Recent developments in psychiatry have required increased inter-disciplinary collaboration to ensure co-ordination of specialist skills. Simultaneously, changes in management structures of participating disciplines have produced vertically organised systems of management with multiple tiers often referred to as line management. The membership of multidisciplinary teams (MDTs) now comprises individuals at varying levels in management hierarchy and with different abilities to contribute to the decision making process. Managers usually impose attitudes, expectations and obligations on staff working in MDTs which are often major obstacles to effective teamwork by causing ambivalence and opposing loyalties leaving individual workers in invidious positions (Fagin, 1985). This paper reviews current thinking on multidisciplinary teams and present day management structures among disciplines in psychiatry and discusses the practical problems and areas of conflict resulting from their interaction in settings where MDTs are expected to operate.

Most research on electroconvulsive therapy (ECT) has focused on technical aspects, such as indications for treatment, efficacy, side effects of treatment, and theories of mechanism of action. Little investigation has been made of the attitudes and experience of patients receiving ECT and less regarding patients' understanding and knowledge of this treatment. Earlier studies have looked at specific aspects of patients' perceptions of ECT, such as subjective side effects, (Gomez, 1975), or the effect of the media on attitudes towards ECT (Bird, 1979). Other studies have investigated these and related issues more comprehensively (Freeman & Kendell, 1980; Hughes et al, 1980). These studies were carried out some time after the ECT course had been completed; in some cases, over a year. It may be that patients' perception and knowledge of ECT are different before and after treatment. Attitudes and knowledge may also change or fade over time.

This paper focuses on issues relating to the place of psychotherapy within general psychiatry rather than describing details of psychotherapeutic methods and their range of application in psychiatric practice.

The current situation in Soviet psychiatry needs a surrealist of Kafka's skill to describe it. On the one hand, an increasing range of Soviet journals have, since last November, been forthrightly saying what Soviet dissidents and Western observers have said for 20 years. This is that politically motivated abuse of psychiatry has taken place in the USSR on a large scale for decades, causing enormous human suffering. Second, some of these journals point out that abuses, though much reduced in scale, continue to occur today.

Medical audit has been defined as the systematic, critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources and the resulting outcome and quality of life for the patient (DOH, 1989). The White Paper Working for Patients states that the Government proposes that every consultant should participate in a form of medical audit agreed between management and the profession locally. It also states that management should be able to initiate an independent professional audit.

The arrival of HIV has challenged the traditional services for intravenous drug users providing the impetus to re-examine working practices. Only 10% of intravenous drug users attend hospital based treatment centres offering out-patient programmes based on reducing doses of oral methadone with an ultimate goal of abstinence (Hartnoll et al, 1985), yet for public health programmes designed to limit the spread of HIV it is important to increase the contact between high-risk groups and health professionals. Satellite clinics originally introduced to provide low cost help for drug users at a more local level may also be effective as a means of reaching intravenous drug users at high risk of HIV who would otherwise not be exposed to treatment and health education. Strang has described how a satellite clinic may be established with few resources, with staff who can be supervised by more senior workers at a central site (Strang & Creed, 1985). In this study the client groups of a satellite clinic and a conventional drug dependency unit were compared in order to characterise the clientele of the satellite clinic and to discover whether it was indeed fulfilling a useful role in terms of attracting such high-risk individuals for treatment.

Twenty-five years ago, the Ministry of Health recommended that 20 to 25 beds per million population were needed for treating psychiatrically disturbed adolescents, a figure similar to that recommended by the Royal College in 1956/57. The College also recommended in 1976 the provision of one adolescent psychiatric team per half a million population. None of these norms has been met, nor are they likely to be this century. The decline in the teenage population may slightly reduce the need temporarily until the anticipated increase from the late ‘90s. Meanwhile, government financial restraints call for innovative and creative alternative solutions for the treatment of disturbed adolescents wherever possible without admitting to a residential unit. Indeed the pressure is so great that a number of adolescent units have already been closed, or their beds drastically reduced.

A psychogeriatrician was recently given the opportunity of five sessions of speech therapy for his service. His response was that he had no need of a speech therapist as he was perfectly well able to do his own assessment of dysphasia. This attitude is perhaps understandable since there has been so little exposure to the skills of speech therapists within this clinical field. In 1985 a full-time speech therapist was appointed by Central Manchester Health Authority to be part of the multidisciplinary team working in old age psychiatry. At the time this was, to our knowledge, the first full-time position of its kind. This article reviews progress thus far and outlines the contribution of speech therapy skills to the management of the elderly mentally ill.

In politics some things can happen very quickly when a sufficient head of steam has been built up, as we have seen in the recent European Community election results. The message from the medical profession about the proposed changes in the NHS may now have been understood by politicians but we should never assume that governments will withdraw foolish or damaging proposals, so the time is ripe for renewed pressure for their withdrawal.

Those working with families in the field of child abuse often find themselves becoming intimately involved with Family Law. Although the involvement may produce confusion and frustration in professionals untrained in the law, it may also help facilitate appropriate and effective treatment of severely disordered families. I believe not only that legal framework can help those working in the mental health field, but also that a psychotherapeutic understanding of individuals, families and groups can aid lawyers steer families more effectively and humanely through the legal process. By the term psychotherapy I mean a body of theoretical and clinical knowledge concerned with looking at people's conflicts, feelings, anxieties and reasons for actions, which includes an understanding of the unconscious processes of the mind. A psychotherapeutic approach cannot provide a substantial basis for legal theory, for the latter is heavily weighted towards the notion of the ‘reasonable’ man, whose unconscious ideas and emotions are significant only if they lead to an intention to act illegally and the carrying out of the illegal act. However, the day-to-day practice of law may perhaps be enriched by a more rigorous attempt to understand human emotions, particularly in the often emotionally painful areas of Family Law. Moreover, I suspect that there are a number of shortcomings in the current complex, sometimes muddled, way that families have to deal with the law, which the proposed new legislation (DHSS, 1987) may not address. A psychotherapeutic understanding of some of the reasons for this muddle as well as of the general issues in this field may have benefits for lawyers, mental health workers and clients.