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. ^{Reference Slade, McCrone, Kuipers, Leese, Cahill, Parabiaghi, Priebe and Thornicroft1,Reference McCabe, Saidi and Priebe2} 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. ), 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. ^{Reference Monahan, Redlich, Swanson, Robbins, Appelbaum, Petrila, Steadman, Swartz, Angell and McNiel3} People with schizophrenia often lack drive and interests and yet plans to persuade them into employment appear to be successful (Killackey et al, pp. ), ^{Reference Latimer, Lecomte, Becker, Drake, Duclos, Piat, Lahaie, St-Pierre, Therrien and Xie4} and the (often coercive) treatment of those who are risk of harming others ^{Reference Wong, Gordon and Gu5} may have something to do with an encouraging drop in the number of homicides attributed to mental disorder (Large et al, pp. ). Similarly, the dilemma of the worried parent being aware of suicidal risk in their children (Oldershaw et al, pp. ), heightened further if they know of past abuses (Brezo et al, pp. ), 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. ). 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. ), 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. ) 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. ^{Reference Tyrer6} 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.