The Patron of the Royal College of Psychiatrists has pointed out the irony involved in recording patients' religion, without seeking to discover that all this means to them in terms of understanding and coping with their illness (HRH The Prince of Wales, 1991). One College past-President (Sims, 1994) firmly recommends evaluating the religious and spiritual experiences of our patients in assessing aetiology, diagnosis, prognosis and planning treatment. Across the water, an American Journal of Psychiatry editorial (Andreasen, 1996) has it that, ‘We must practice and preach the fact that psychiatrists are physicians to the soul as well as the body.’

Mental health services are not yet organised to allow patients with personality disorders easy access, and practitioners lack the necessary skills to implement effective treatment. A number of service models have developed, albeit without a clear evidence-base. These include sole-practitioner, divided-functions and specialist-team models. In general, a divided-functions or specialist-team model is probably best for reducing risk and improving outcomes. Both models present difficulties with integrating treatment, but these can be overcome by good communication. Good management of patients requires careful assessment of need and risk, a consistent approach, constancy of staff, team coherence and adequate in-patient support. Not all practitioners can treat patients with personality disorders and the interpersonal skills of the mental health professional may be crucial in maintaining a patient in treatment.

There has been significant anxiety among prescribers regarding the potential for cardiac adverse effects associated with acetylcholinesterase (AChE) inhibitors in Alzheimer's disease. There is no consensus on how to manage this cardiovascular risk, and memory clinics vary widely in their practice. Review of published evidence reveals that the incidence of cardiovascular side-effects is low, and that serious adverse events are rare. Intensive cardiovascular screening such as pre-treatment electrocardiograms or 24 h cardiac monitoring is not justified. Furthermore, there are no high-risk groups to target. This article suggests pragmatic guidelines for managing cardiovascular risk in patients receiving AChE inhibitors. The guidelines are intended to be easy to incorporate into routine clinical practice in a memory clinic.

National policy in the UK emphasises the importance of involving service users and caregivers in all types of mental health provision. The training of mental health care and social service professionals has always relied on seeing patients, but the patients' role has usually been a passive one. This is now changing, and service users and carers are becoming active educators in professional training, benefiting both the teachers and those taught. Provision is still very variable and is dependent on local initiatives. Voluntary organisations are active in this field, and there are now two academic posts for service users in the UK. This article explores the current forms of service user training, its benefits and drawbacks, and makes recommendations for future work.

Unemployment is high among those with mental disorders, particularly severe mental disorders, and there are a range of social and economic barriers impeding their employment. In general, there is a lack of vocational rehabilitation services in the UK for people with both physical and mental illnesses, despite good evidence for the effectiveness of some work schemes. Here, the need is discussed for a national strategy for vocational rehabilitation that involves employment and health services, and covers both physical and mental disorders.

Peer-supported open dialogue is a variant of the ‘open dialogue’ approach that is currently practised in Finland and is being trialled in several countries around the world. The core principle of the approach is the provision of care at the social network level, by staff who have been trained in family, systems and related approaches. These staff include peer workers, who will help to enhance the democratic nature of the meetings around which care is centred, as well as enabling such meetings to occur where networks are fragmented or lacking. Certain organisational and practice features and underlying themes are key to the approach. Crucially, open dialogue is also a system of service provision. Staff trained in peer-supported open dialogue from six National Health Service (NHS) trusts will launch pilot teams in 2016, as part of an intended national multicentre randomised controlled trial.

The importance of considering antisocial behaviour among people with autism-spectrum disorders is apparent from the significant number of case reports and case series describing criminal behaviour of people with a diagnosis of Asperger syndrome. The evidence so far does not support a specific association between the syndrome and criminal offending. However, a small yet significant number of offenders with autism who engage in illegal behaviour find themselves socially excluded or detained in secure provisions for prolonged periods. This article gives an overview of the scant empirical evidence relating to criminality within the context of Asperger syndrome, and offers suggestions for managing the syndrome in mentally disordered offenders.

Recovery is an increasingly important concept in mental health services research and policy-making. However, despite burgeoning interest in the concept, no overarching theoretical or empirical framework has been offered to support its key ideas. Further, it is often unclear how recovery ideas translate into routine practices of mental health programmes and practitioners. In this article, a theoretical framework for recovery ideas is derived from self-determination theory, a widely researched and empirically validated theory of human need fulfilment. I discuss the conceptual overlap of self-determination theory and recovery ideas, and, using key motivational concepts, develop a typology of recovery-oriented practices for three hypothetical programme types (controlling, traditional/paternalistic and recovery oriented). I describe existing measures of recovery-oriented practice and consider the implications of self-determination theory for measurement of and research on recovery-oriented practice.

Although there is an increasing focus on recovery within mental health services, there has been limited exploration of the applicability of these principles within forensic services. The authors draw on their experiences within forensic rehabilitation services to discuss the potential obstacles to secure recovery, exploring the systemic and risk management aspects of such a setting as well as considering attachment theory within this context. Some proposals based on clinical experience are given on how such obstacles are faced and tackled.

Beck's cognitive therapy originally developed as a short-term treatment for depression (Beck et al, 1979). It has been shown to be effective with a range of other disorders including panic disorder, generalised anxiety disorder, social phobia, eating disorders and sexual dysfunction (Roth et al, 1996). It is promising in the treatment of yet more disorders, many of which have traditionally been thought relatively impervious to psychotherapy, for example, bipolar disorder, chronic fatigue and psychosis (Clark & Fairburn, 1997). However, not everyone responds well to short-term cognitive therapy. In particular, it has been proposed that people with multiple, chronic problems that are apparently expressions of personality, rather than temporary responses to adverse life experiences, require more extended therapy (Beck et al, 1990).

