“The therapist can cite Bertrand Russell's observation that the degree of certainty with which one holds a belief is inversely related to the truth of that belief. Fanatics are true believers, scientists are sceptics”. (Beck et al, 1979)

I propose to describe the evolution of behavioural treatments, and the more recent leap forward made by cognitive therapy. Exciting new treatments are now available that did not exist when I was a trainee. The accepted term for these treatments is “behavioural-cognitive psychotherapy’ (BCPT). They are behavioural in the sense that emphasis is on observable behaviour, e.g. avoidance of supermarkets in agoraphobia. They are cognitive because many approaches involve working with patients' thoughts, e.g. the negative thinking of depressed patients. The treatment is psychotherapy as it is therapy that works at the mind level, rather than at say the synaptic level as pharmacotherapy does. BCPT combines well with pharmacotherapy, and other therapeutic methods such as social therapy, and so is suitable for a multidisciplinary approach to a psychiatric problem, as well as offering specific techniques for identified disorders.

As psychiatry broadens its perspective beyond a predominantly hospital focus, the tools of its trade need some reshaping to serve the needs of an altered working environment. The instrument indispensable to every psychiatrist is the scheme for assessment, comprising history-taking and examination of the mental (and physical) state. Honed by long familiarity and usage, its employment is the fundamental skill demanded of aspirants to medical practice and to psychiatry.

Just as the management of individual patients requires specific and timely information upon which clinical decisions can be based, so managers and clinicians, responsible for service planning, require appropriate information on the activity levels and functions of their services. This is true at all levels, from individual clinicians and teams who wish to audit their activities, through clinical directors and managers of departments and units, to those who plan for Districts and Regions. Casemix is an attempt to facilitate this process by developing a meaningful language, to describe and measure clinical activity.

Several studies in the United Kingdom have highlighted the lack of knowledge that patients show about electroconvulsive therapy (ECT), both before treatment starts (Malcolm, 1989) and after it is completed (Freeman & Kendell, 1980; Hughes et al, 1981), with only 10 to 15% of patients having a full understanding of the treatment. In an American study (Baxter et al, 1986) patients seemed slightly better informed; this might be because they were given written information. However, subjects who watched a videotape of someone having the treatment did not score higher on a knowledge questionnaire than a control group and the authors postulated a ‘ceiling effect’. Bird (1979) demonstrated that access to media coverage about ECT improved patients' knowledge without increasing anxiety about the treatment.

Electroconvulsive therapy (ECT) has long been recognised as an important method of treatment in adult psychiatric disorders, especially severe depression. However, in spite of increasing concern about the occurrence of depressive disorders among the young (Klerman, 1988), very little is known about the use of ECT in children and adolescents. Indeed the published literature on ECT in this age group consists almost entirely of case reports (Bertagnoli & Borchardt, 1990). This paper is concerned with an important determinant of such practice, the attitudes of child and adolescent psychiatrists.

The relatives of people with schizophrenia are a group who have much to offer professional carers and other relatives. They have a huge store of knowledge, often gained painfully by trial and error, about the problems involved in caring for sufferers from schizophrenia.

We report two cases from a study of Oxford hostels for the homeless of patients who were suffering from schizophrenia and are not receiving medication. After compulsory admission to hospital and treatment both showed a dramatic improvement in behaviour which was confirmed by a standardised rating scale. We discuss how hostels for the homeless have become both asylums and traps for those who suffer from schizophrenia and conclude that doctors should not under-estimate the potential benefit of anti-psychotic drug therapy even in homeless people with chronic psychosis.

Universal suffrage has been a cornerstone of democracy in Britain since 1948. However, by application of the common law, the vote is denied to people deemed “insane” or “idiots”. In practice mentally disordered people have been, until recently, disenfranchised by section 4(3) of the Representation of the People Act 1949 which prevented recognition of a mental hospital as a place of residence for the purpose of electoral registration. Significant change was introduced by section 7 of the Representation of the People Act 1983 which applies to both England and Wales, and Scotland. This enables informal patients in mental hospitals to register for the vote provided they can complete a patient's declaration. We examined the implementation of these provisions in the 1992 general election at two hospitals in Edinburgh for people with mental illness and learning disabilities respectively.

The UK has recently held a general election in which the future of the National Health Service has been a major issue. The elderly constitute a growing proportion of the electorate and are frequent users of the Health Service, yet some may have been unable to vote because they are in-patients. Elderly in-patients can vote by post or proxy or by being taken to their polling station by relatives or party representatives, but for many these arrangements may be inadequate.

With changing patterns of care, it is expected that more doctors will have contact with people with mental handicap. This study looks at medical students' evaluation of an aspect of the training they received to prepare them for such contact.

An active interest in research aids understanding of research methods helps in the reading of scientific papers, and is rapidly becoming a prerequisite for career progression in psychiatry.

For some time it has been recognised that death and non-death loss events are commonly associated with the onset of psychiatric illnesses, especially affective conditions (e.g. Murphy, 1982). Studies have shown that counselling targeted at high risk grievers can significantly reduce their psychological and psychosomatic manifestations of grief, with an associated reduction in the use of statutory services (Raphael, 1977; Parkes, 1980). Bereavement counselling thus offers one of the few opportunities to implement preventive psychiatry.

A recent paper by Lewis (1991) found authorship of a publication to be the only variable that significantly predicted whether applicants for a senior registrar (SR) rotation in psychiatry at a London teaching hospital were shortlisted. We have re-examined curriculum vitae (CV) predictors of shortlisting at SR level within a comparable London teaching hospital rotation (University College and Middlesex Medical School, UCMSM), and extended the study to examine applicants for the corresponding SHO/registrar (REG) rotation. We have also compared the two groups in terms of demographic data and academic achievements. Our intention was to replicate Lewis' findings, and to examine in more detail the possible predictive effects of academic achievement and ethnicity.

The NHS and Community Care Act 1990 has been described as the biggest shake-up to the NHS since its inception. Most psychiatrists will by now be familiar with the new arrangements for community care, but what are the implications of the structural changes in the NHS for psychiatry?

When I began my six month placement at The Lodge, an in-patient therapeutic community for those with emotional and personality disorders, there were 13 residents. Three left and two more joined us over the following month. Our consultant was on annual leave when the community was devastated by the unexpected death of a long-standing resident, who I will refer to as B. At the time of his death he was a well integrated member of the community.

The recent release of British and American hostages held by fundamentalist Islamic groups in Lebanon has received national and international publicity. The Psychiatric Division of the Royal Air Force Medical Service has been involved with the management of released British nationals and others but, in the interests of the hostages and their families, has delayed public discussion of the matter. From the British and American viewpoint the recent hostage crisis in the Lebanon has now resolved. It therefore now seems appropriate to describe in general terms the principles upon which early management was based.