management adage ‘You get what you measure’ suggests that if you want to achieve an objective, you need to quantify it and monitor it, holding everyone in the organization accountable for the results. This creates a sense of shared purpose, enabling change. However, there are now numerous examples of target-driven healthcare initiatives distorting priorities (as the thing that is not being measured is no longer pursued) and even leading to harm, if the values of support for patient dignity are eclipsed in the pursuit of efficiency (Mid Staffordshire NHS Foundation Trust Public Inquiry, 2013).

The elimination of suicide makes an appealing target for health service improvement, as suicide rates are relatively easy to measure, especially in comparison with factors such as suicidal ideation or mental distress. However, target selection is a value-laden process and close attention to the values that underpin the choice of target is necessary to reduce the risk of creating perverse incentives and unintentionally damaging patient care (Fistein and Malloy, Reference Fistein and Malloy2017).

The principles of VBP encourage a focus on process – the goal itself is less significant than the process followed to select it. The call is to focus on the perspective of patients and to balance legitimately different value perspectives by listening to and exploring the nature and extent of differences in values, aiming for mutual understanding and respect (Fistein and Malloy, Reference Fistein and Malloy2017).

Someone who dies by suicide suffers the harm of losing their life – something that they had, presumably, ceased to value at the time of their suicide attempt, even though it may have been something that they would have come to value again had they not died. It is striking, however, that much of the harm associated with suicide is experienced by others, especially people who valued the life that has been lost. Balancing the different perspectives of the suicidal person, their future self, and those who would be affected by the suicide is no simple matter. Nonetheless, VBP calls on us to try.

One reason to be concerned about suicide is the evidence that it is often associated with severe mental illness – cognitive distortions such as beliefs that one is trapped, helpless, and hopeless (O’Connor and Kirtley, Reference O’Connor and Kirtley2018) – and therefore may not represent a rational decision or the genuine, authentic will of the person who has died. What does seem clear is that behind the impulse to end one’s own life lies a great deal of distress and suffering (O’Connor and Kirtley, Reference O’Connor and Kirtley2018) and that both the suicidal person and those that would prevent their suicide place high value on ending that distress and suffering – they are simply choosing different means to achieve this end. Furthermore, to simply aspire to eliminate suicide rather than the suffering that drives suicidality risks arriving at an inhumane solution where people thought to be at risk of dying by suicide are deprived of their liberty in order to save their lives, but at the cost of their continued suffering.

A values-aware approach to suicide prevention would acknowledge the purpose of a Zero Suicide initiative: to strive to eliminate the distress and suffering that drives suicidal behaviour and that affects the ‘second victims’ of suicide. The focus would be on resourcing high-quality mental health care for all who would benefit from it and making this care accessible and acceptable to as many people as possible.

In comparison with a target-driven approach, underpinned by the values of management science, a VBP approach, underpinned by the values of psychiatry, has numerous advantages:

• By balancing the multiple values of patients and service providers, respect for autonomy can remain at the heart of medical care.

• Providing care that is consistent with the values of those who need to access it reduces the need for coercion and increases the scope for practice consistent with the rights, will, and preferences of patients.

• By concentrating on quality of care for all, rather than identifying high-risk individuals, the problems associated with imperfect risk-assessment tools (false positives and false negatives) are reduced.

• Reducing distress and suffering through the provision of effective, evidence-based treatment for mental ill-health should reduce the downstream consequences of that distress, including suicide.

• Reducing the likelihood of blame attaching to failures to prevent suicide should enable more focus to be placed on quality improvement in the context of a just culture.