Pursuing The Journal Mission

Managing discourse

This subheading by itself ought to stir a certain level of tension; it could be seen as oxymoronic, depending on what is meant by such management. We intend for The Journal to be a “vibrant medium” for “lively exchange” of ideas and scholarly activities. But what happens when the discourse becomes too lively? And, as The Journal's gatekeepers, how should we know when that line (if it is a line) has been crossed?

These circumstances do not occur frequently, but there is nonetheless some regularity to them. Colleagues can hold dearly to widely divergent and conflicting points of view on any number of topics. As a necessary consequence of the passion brought to these points of view, published research, analysis, commentary, and opinion must be exposed to critique. Because authors often link their self-images to their published works, they are more vulnerable to criticism or ad hominem peer critiques; and, of course, some critics can be quite passionate about expressing their disagreements with others' work when zealously advocating their own position. Hence, we acknowledge the necessity of managed discourse, which should follow some principles that can be evenly applied to most, if not all, situations.

The chief principle applied in these instances is respect for persons, which might additionally be described as professionalism. Engaging this principle may be manifest as a request that language be softened or that it be redirected toward the theory or idea rather than the person holding the idea. We have asked authors to rewrite some phrases or passages with respect for colleagues in mind. Sometimes a critical comment is unnecessary, and we simply ask the author to delete it. Such deletions are occasionally necessary in the Legal Digest section of The Journal when, for example, the performance of an expert witness is questioned or criticized in the decision. It can be tempting to describe the expert's failures in the analysis of the case, but we try to redirect authors to emphasize the take-home message rather than the faulty performance. While forensic psychiatrists are invited to provide critique about their colleagues' work when it is presented in peer review settings, for which appropriate safeguards and processes are in place, having one's name appear in a case decision is not such an invitation.

We have also used the technique of seeking consultation from disinterested colleagues to help arbitrate whether a commentary is too forceful or may reasonably be interpreted as disrespectful. These are often value judgments, as it is quite difficult to advance a set of rules that would resolve all questions and direct all decisions. In these matters, seeking the opinions of experienced colleagues known for their evenness and prudence can sometimes be the only path to resolution.

Structure versus creativity

Here again, we face the problem of contending with opposing forces along this dimension. There must be sufficient structure to The Journal overall, and within each of its sections, to promote and ensure professionalism and scholarship. The Journal cannot publish a hodgepodge of ideas, expressed in the many forms that might be employed by our authors. Yet we must also be careful not to create structures so rigid that they inhibit creativity and expression, particularly of new voices. An emerging ethic in publishing, based on human rights arguments, is that publications should be accessible to all writers and to divergent points of view.⁵ Our efforts to cope with each of those cautions deserve further explication.

The sections of The Journal have been designed to promote creativity in a variety of writing styles, enabling the broad exchange of ideas. In 2011, the senior editors devoted considerable attention to refining the descriptions of each of those sections. These efforts included substantial discussion with the full Editorial Board, to make clear the distinctions we were attempting to elaborate. The new descriptions first appeared in Volume 40, Number 1, 2012. Regular articles were defined as “original scholarship in psychiatry and the law” ³ not to exceed 6,000 words. In the past, Analysis and Commentary (A&C) was referred to only as a “non-peer-reviewed” section of The Journal, which provided no guidance to authors about the intended content or style. In the new instructions, an A&C article “reviews the literature on a particular topic and summarizes the differing views on that topic. The author also offers expert commentary on the topic.”³ The length is set at 5,000 words. With the conceptualization of this section more clearly articulated, we thought it desirable to have A&C articles undergo blind peer review, which began with the June 2012 issue.

In other efforts to stimulate creativity, we have encouraged the submission of Biography articles that “highlight an individual who has made sustained important contributions to psychiatry and the law in any country.”³ We adopted an international scope to embrace the principle of diversity and to promote contributions of leaders from other cultures and countries. Particular efforts were made to define a Reflections and Narrative section so as to encourage authors to think about experiences in their professional lives and to describe them in first- or third-person accounts that may even be fictionalized or described in poems.⁶ We have converted the Book Review section to Books and Media, in an effort to encourage reviews of movies, plays, and other forms of expression. It has also been our hope that the structures attached to these modalities would make them more accessible, both to the author who is attempting to find an appropriate medium of expression and to the reader who may benefit from the reassurance of delineated formats. Editors must strive to be open to many different ideas and the diversity of technical mechanisms for expressing those ideas; their work must convey a genuine interest in writing and the performative nature of language.⁷ We are conscious of the editor's role in regulating the “art and science of portraiture” in publishing.⁸

