In their book Built to Last: Successful Habits of Visionary Companies, the authors Collins and Porras coined the term Big Hairy Audacious Goal (2016). This describes a visionary medium term organisational goal which is compelling, stretches the workforce but is ultimately achievable. Reflecting on Self Injury Awareness Day (1 March 2017) I wonder whether the zero suicide movement represents mental health’s big hairy audacious goal.
Zero suicide refers to the idea that a mental health provider can eliminate suicide among its patient population. My first exposure to this was when I heard about the Henry Ford Center’s Perfect Depression Care initiative, which was launched in the early noughties in Detroit. Zero suicide lay at the heart of this strategy and was built around organisation-wide culture which viewed suicide as preventable, demanded high levels of competence among staff in risk assessment and developed a rapid response system to identify and treat high risk patients.
Over the years, I have been disappointed to see and hear colleagues of mine dismissing this approach and finding reasons why it could not be implemented locally. Whilst I do accept that some of the criticisms, including the view that some suicides occur in ways that appear to be unpredictable, I saw nothing wrong with an organisation trying to challenge the status quo.
I will be interested to see what results are delivered by providers that have taken up the challenge. One is Mersey Care NHS Foundation Trust, a mental health provider in the UK, which has adopted a zero suicide policy.
Another key development in recent years has been the introduction of Suicide Behaviour Disorder in DSM-V, the American diagnostic manual for mental and behavioural disorders, as a diagnosis it its own right. On the one hand, I remain sceptical about adopting a new diagnosis, when suicidal behaviour can and does – in my opinion – occur in the context of existing disorders such as Depression.
I also have concerns that we risk medicalising a complex problem, particularly given that not every suicide occurs in the context of a mental disorder. However, it could prove to be a useful way of concentrating our minds around the identification of suicidal behaviour and implementing and enhancing evidence-based interventions to reduce suicides.
To this end, US based behavioural health organisation Beacon Health Options have taken up the mantle in their recent White Paper We Need to Talk About Suicide. This outlines a framework for addressing the problem, including some of the evidence based treatments, such as 24-hour crisis services and a range of psychological therapies.
We are still at a very early stage in this movement. A recent systematic review by Chan et al (2016) poured cold water on the idea of using risk assessment scales to predict suicide following self-harm. However, psychiatry has achieved big hairy audacious goals in the past. Moving vast swathes of patients from asylums into the community was one of them and would have required the same level of optimism and audacity to push it through.
I do think the vision of eliminating suicides within psychiatry is compelling and one worth pursuing. As psychiatrists we are often weary of developing a Messiah complex, but in this case, if we do want to ‘walk on water’, we will have to get out of the boat!
Dr Chi-Chi Obuaya is an NHS Consultant Psychiatrist and a partner with Psychiatry UK. You can view his profile here