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Deliberate practice (the seeking of situations in which one's skills are
challenged and thus improved) is key to the acquisition of clinical
expertise. This editorial outlines the philosophy of deliberate practice and
potential difficulties in making use of it in psychiatry.
I discuss the productive interface between psychiatry and the arts in the
20th century and ask whether such an interface is likely to remain as
vibrant into the 21st. I review how new models of mental functioning that
have an impact on current psychiatric practice have a wider cultural
relevance. This editorial looks forward to a series of articles in future
issues of APT which will explore some of these ideas in
People turn to poetry and to psychotherapy when in states of heightened
emotion – love, elation, despair, death and loss. Through the analysis of a
particular poem this article suggests that there are formal similarities
between poetry and psychotherapy that can illuminate the workings of the
latter. Perhaps the most overarching of these is mentalisation: the capacity
to ‘think about feelings’ or to be ‘mind-minded’. Finding the ‘right words
in the right order’ is a task for therapists and their patients as well as
for poets, since the appropriate image or metaphor can mirror or evoke
feelings in the listener in a way that facilitates empathic attunement. If
feelings can be objectified, their power to distress or overwhelm is
mitigated. Thus, poetry and psychotherapy are similarly concerned with
processes of repair of the human experiential and communicative fabric.
Choice, responsibility, recovery and social inclusion are concepts guiding
the ‘modernisation’ and redesign of psychiatric services. Each has its
advocates and detractors, and at the deep end of mental health/psychiatric
practice they all interact. In the context of severe mental health problems
choice and social inclusion are often deeply compromised; they are
additionally difficult to access when someone is detained and significant
aspects of personal responsibility have been temporarily taken over by
others. One view is that you cannot recover while others are in control. We
disagree and believe that it is possible to work in a recovery-oriented way
in all service settings. This series of articles represents a collaborative
dialogue between providers and consumers of compulsory psychiatric services
and expert commentators. We worked together, reflecting on the literature
and our own professional and personal experience to better understand how
choice can be worked with as a support for personal recovery even in
circumstances of psychiatric detention. We were particularly interested to
consider whether and how detention and compulsion could be routes to
personal recovery. We offer both the process of our co-working and our
specific findings as part of a continuing dialogue on these difficult
We consider the value of dialogue between healthcare professionals and
mental health service users with severe mental illnesses. Discussion with
the service user before, during and after a psychiatric crisis should help
services to offer choice even to individuals under compulsory detention.
We outline how the values-based approach adopted in training materials
supporting the Mental Health Act 2007 for England and Wales will complement
recovery-based practice in compulsory psychiatric detention.
We have developed this succession of articles as a series of iterative
steps, each seeking to uphold the recovery values of co-working and
collaboration, looking for agreement and commonality but valuing equally
diverse viewpoints and difference. Our conclusion is that this is the
beginning of a creative dialogue on choice as a route to recovery for people
who are psychiatrically detained. We commend our method of engaging with the
inevitable tensions and dilemmas by: clarifying the story behind difficult
interactions, identifying the relevant guiding principles and jointly
working to explore from different viewpoints what can be done to promote
This article focuses mainly on issues regarding doctors' clinical
performance (capability) and behaviour (conduct), and is aimed at medical
managers who deal them. It covers identifying problems and how to manage
them, describes typical underpinning (disciplinary) frameworks and sets out
the role of the UK's National Clinical Assessment Service and other external
bodies in more serious cases.
It takes courage, leadership and planning to successfully implement a
smoke-free policy in mental health settings. The content of the policy is
crucial in setting parameters for implementation. Management and clinicians
should work closely together to develop and coordinate the implementation
strategy, ensuring that resources are effectively used and deadlines are
met. Key success factors are effective management at both central and local
levels, as well as consultation with service users, carers and staff to gain
support for the policy and obtain suggestions for improvement. Other
important factors are advance planning, recruitment of experienced staff,
effective communication and extensive training of staff in smoking cessation
support. Local teams should develop appropriate procedures based on the
policy. They should work closely with the central management team. The
resources developed and obtained by local teams should be shared throughout
the organisation and should be tailored to meet the needs of particular
This article reviews the current literature regarding treatments for smoking
cessation in both the general population and in those with mental health
problems. The gold-standard treatment for the general population is
pharmacotherapy (nicotine replacement therapy, bupropion or varenicline)
coupled with individual or group psychological support. This is also
effective in helping people with mental illness to reduce or quit smoking,
but care must be taken to avoid adverse medication interactions and to
monitor antipsychotic medication in particular as cigarette consumption
Smoking is the largest single cause of preventable illness in the UK. Those
with mental health problems smoke significantly more and are therefore at
greater risk. The new Health Act (2006) will require mental health
facilities in England to be completely smoke-free by 1st July 2008. This
article reviews the current literature regarding how smoking affects both
the physical and mental well-being of people with mental health problems. It
also considers the effects of smoke-free policy in mental health
A good medical history is an essential starting point in ensuring that the
physical health needs of people with severe mental illness are addressed.
Psychiatrists have an important role in helping to tackle the general ill
health, excess of undiagnosed physical illness and reduced survival rates
among their patients. To do this they need to use their medical training,
communication skills and regular contact with patients. Assessments should
include family history, past and current physical health, medication,
lifestyle, healthcare and physical symptoms. Some groups of patients will
need more detailed assessments.
Intellectual and other more specific neurocognitive impairments in
schizophrenia are important for understanding the aetiology of the condition
and its likely outcome. However, these impairments are not usually
considered important for supporting a diagnosis in suspected early
schizophrenia. IQ testing is widely available and probably acceptable to
most people likely to be experiencing the early stages of psychosis and who
might be unable or unwilling to disclose details of their history and mental
state or to cooperate with more comprehensive neuropsychological assessment.
Although in general IQ tests have only limited diagnostic value in
schizophrenia, the finding of a substantial decline in IQ score from the
estimated premorbid level may be helpful in supporting a provisional
diagnosis of early schizophrenia in cases without organic signs in which the
clinical picture is unclear or incomplete. More important, the results of IQ
tests may contribute to a better understanding of patients' impairments and
assist clinical management in a number of ways, as illustrated here by three
fictional case studies.