The Ashenputtel principle
We are pleased to publish an editorial from Dr Schanda from Austria in this issue. It is intriguing to an English psychiatrist, like me, to see that similar difficulties concerning the management of troublesome patients occur in other parts of Europe, and I know from colleagues elsewhere that they also arise in other parts of the western world. Dr Schanda's piece is provocative and throws down the gauntlet to psychiatrists ending with a plea that they should act more maturely, by which he means, I think, that they should be readier to accept difficult patients into their services. When one sees some of the rejecting behaviour of psychiatrists it is a tempting conclusion to arrive at. However, it begs an important question and it has to be put into a contemporary context. The question that needs to be asked is: 'Why is it that many psychiatrists do not like troublesome patients and will go to great lengths to avoid having them in their services?' This is neither a trite question nor easy to answer. It deserves research in its own right. It seems to me that we have to be better at choosing which psychiatrists are appropriate for which jobs. Part of the difficulty we encounter in Britain is that psychiatrists find themselves undertaking tasks they neither relish nor believe they were trained for.
The context that Schanda alludes to in his piece is equally important. Psychiatric services in Britain are badly funded when compared with other health services. They are quite severely stigmatized, particularly at medicalschool level, and students are actively discouraged by both their peers and their teachers from 'wasting their time' undertaking a psychiatric career. Finally, the government in England -which is responsible for the vast majority of psychiatric services -is embarrassed by the occasional high-profile serious act of violence caused by a patient who has been rejected, neglected, or both and in a classic attempt to find a scapegoat for each and every one of these cases, all homicides brought about by a patient who is in psychiatric care are subject to a public inquiry. These public inquiries never exonerate the mental health professionals and psychiatrists are the prime targets. Add this disincentive to the stigmatization which exists anyway and perhaps it is no surprise that doctors do not enthusiastically come forward in large numbers to