The pursuit of new voices has required openness to less experienced authors. We have thought of this as a mentoring process, necessitated by the desire for a “diverse range” of new ideas. This mentoring takes the form of extensive suggestions for editing, reframing, refocusing, and reorganizing the authors' written thoughts. This is not, however, a traditional editorial stance. The question arises as to how much mentoring is appropriate, especially when both Regular and A&C articles are now subject to peer review. We rely on peer review to uphold standards of publishing and as a check on the veracity of an author's descriptions and views. We also have many generous peer reviewers who are willing to offer extensive comments, questions, and suggestions that assist authors in their development. The different natures of these two sections are such that greater latitude seems possible in A&C articles for the editor to provide more mentoring and guidance where it seems warranted. But we have clearly attempted to be helpful to authors, especially new authors, in both sections and have not conceptualized the editorial task as only one of rigid gate-keeping.

Case Reports, Institutional Review, and Respect for Persons

We have previously discussed some of the ethics challenges involved in the publication of case reports.⁴ Hanson, Martinez, and Candilis⁹ contribute their thoughts on this topic elsewhere in the special section. It is worth briefly mentioning at this point the direction taken in The Journal since the 2011 article on ethics in publishing. There is now in place a two-stage process of consideration for case reports that has been described in The Journal since Volume 40, Number 3, 2012. First, all manuscripts containing case reports of human subjects must meet the requirements that have been outlined in The Journal for ethics in research. This consists primarily of seeking appropriate institutional review board (IRB) approval or exemption from review. Authors without access to an IRB are invited to discuss alternatives with the editors. The second stage requires authors to obtain informed consent or describe the reasons that consent could not be obtained. A further requirement has been added for editorial consideration: “Case reports will be published only if they are central to the scholarly endeavor of the article and illustrate some important dimensions of the discussion.”³ For publication, potentially identifying data are removed, and composite or fictionalized accounts are identified as such.

These limitations run counter to the approach otherwise pursued in The Journal to encourage various types of writing and scholarship. We have no doubt that the concerns for respect and privacy are validly applied to editorial decision-making, but we recognize the tension created by our desire to avoid inhibiting scholarly discourse or the use of narrative in forensic literature. It is not our intention to restrain story-telling, but these limits seem unavoidable due to other ethics principles.

Peer review and diverse opinions

A similar tension is found in the management of peer review processes. Felthous and Wettstein¹⁰ provide a careful examination of the topic of peer review as a separate article in this section. Peer review is necessary to the maintenance of professional standards in publishing. This necessity is more straightforward when peers are asked to review empirical methodology. Peer reviews can also be relatively uncomplicated when dealing with questions of coherence, organization, effectiveness of a written product, and the inclusion of important and relevant references. The peer review for A&C articles, begun in 2012, has forced us to confront the purpose of peer review of opinions and commentary. We have adapted the peer review instructions and forms for A&C articles in an effort to cope with these concerns. Reviewers are reminded: A&C is a forum for exchange of ideas, not necessarily the presentation of new findings. Thus, the focus shifts from review of scientific merit to review of relevance, clarity, and organization, with an attitude of encouraging our colleagues in their efforts to contribute to dialogue and discussion in our professional literature.¹¹ Our reviewers have understood the distinction, and we have not had to struggle with peer review that stifles differences of opinion or different styles of expression. The A&C editor has molded peer reviews to advance the cause of mentorship and the raising up of new voices, as noted above. We have also adapted a form that guides peer reviewers to the A&C process, after review and approval by the full Editorial Board. The amended form makes inquiry about the usefulness of a commentary on a topic of relevance to forensic psychiatry, rather than the appeal of the argument to the reviewer. Reviewers are also asked to comment on ethics-related concerns, especially as applied to any case material included in a manuscript. Another question asks whether the paper demonstrates respect for others, including colleagues, patients, and evaluees.

Considerations of mission and vision have been particularly important in circumstances that occur more frequently than one might imagine: wildly divergent reviews about the same article. We are thus continually reminded of the relevance and importance of divergent opinions on any number of topics in the field. We are also reminded of the divergence of reader sensibilities and preferences in styles of expression. The synthesis of discrepant reviews often involves appeals to the variety of defensible opinions, the tone of feedback provided to authors and ultimately, its helpfulness in the author's efforts to contribute to The Journal's mission and vision.

