Background: Patient and carer participation in old age psychiatry is less developed than in other areas of mental health. What can we learn from the historical context about increasing participation and how can it be conceptualized?

Methods: The historical and policy context of patient and carer participation in the National Health Service is reviewed and related to the development of old age psychiatry in England and the parallel development of the mental health user movement.

Results: Systemic theory is offered as a way of understanding how partnership between healthcare professionals, patients and carers might lead to service evolution by bringing a range of perspectives together in order to co-construct a mutually influenced outcome. It is further suggested that this might empower not only patients and carers but also healthcare staff at a time when they are under increasing pressures.

Conclusions: Old age psychiatry patients and carers struggle to be heard but have much to offer to services in partnership with healthcare professionals as partners and allies in service development.

A significant proportion (4%, Australian Institute of Health and Welfare, 2008) of children and young people in Australia live in some form of residential care, usually in small group-homes staffed by residential care workers in shifts. However, as Hawkins-Rodgers (2007) points out, these placements are often not resourced to heal the effects of trauma and multiple attachment disruptions in their residents. The lack of an archetypal ‘family’ has led in the past to family therapists considering that there is little work to be done with such clients. This leaves such placements to be supported most frequently by clinicians who specialise in behaviour management and other linearly founded models of practice. The Alternate Care Clinic (ACC) is the first mental health service in New South Wales dedicated entirely to children and young people in out of home care with a high level of complex needs. This article examines the systemic therapeutic model the clinic has developed in the last two years. In particular, the article seeks to explore the importance of ‘meaning making’ in a diffuse parental system, particularly with regards to the term ‘family’. The complexities of working in this area and possible ways forward are illustrated with a closely worked case study.

The following interview was conducted during the 29th Australian Family Therapy Conference, September 29 to October 3, 2008, at The University of Queensland, Australia. Paolo Bertrando, psychiatrist and systemic psychotherapist, was trained in Milan by Gianfranco Ceechin and Lugi Boscolo, with whom he collaborated in the 1990s. His present interests concern the dynamics of systemic therapy, the use of systemic therapy with individuals and the relevance of emotions for systemic practice. Michael Locke works as a consultant in practice development and service delivery systems at Centacare Catholic Family and Community Services, Brisbane. He has worked in both public and community based agencies utilising both systemic and brief therapy orientations with individuals, couples and families.

This study investigates ways in which systemic psychotherapists address sexual issues. Qualitative data were collected through semi-structured group and individual interviews and analysed using discourse analysis. Particular attention was paid to participants' accounts of the ‘resources’ they draw on and of perceived ‘constraints’ when approaching the subject of sex. Main findings indicate that systemic training and practice would benefit from greater inclusion of sexual issues to overcome current deficiencies in the field.

In this article we explore and discuss the relevance of the concept of powerlessness in systemic practice. The views and concerns of systemic trainees' groups are compared with those of experienced therapists'. We interviewed 12 experienced systemic therapists and investigated what made them feel powerless and how they dealt with it. Extracts from interviews are quoted and summarised in the text. We argue that therapists' powerlessness is a marginalised subject in the systemic approach and that open discussion about the topic would enhance therapists' self-reflexivity and contribute to a fuller understanding of the part that power and powerlessness play in the therapeutic relationship. We consider the place of gender, culture and wider sociopolitical contexts in the experience of therapists' powerlessness. Finally we discuss the implications of our findings for systemic therapy, training and supervision.