Risk assessment has become a large and anxiety-provoking part of the work of many psychiatrists. This article unpicks the different meanings of the word ‘risk’ to seek out the source of that anxiety, looking at both statistical and sociological ideas about risk. A risk assessment is often a subjective, plastic and context-dependent statement about a patient that carries strong moral overtones. Risk management is also highly anxiogenic for those charged with carrying it out, because uncertainty about the future is impossible to eliminate and the consequences of an adverse outcome in the patient may also carry hazards to the doctor making the risk assessment. This leads to behaviour change in people carrying out risk assessments as they attempt to minimise their anxiety in a rationally selfish way, often with unintended negative consequences for patients, doctors and health service providers generally. Some possible strategies for minimising this effect are considered.

Explanatory models of illness – the way people perceive, interpret and respond to it – are mediated not only by the illness itself, but also by cultural and social contexts. This article discusses recent evidence showing how the exploration of explanatory models can help to shape treatment and outcomes for some of the most common categories of mental illness, and presents case studies illustrating dilemmas clinicians face when their explanatory models differ from those of their patients. It concludes with recommendations on how a culturally sensitive clinical approach based on the exploration of explanatory models during assessment and treatment can be used as an effective way of dealing with the complexity of patients' and families' needs.

The family and therapy

The term family therapy can be misleading. ‘Family’ is open to many interpretations, if not attacks, because it is frequently read as implying a two-parent, heterosexual couple with two children, with the woman primarily the ‘homemaker’ and the man the ‘breadwinner’, with occasional backup from the grandparents. Such a picture would seem to marginalise or exclude other family forms, such as childless couples, single parents with children, gay or lesbian couples and unattached elderly persons. However, the reality is that family therapists treat many different forms of committed relationships and friendships. As to the term therapy, it tends to imply the presence of illness or dysfunction, located in the family rather than one of its individual members, and may thus be quite unacceptable to families who often believe that it is the patient and not them whom requires help. Being at the receiving end of family therapy can have strong connotations of blame. Practitioners therefore increasingly use the term systemic therapy, which is also more informative because some of the work often involves the wider system. The systemic approach is essentially a contextual approach – seeing and treating people in context.

Attitudes to sex and the perceived role of sexual activity are very strongly influenced by cultural values. Culturally determined gender roles influence relationships between different-sex partners, and cultural values affect attitudes towards sexual variation. Cultures define what is deviant and from where help is sought. Through differing patterns of child-rearing, cultures also affect individuals' cognitive development, world views and explanatory models of emotional distress. It is critical that clinicians are aware of the role of culture in defining sexual dysfunction and how cultural factors can be used in initiating treatment as well as in therapeutic engagement and alliance. Although epidemiological data on prevalence of sexual dysfunction across cultures are scanty, it is likely that prevalences vary, as will pathways into care and patterns of help-seeking. In this article we discuss the potential impact of culture on sexual dysfunction, and issues that clinicians, whether in specialist or in general services, need to be aware of in assessing and treating patients who present with sexual dysfunction.

The ideas of critical psychiatry are influencing a growing number of psychiatrists in Britain and elsewhere. In this article we examine the origins and development of critical psychiatry over the past 25 years, through the work of philosophers such as Foucault and of critical social theorists such as Ingleby, Miller and Rose. We outline the important differences between critical psychiatry and anti-psychiatry. Finally, we examine the current status of critical psychiatry, and what is called postpsychiatry. We regard both as an attempt by practising psychiatrists to engage with service users' concerns about psychiatry, with government policies that stress democracy, citizenship and the importance of social and cultural contexts in health care, and with what might broadly be described as postmodernism.

Many health professionals feel ill-equipped to deal with the complex needs of asylum-seekers and refugees. This article offers an overview of the literature, and reviews the demography, epidemiology and causes of mental illness in refugee and asylum-seeker groups. It discusses the types of service configurations and service response that would be appropriate. It highlights the findings of the Royal College of Psychiatrists' consensus team and their position statement on the treatment of refugees and asylum-seekers. It finishes with some thoughts about what clinicians can do to improve their treatment. Clearly, there is a need for more training, education and service development.

People with learning disabilities are much more vulnerable to psychiatric illnesses, and will increasingly be accessing generic services. Treatment and management of psychiatric disorders is problematic, primarily because of difficulties in diagnosis, since classificatory systems are standardised on people with average intellectual functioning. This article provides an overview of the clinical implications of anxiety disorders within the context of learning disability.

Discrimination and prejudice against people with mental illnesses is ubiquitous, pernicious and wrong. The overwhelming case against such stigma has been recognised by initiatives from the UK government, the Royal College of Psychiatrists, the US Surgeon General, the World Psychiatric Association and many other organisations

There is little doubt that dementia is a very common cause of disability and dependency in our society. Since dementia of whatever type is usually more common with increasing age, then as population demographics change, so will the prevalence of dementia. Dementia is a generic term and the objective for clinicians, once dementia is suspected, is to attempt to define the cause. Alzheimer's disease is the most common cause of dementia, and in most centres vascular dementia would feature as the next most common aetiology. In some centres, Lewy body dementia is the second most common cause. Mixed Alzheimer's disease and vascular dementia would also feature high on the list at most centres.

Cognitive–behavioural therapy (CBT) is an effective treatment for a number of psychiatric disorders in adults of all ages. With the proportion of the population aged 65 or over increasing steadily, it is important to be aware of how the CBT needs of this age group can be best met. This article provides an overview of CBT and the historical context of using it with older people. Although an understanding of the individual, irrespective of age, is at the core of CBT, potential modifications to the procedure and content aimed at optimising its effectiveness for older people are discussed.