Since that mission includes a commitment to multiple viewpoints, another possible response to discrepant reviews is to consider whether the subject of an article might well be material for a commentary or two published along with the article. This is a method employed for Regular Articles as a common practice, even when reviews are uniformly positive. It is useful to consider the merits of published commentary in situations where different reviewers have respectively provided significantly positive and negative feedback.

Which voices to include?

The question of reader or member preferences arises in considerations of the types of articles accepted by The Journal editors. For example, at a recent business meeting of AAPL, a member suggested that The Journal was accepting too many empirical research articles from other disciplines, rather than restricting the publication focus to other efforts of forensic psychiatrists. There was no opportunity in that setting for a full discussion or more adequate understanding of the contours of the concern, so we will address it here. As noted in Instructions for Authors³ and in the thoughts elaborated above, our interest is in diversifying the range of contributions by authors with various opinions and vantage points, forms of scholarship, and styles of expression. We seek neither to promote empiricism nor to discourage it relative to other types of contribution to the forensic literature. Ultimately, despite all our encouragements, we are at the mercy of the inbox. The rate of submissions waxes and wanes to some degree, as do the types of submissions. Given that our mission statement calls for “the exchange of multidisciplinary ideas,”³ we would be hard pressed to suppress contributions from any discipline or of any relevant type of material. That does not mean, however, that we foreclose any further discussion of that posture in the AAPL Council or other appropriate settings.

A related question is whether our submissions ought to be limited to contributors who are professionally engaged in the field. How should we, for example, consider a contribution from a consumer of our services? Is relevance to forensic psychiatry a sufficient criterion? How should we handle the usual consideration of the level of sophistication of an article for a professional audience? While it seems appropriate for us to engage in some degree of mentoring of the writing skills of junior colleagues, the same approach may not be viable for all others. A poignant article from a consumer may pose no special problem in our Reflections and Narrative, or perhaps even A&C sections. But a manuscript more akin to a diamond in the rough may require considerable effort and skill to fashion and refine, raising questions about the nature of the relationship between editor and potential contributor, and the very real limitations of time available to undertake the task. When that relationship is also collegial and may reasonably include mentoring efforts, the terrain feels more familiar. We are accustomed to teaching and advising our younger colleagues in professional activities. To what extent are we expected or permitted to engage in tutoring writing for contributors who are not among our peers? At what stage would the concern raised in the business meeting about other disciplines be raised about the voices of consumers? This is a difficult subject. We frame it without offering any clear answers, but with a willingness to hear the opinions of our members and readers.

Defining Conflicts of Interest

In 2011, the Editors asked the Editorial Board of The Journal to review and discuss the standards published by the International Committee of Medical Journal Editors (ICMJE) in April 2010¹² dealing with the subject of potential conflicts of interest (COI). Based upon a review of those standards and the proposed COI form from the ICMJE,¹³ The Journal adopted a revised Statement of Authorship Responsibility, Financial and Other Disclosures, Protection of Research Subjects, and Transfer of Copyright as part of the Instructions for Authors.³ Part of that form includes the statement, “The author and co-authors agree to identify in writing any financial involvement or other potential conflict of interest they may have in relation to the manuscript.”³ Authors are informed that, when appropriate, such disclosure will be published as part of the article “so that the reader may be aware of any possible biases of the author or co-authors.”³

That notice certainly seems intelligible and inarguable at first glance. In practice, however, the question quickly arises as to where the boundary is erected between financial and other interests that represent conflicts and those that are so universal as to constitute meaningless notification. For example, all academic psychiatrists have an interest in having their work published to maintain their academic position—the source of their professional earnings. Publication is likely to enhance the psychiatrist's prospects of being sought by retaining counsel. All authors are interested in the dissemination of their ideas. Some published works even provide royalties, at least in theory. So where do we draw the line between the financial interests we consider routine, and thus not meriting special disclosure, and those we consider potential conflicts warranting distinct notice to readers?

