© 2008 The Royal College of Psychiatrists
COLUMNS |
From the Editor’s desk
Coercion comes with the territory
Psychiatrists, unless they practise in the outer fringes of the subject, bludgeon sometimes, are coercive often and challenging always. In these roles they naturally arouse the ire of their patients and those who campaign on behalf of their human rights. The core skill of a good clinician is to behave in this way when necessary but not to lose the respect of the patient when so doing, so that when the coercive period is over a good relationship can still be developed or maintained. My fundamental policy is honesty here; if you tiptoe gently round these issues, you are in danger of being accused of double-standards or, much worse, lying. When honesty is linked with feedback the evidence suggests it improves the therapeutic relationship and clinical outcomes.1,2 The dilemma between choosing selective coercion or temporary condoning of behaviour that constitutes an offence against the patient’s health or the rights of others is rehearsed in many of the papers in this issue, most obviously in our good-tempered debate on community treatment orders (Lawton-Smith et al, pp. 96–100), and in the evocative painting by Vonn Stropp on our cover. We must remember that the suffering of patients is often because their symptoms too are coercive and that paradoxically a successful unwanted treatment may relieve them. But so many of the subjects of other papers seem to have hidden compulsion (or at least leverage) behind them, and this is not surprising when half of all psychiatric patients share this perception.3 People with schizophrenia often lack drive and interests and yet plans to persuade them into employment appear to be successful (Killackey et al, pp. 114–120),4 and the (often coercive) treatment of those who are risk of harming others5 may have something to do with an encouraging drop in the number of homicides attributed to mental disorder (Large et al, pp. 130–133). Similarly, the dilemma of the worried parent being aware of suicidal risk in their children (Oldershaw et al, pp. 140–144), heightened further if they know of past abuses (Brezo et al, pp. 134–139), yet feeling that anything that is suggested may be counterproductive, also has the whiff of compulsion hovering over what should be a warm and supportive interaction. Coercion that is more common in some ethnic groups could be racist, but one treatment commonly associated with coercion, antipsychotic drugs, shows no such evidence of ethnic variation (Connolly & Taylor, pp. 161–162). Added to this is that some treatments that appear to be markedly coercive, such as the magnetic seizure treatment described by Kirov et al (pp. 152–155), are desired very strongly by patients; one of my own patients is moving heaven and earth in attempting to receive this treatment.
Of course there are bound to be some psychiatrists and, indeed, other mental health professionals, who are gratuitously coercive and derive pleasure from exercising a degree of control over people’s lives not possessed by any other medical discipline. What better than a good and reliable 360-degree assessment of consultants to ensure that such behaviour is identified early and corrected, and Lelliott et al (pp. 156–160) may have found the answer. Perhaps before long we can be defining a good psychiatrist as ‘a completely rounded physician who can diagnose mental illness reliably, treat it well by consensus and, when necessary, compulsion, and who enjoys both the respect of colleagues and the gratitude of patients’.
Citing and exciting journals
The impact factors of academic journals for 2007 are now published and that
for the British Journal of Psychiatry has risen slightly to 5.446. We
are now third in the list of general psychiatric journals behind Archives
of General Psychiatry and American Journal of Psychiatry and
hope that before long when people ask ‘have you read the latest article
in the Journal?’ it will not be necessary to ask ‘which
one?’ Our new-style journal will take time to filter through to impact
and immediacy ratings but I hope that we can now concentrate on other ways of
improving our content outside the league table mentality that we must try hard
to dispel.6 Despite
limits on the size of the journal we are able to publish more material and one
gratifying consequence is an quinquennial increase of nearly a quarter in our
cited articles published in the previous two years (Figure). With a similar
increase in the number of hits on the journal website we do not pass
unnoticed.
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REFERENCES
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1
- Slade M, McCrone P, Kuipers E, Leese M, Cahill S, Parabiaghi A,
Priebe S, Thornicroft G. Use of standardised outcome measures in adult mental
health services: randomised controlled trial. Br J
Psychiatry 2006; 189: 330
–6.
[Abstract/Free Full Text] 2 - McCabe R, Saidi M, Priebe S. Patient-reported outcomes in
schizophrenia. Br J Psychiatry 2007,
191 (suppl. 50): s21
–8.
[Abstract/Free Full Text] 3 - Monahan J, Redlich AD, Swanson J, Robbins PC, Appelbaum PS, Petrila
J, Steadman HJ, Swartz M, Angell B, McNiel DE. Use of leverage to improve
adherence to psychiatric treatment in the community. Psychiatr
Serv 2005; 56: 37
–44.
[Abstract/Free Full Text] 4 - Latimer EA, Lecomte T, Becker DR, Drake RE, Duclos I, Piat M,
Lahaie N, St-Pierre M-S, Therrien C, Xie H. Generalisability of the individual
placement and support model of supported employment: results of a Canadian
randomised controlled trial. Br J Psychiatry 2006; 189: 65
–73.
[Abstract/Free Full Text] 5 - Wong SCP, Gordon A, Gu D. Assessment and treatment of
violence-prone forensic clients: an integrated approach. Br J
Psychiatry 2007; 190
(suppl. 49): s66–74.
[Abstract/Free Full Text] 6 - Tyrer P. Practical impact (letter)? Br J
Psychiatry 2008; 192: 69
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[Free Full Text]
Related articles in BJP:
- Vocational intervention in first-episode psychosis: individual placement and support v. treatment as usual
- Eóin Killackey, Henry J. Jackson, and Patrick D. McGorry
BJP 2008 193: 114-120.[Abstract] [Full Text] - Homicide due to mental disorder in England and Wales over 50 years
- Matthew Large, Glen Smith, Nicola Swinson, Jenny Shaw, and Olav Nielssen
BJP 2008 193: 130-133.[Abstract] [Full Text] - Predicting suicide attempts in young adults with histories of childhood abuse
- Jelena Brezo, Joel Paris, Frank Vitaro, Martine Hébert, Richard E. Tremblay, and Gustavo Turecki
BJP 2008 193: 134-139.[Abstract] [Full Text] - Parents’ perspectives on adolescent self-harm: qualitative study
- Anna Oldershaw, Clair Richards, Mima Simic, and Ulrike Schmidt
BJP 2008 193: 140-144.[Abstract] [Full Text] - Quick recovery of orientation after magnetic seizure therapy for major depressive disorder
- George Kirov, Klaus P. Ebmeier, Allan I. F. Scott, Maria Atkins, Najeeb Khalid, Lucy Carrick, Andrew Stanfield, Ronan E. O’Carroll, Mustafa M. Husain, and Sarah H. Lisanby
BJP 2008 193: 152-155.[Abstract] [Full Text] - Questionnaires for 360-degree assessment of consultant psychiatrists: development and psychometric properties
- Paul Lelliott, Richard Williams, Alex Mears, Manoharan Andiappan, Helen Owen, Paul Reading, Nick Coyle, and Stephen Hunter
BJP 2008 193: 156-160.[Abstract] [Full Text] - Ethnicity and quality of antipsychotic prescribing among in-patients in south London
- Anne Connolly and David Taylor
BJP 2008 193: 161-162.[Abstract] [Full Text] - Community treatment orders are not a good thing
- Simon Lawton-Smith, John Dawson, and Tom Burns
BJP 2008 193: 96-100.[Abstract] [Full Text]
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