WHOSE LOCUS OF CONTROL?

I have always found the notion of locus of control (Reference RotterRotter, 1966) to be one of the most relevant to clinical psychiatry. Striking the balance between an external locus, where all important actions are decided by others, and an internal locus, where people make all their own decisions, is an essential element of good mental health, and the novels of Kafka and Hunter S. Thompson illustrate the extremes. This issue shows how sensitive is this balance. Letting people find their own solutions seems to have worked remarkably well for nearly half the heroin addicts from a well-integrated affluent town in the south of England (Rathod et al, ). They avoided the need for maintenance methadone substitution and its attendant risks and were abstinent from drugs 30 years later. It might have been very different if the population had come from centres of social fragmentation in Scotland (Allardyce et al, ). Even when an external locus is deemed appropriate – as, for example, in patients treated by assertive outreach teams – the yearning for an internal locus does not disappear, and Priebe et al () suggest that when teams become too assertive they prevent the more equal partnership, so necessary for successful engagement, from developing properly. The advantages of the internet as a vehicle to promote an internal locus of control are shown by Andersson et al (). Although this approach may be good for achieving some goals, there are others, such as suicide prevention, which often need an external locus but where we are surprisingly ineffective in deciding what to do. This is well illustrated by Owens et al (), who can find no satisfactory specific predictors of suicides from a self-harming population. However, in the general microcosm of mental illness services, imitative suicide (McKenzie et al, ) does tend to cluster, and those deemed to be at particular risk could merit specific (preventive) intervention.

Finally, it is good to note that Farrow and his colleagues () found a direct relationship between the anatomy (volume of left anterior cingulate gyrus) and physiology (motor activity) of patients with schizophrenia, those with reduced anterior cingulate volume showing generally less motor activity. Our colleague from Sweden, Wolfgang Rutz, regards neuroimaging studies to be the new science of ‘intracerebral phrenology’ – but may now wish to reflect a little, particularly when he reads the editorial by Toal and her colleagues (). Perhaps in the future we may find a ‘locus executor’ in the brain that determines the balance of action and both external and internal control; such a measure of our destiny would be of great value to all.

RISK, VIOLENCE AND PREMATURE DEATH

Another external influence of control for psychiatrists is their responsibilities for the protection of society when assessing any disorder associated with violence. The results of Vevera et al () suggest that the prevalence of violence in schizophrenia has not altered in Prague significantly over a 50-year period apart from some slight increase in 2000. I have always felt that the association between schizophrenia and violence is much more a consequence of adventitious factors such as substance misuse (Reference Arseneault, Cannon and WittonArseneault et al, 2004) and personality status (Reference Moran, Walsh and TyrerMoran et al, 2003) and the focus on the association with schizophrenia per se is inappropriate, even though it continues to be believed by a majority of the population (Reference Crisp, Gelder and GoddardCrisp et al, 2005). The much higher rate of substance misuse in the 2000 sample led Vevera et al to conclude that ‘paradoxically patients with schizophrenia could benefit from the high level of control typical of a totalitarian state’ (), which brings us back once more to the problem of balance. Clearly, the lack of balance that has followed the sudden removal of excessive external control in the communist regimes of eastern Europe has been very detrimental to health; this is well documented by Marmot and his colleagues (Reference Bobak and MarmotBobak & Marmot, 1996). However, it is pleasing to note from a paper earlier this year in the Journal (Reference Gater, Jordanova and MaricGater et al, 2005) that the pathways to care in these countries are now moving towards greater integration and that the young psychiatrists from Serbia/Montenegro, Macedonia, Romania, Albania, Bulgaria and Croatia, together with their other European collaborators, received an Okasha prize for the best original research from developing countries at the World Psychiatric Association Congress in Cairo in September. But we still have abnormal mental health pathways in the region. It is fortunately uncommon for mental health professionals and administrators to lose their lives through execution of their duties even under these circumstances, but the death of Levan Samkharauli earlier this year might not be as rare an exception as it appears. Levan was the head of the National Forensics Bureau of Georgia. A lawyer by education and one of the bright young people in the new Georgian government, achieving this elevated position at the early age of 24, Samkharauli set himself the task to set up a modern centre for forensic expertise, including the field of forensic psychiatry. Just before his death he visited Amsterdam on a working visit. Within 24 hours of his return to Georgia he was dead. It seems more than likely that the assassination was politically motivated. We in more favoured countries sometimes need to reflect on our geographical luck.