The situation becomes even more complicated when the argument can be made that authors' disclosures might appear to be self-promoting, (e.g., advertisement or even boasting). We have faced this situation in two circumstances recently. In one case, a book review author wished to disclose that he was the editor of a similar text (out of sincere concern for the ethic of full disclosure). In another, an attorney disclosed that he had been engaged in the work from which he was sharing his experiences and arguments as counsel in a certain type of class action lawsuit. Again, his disclosure to the editors was a sincere effort to fulfill author obligations. But as a notice to readers, it amounted to little more than alerting the reader that the author was actually engaged in the work he was describing.

The requirement of the ICMJE standards is that authors report this type of information to the editors. Editors are permitted to use it in published disclosures and “as a basis for editorial decisions.” Those standards then provide this direction to editors: “Editors should publish this information if they believe it is important in judging the manuscript.” The standards also note that “Not all relationships represent true conflict of interest” but do not offer any specific guidance on distinguishing “true” conflicts or deciding what information is “important” to any judgment of an article (all quotations from Ref. 12, p 4).

In the examples noted above, the book review situation was resolved by noting the author's disclosure about the similar text, without giving the name of the text, in an effort to not create the appearance that either the author or The Journal was engaging in advertisement of or comparison with the similar text. This was our effort to balance notice to the reader that would help judge bias with the risk of undue inference.

In the other example, it was clear that the attorney author was representing an argument conducive to one side of a series of class action lawsuits. This seemed obvious from the text and thus constituted both a source of experience from which the author was writing and a presumptive posture of opinion. But if an author describes in a scholarly fashion the opinions he has held and defended in public arguments, is he automatically presumed to be misrepresenting information? Our theory of justice depends on zealous advocacy of adversarial positions. What is then so remarkable about that situation that it deserves notice by the editors of its existence? Could not such notice also be criticized as self-promotion, or alternately, as an expression by the editors that the reader should be cautiously skeptical about the content of the paper? If the latter were the case, the article probably should not be published in the first place. In this case, the editorial decision was made to forgo the notice to the reader in the article, given that the author's experience was a matter of public record and could be inferred from the article itself. More important, the arguments advanced by the author were made clearly, had been subjected to peer review, and were fully open to the analysis of readers. The task then becomes deciding whether under those conditions, the disclosure is “important in judging the manuscript” (Ref. 12, p 4). Given that the logic and formulation of the argument expressed in the paper were available to any reader's scrutiny, the notice of financial information was not necessary to judging the paper; it stood or fell on its own merits or lack thereof. The sophistication of our audience played a role in that determination.

We reached these decisions only after considerable discussion. This also led to our attempt to articulate the policy or principles at play in this decision-making. At the time of this writing, we have yet to examine these principles with the full Editorial Board, but the following ideas were part of our preliminary drafting: authors writing in The Journal affirm their previous public statements, written or oral, as well as their public records of professional activity, unless otherwise noted; articles are accepted on the basis of editorial judgments about the authors' demonstration of expertise and interest in the topic and the results of peer review; and author declarations on matters related to employment, consultation, or prior publication are not routinely published. Authors are thus presumed to stand on their public records of professional activity. That authors profit from their daily labors in the public marketplace and have an interest in the fruits of their work is obvious and does not form the basis of revelation. No professional is free from such interests, and our readers are presumed to be aware of that fact. Statements about financial interest should reveal relationships that are not obvious and in which there is potential for true competing interests. So, for example, the source of funding for a study of a new pharmaceutical agent is an important piece of information for the reader to have. But if Professor Jones writes another article about his well-known Theory X, the editors have no need to call attention to Professor Jones' interest in his own career and theories.

We do consider this an evolving area of editorial practice. Universities have struggled with disclosures of conflicts of interest and have retreated from the high water mark of required reporting of everything imaginable, because such elaborate reporting is impractical and unproductive. We have taken a step in the direction of applying such restraint to COI disclosures in publishing. We will have the benefit of the full Editorial Board discussion to help shape these policy decisions. Ultimately, by way of this published self-examination and explanation, we will have the benefit of our readers' thoughts as well. We hope that future deliberations of the ICMJE will be influenced by these developments in practice.

Editorial Independence

We began this article by noting that The Journal is an instrument of AAPL, its parent organization. In nearly all circumstances, the organization and the publication are mutually aided in mission by the existence and activities of the other. But the interests of the two entities do not always align fully. The organization may wish at times to use the publication to promote its activities or interests in ways that do not conform completely to the scholarship goals of the publication. This is where the concept of editorial freedom or independence comes into play, defined by the ICMJE as “full authority over the editorial content of [the] journal and the timing of publication of that content” (Ref. 12, p 3).

