Trying to put one's career into perspective is like selecting those eight records for the Desert Island; what should one choose? My recollections are more of people than events. A few individuals have had a lasting influence on me, many more have enriched my life, only rarely have I met somebody I would not care to meet again. People of all types have always fascinated me, and this is perhaps why I have greatly enjoyed my time in psychiatry. My career lacked any master plan, things happened, opportunities arose but my path was determined as much by chance as anything else.

Toronto is a large multicultural society with a metropolitan population of several million people. It is mainly English-speaking, although it contains Portuguese, Chinese, Italian and other communities. Although similar in population to the larger industrial cities of the United Kingdom, and despite a common language, there are important cultural differences which are relevant when assessing treatment programmes. In particular, in contrast to the urban decay, high unemployment rates, and increasing number of elderly residents prevalent in UK cities, Toronto is a young, thriving city with a low unemployment rate and affluent population. There is a low crime rate, little evidence of vandalism, but ample evidence of an advanced structure, e.g. public transport, play schemes etc. Accommodation is, however, expensive and mainly in private ownership.

The issue of the rights and obligations of those involved in doing research on patients who are incapable of giving their consent to treatment is a difficult one. This difficulty is reflected in the papers and discussion which form the basis of the book Consent and the Incompetent Patient: Ethics, Law and Medicine (eds. S. R. Hirsch & J. Harris) and that were the subject of the conference that led to it. Had I been in attendance, I am sure that I would have gained insights not available from the printed version on which I have had to rely. Nonetheless, I have sufficient sense of the proceedings to see where there are areas that an American view, or at least the views of one American lawyer, might be of interest.

The 50th anniversary of the first ECT provides an opportunity to look back and reconsider whether we are using this important treatment as well as we might.

One of the topics discussed at the recent Trainees Day of Thames Health Authority, Southern Division, was part-time training. Trainees were concerned about difficulties experienced by those wishing to train on a part-time basis.

Having been closely involved in the admission of patients into hospital under various provisions of the Mental Health Act 19831,2,3 (and its predecessor, the 1959 Act), I have made notes over the years of aspects of the 1983 Act which need to be amended in the interests of the patients, their families and the professionals who have to care for them in hospital and in the community.

A worldwide demographic shift towards old age is being accompanied by a corresponding increase in the number of old people presenting with psychiatric disorders, and traditional systems are unable to cope with the problem.

Although there has been considerable interest into the amount of liaison work that general psychiatrists do with general practitioners in primary health care settings, and into the role that social workers can play in liaising with the primary health care team, less is known about the extent to which general psychiatrists have established liaison links with particular social services offices, what form the liaison takes and whether the liaison has worked satisfactorily.

There has been a dramatic increase in the numbers of community psychiatic nurses (CPNs) in the last decade; in the period 1980–1985 the number grew from 1667 to 2758, an overall increase of 65%. Traditionally, CPNs were based within psychiatric institutions. However, in the period 1980–1985 there was growth from 8% to 16.2% in the population of CPNs based in health care centres or General Practitioner (GP) surgeries. Some of the functions of CPNs is also changing, developing away from involvement with chronic psychiatric patients towards patients with minor disorders. CPNs have also argued that work in the community and in GP surgeries is synonymous with primary prevention.

Concern among black and ethnic minorities with current research in ‘transcultural psychiatry’ entails future work taking into account their collaboration to minimise the possibility that it is prejudicial to their interests. An instance is given of a project initiated by black community groups which looks at psychiatric conceptualisations of a diagnosis commonly used locally in inner-city Birmingham: cannabis psychosis. Responsibility remains with the researcher.

The question is often asked: “Does family therapy work?” This is an important but useless question. It is important because an enormous amount of time, energy and money is put into the clinical practice of family therapy. It is practised in every continent; there are many training courses and qualifications in very many countries, and there are over 40 journals devoted to families and family therapy. Yet there is a healthy and justified scepticism. So yes, we ought to ask whether it works.

A funny thing happened to Mr Kenneth Clarke on his way to the House of Commons in October 1982. It was the last day of debate on the Mental Health (Amendment) Bill and for some peculiar reason the then Minister of Health decided to reject the advice he had just been given by DHSS officials and instead accepted at the last minute an amendment proposed by the Opposition which extended the consent to treatment provisions for psychosurgery and certain other (then undefined) treatments to voluntary patients.