Concordance

Concordance may seem an unlikely theme for my column in an issue of Advances that features articles on hostage-taking, human rights abuses and new mental health legislation in the UK. Concordance was suggested as a new way to address non-adherence to medication in chronic illnesses: ‘a worldwide problem of striking magnitude’, according to the World Health Organization (see Britten et al, pp. 207–218). Instead of trying to improve ‘compliance’ – a ‘morally and psychologically flawed’ concept – doctors should endeavour to form reciprocal therapeutic alliances with patients, allowing patients to make ‘the most important determinations’, albeit as fully informed as possible by their doctors (Marinker 1997). In this issue Bedi & Vassiliadis (pp. 184–192) regard building a therapeutic alliance as central to supportive psychotherapy. For Whitfield (pp. 219–227) therapeutic relationships ‘must be as collaborative and non-threatening as possible’. This is more complicated where impairments affect communication and understanding, as illustrated by Kiani & Miller (pp. 228–235). Behavioural problems may be caused or worsened when sensory impairments are missed by carers, or are wrongly perceived as lack of cooperation and viewed as ‘he can see/hear what he wants to’.

Unlikely as it may seem at first glance, involvement, collaboration and the therapeutic alliance are central concerns of legislative reform too. ‘Participation’, which includes involving patients in planning, developing and reviewing their treatment and care, is a ‘guiding principle’ in the new Code of Practice for the Mental Health Act 1983 (Branton & Brookes, pp. 161–167). For Lyons (pp. 158–160) ‘a culture of “doing things with” rather than “doing things to” must pervade our clinical practice’. One reading of the articles by Curtice (pp. 199–206) and Alexander & Klein (pp. 176–183) throws into sharp relief what is being guarded against: on the one hand distorted treatment characterised by neglect and unnecessary coercion, on the other the adverse effects of prolonged periods of disempowerment and detention.

Active engagement with psychotropic medicines

Marinker (1997) takes as the title for his paper part of a sentence from a Kafka short story The Country Doctor: ‘To write prescriptions is easy, but to come to an understanding with people is hard’. The article which is my Editor's pick this month develops our thinking on how as clinicians we might better come to an understanding with our patients. Those who think that non-adherence is a problem peculiar to psychiatry should read the fascinating paper by Pound et al (2005), which is the starting point for Britten et al (pp. 207–218). Although patients passively accepting their medication might at times suit doctors this is not concordance. Actively taking medication involves a period of ‘lay evaluation’ by the patient, leading to either acceptance or modification of the regimen. Britten et al explore reasons for and methods used by patients conducting their lay evaluations, along with implications for realising concordance in clinical practice.