An example of this partial divergence of interests has occurred in recent discussions about the publication of AAPL Guidelines, especially given the newly adopted practice of revising each of the guidelines every five years to comply with recognized standards.¹⁴ In the past, when a guideline was considered a one-time production authored by a group of people, it could more easily be treated as a near-typical submission to The Journal, following rules of authorship, originality of material, and so on. The submissions were nevertheless unusual in being much longer than standard submissions, and there were special considerations about peer review. Guidelines are first approved by the organization, through its Council. They are thus approved as an established document. When that document is submitted for publication, it must undergo peer review. But the peer review process becomes constrained, given that the document cannot be altered in any significant way on the basis of peer review critique or suggestion, since it has already been reviewed by the entire organization and approved by its official leadership. The Journal also has rules of style that are preserved from issue to issue to create a coherent and stable publication. Those rules of style sometimes conflict with guidelines documents as written, and compromise is necessitated.

We discovered a more critical conflict between the missions of AAPL and The Journal in the desire to treat guidelines submissions to The Journal as scholarly contributions to the literature in forensic psychiatry. As such, The Journal's mission calls for the exchange of ideas and thoughtful analysis by multidisciplinary colleagues. From the organization's perspective, the time for thoughtful deliberation has been accomplished by the time the final product is submitted for publication. The time for commentary has passed. But from The Journal's perspective, the document is now a new creation in the literature, with its life of scholarly commentary and exchange just beginning.

The ICMJE standards note that “Editors should be free to express critical but responsible views about all aspects of medicine without fear of retribution, even if these views conflict with the commercial goals of the publisher” (Ref. 12, p 4). The publisher in this case, AAPL, cannot be said to have “commercial” goals, but it clearly has goals related to its own well-being that are relevant in this context. The editors, therefore, sought a way to serve our scholarly mission responsibly without unnecessarily interfering with the parent organization's self-interests.

Our initial efforts at coping with this divergence of mission and interests were to publish commentary (in the A&C section) about newly published guidelines from colleagues from the perspective of other disciplines or countries, so that we did not appear to reopen debates among AAPL members about the documents' content or utility. Two of the AAPL guidelines^15,16 were thus published with such commentaries.^17,–,20 This tactic allowed The Journal to provide scholarly commentary without undermining the AAPL process for guideline development. While not immune from criticism, this approach remains potentially viable for the publication of future guidelines, depending on the particulars of how the practice of developing AAPL guidelines evolves.

More difficult to resolve have been the concerns raised in the discussions of revisions of already-published guidelines. The members of the organization's original work group for developing a guideline product were also considered its authors. If a new group makes modest revisions to the original group's work, it may seem relatively clear that the guideline still belongs to the organization. However, the new work group cannot claim authorship for work written by others and published years earlier. Nor can material be published in The Journal that has already been published. The first item of the Statement of Authorship required of all authors in The Journal is “The author and co-authors warrant the manuscript … is original work, has not been published before, and will not be subsequently published elsewhere without the permission of the Editor and the Publisher.”³

The emerging management of this conflicting situation is to consider guidelines the work product of the organization, crafted by a work group of the organization and printed in a special section of The Journal related to organizational affairs. Revisions of guidelines will be noted as such, making reference to the original published work that was attributed to a group of authors. It then becomes the responsibility of individual work group members to decide whether to list the product of their labors as a publication (perhaps only legitimately so for the first appearance of a new guideline) or as a committee or work group membership (perhaps more legitimate to the role of review and relatively minor updating of established guidelines). Does this mean that revisions are printed as organizational affairs and are not then governed by the editorial purview of The Journal? If so, does The Journal then become merely the vehicle for dissemination of information important to the organization and its members? Would the matters of peer review, The Journal's style, and the desire to subject scholarly material to review and commentary thus be obviated?

Given that no such revision has yet been published in The Journal, the precise details of the arrangements are yet to be fully realized. All professional organizations that engage in the development of practice guidelines are engaged in such deliberations, and the discussion is an evolving one, in general. We are aware of no result achieved in other organizations and their corresponding journals that might at this time be considered the accepted standard of practice.

From a publishing perspective, the present track of guidelines development appears to be evolving in a manner increasingly inconsistent with the needs and objectives of scholarly publication, per se. Continuing discussions are necessary, and we anticipate further developments in AAPL-Journal accommodations on this subject.