In ancient Japan, written characters and religions were largely based on Chinese cultures. The first foreign physician was invited from Korea to Japan during the Shiragi Dynasty, when an Emperor became ill at the beginning of the 5th century. Since then, Chinese medicine dominated in Japan until Western medicine was introduced in the middle of the 19th century.

The 1975 White Paper Better Services for the Mentally Ill recognises different roles for day hospitals, day centres and the voluntary sector in the provision of psychiatric day care. Two broad client groups, needing short-term support or long-term care, are described. However, Vaughn (1983 and 1985) and Wilkinson (1984) have reviewed lack of co-ordinated planning in the provision of services and the placement of clients. Carter (1981) in a major survey of day care, showed that in many cases it was difficult to differentiate between day hospital and day centre services or client groups.

In order to plan a comprehensive psychiatric service for County Clare, it was necessary to divide the county into four sectors, North, East, South and West. The area I am discussing is the West Sector, which covers 800 square kilometres and has a population of 20, 000. Kilrush town is the capital of the West Sector situated 50 kilometres from the main hospital in Ennis. Psychiatric morbidity was noted to be high in this rural area. Prior to opening a Day Hospital in Kilrush (May 1986) we were using 15 beds in the acute unit. Now we are using, on average, five beds at any given time.

The publication Caring for People: Community Care in the Next Decade and Beyond (DoH, 1989) sets out the Government's plans for community care and is the much awaited response of Government to Sir Roy Griffiths' report on community care. Many health districts have been doing all, if not more, than is recommended in the White Paper but this has been rather costly as far as the DSS funding is concerned. It should be remembered that the high cost of community care to the DSS was one major reason for Sir Roy being asked to investigate and report on such care.

A legal finding of unfitness to plead results in automatic committal of the accused to a mental hospital. In Scotland, if criminal proceedings are under solemn jurisdiction, there is a mandatory order restricting discharge without limit of time and the hospital must be a state hospital unless for special reasons an alternative hospital is appropriate (Section 174 of the Criminal Procedure [Scotland] Act 1975). The mental condition of a person found unfit to plead may subsequently improve such that he may become fit to be tried in the normal way. In England and Wales the Home Secretary has power, under Section 5(4) of the Criminal Procedure (Insanity) Act 1964, to remit to prison for trial a person found unfit to plead who subsequently recovers. On arrival of such a person in prison the hospital and restriction orders cease to have effect. The Criminal Procedure (Insanity) Act 1964 does not apply to Scotland; authority to reprosecute unfit defendants in sheriff courts and the High Court rests exclusively with procurators fiscal and the Crown Office respectively. The status of the original hospital and restriction orders in reprosecuted cases is unclear.

In 1973 a survey was carried out of male schizophrenic patients who had become long-stay residents in Leverndale Hospital, Glasgow, ‘long-stay’ being defined as having been continuously in hospital for more than three years (Todd et al, 1976). The patients were recruited from a four year cohort of admissions in the years 1967 to 1970 inclusive. In the following years there have been many changes in the provision of facilities and in clinical practice. In some countries, such as Italy, the USA and England, there has been a strong drive to reduce long-stay populations along with the closure of some mental hospitals. In Scotland the process has been much more gradual, possibly reflecting the differences in preexisting provisions and patterns of care.

This paper is based on experiences over the past three years in North Devon (population 140, 000), a predominantly rural district that until 1986 based most of its psychiatric facilities in a large mental hospital in Exeter, nearly 40 miles away. When Exeter went ‘Italian’, services were devolved to local districts, and North Devon was given the responsibility for providing comprehensive psychiatric care based on a DGH unit, a Day Centre, two hostels and a small multidisciplinary team. No formal psychotherapy services were included in this plan. This is a familiar enough pattern, one that can be found throughout Europe and North America. I shall try to chart the movement from the heady days of decarceration to current uncertainties about community care, a state which might be called post-deinstitutionalism.

This article argues for a new initiative in the training and appointment of consultants in behavioural psychotherapy or with a special interest in behavioural psychotherapy.

Cognitive behaviour therapy is now widely accepted clinically as a treatment for depression and anxiety, and there is increasing research evidence to confirm its efficacy (Rush et al, 1977; Blackburn et al, 1981; Murphy et al, 1984; Butler et al, 1987; Beck, 1988). Of the various short term psychotherapies currently available, it is probably the most widely known and best researched. Despite this, and the recommendation of the Royal College of Psychiatrists (1986) that trainees receive training in cognitive therapy, there is little opportunity to gain a formal training in this psychotherapy. Short workshops are often available through the British Association for Behavioural Psychotherapy and from other sources, and ad hoc supervision from interested psychologists and psychiatrists may be available in some centres. Scott et al (1985) described a workshop and peer supervision training scheme in Newcastle. Macaskill (1986) reported a course for psychiatrists in training in Sheffield which extended over 20 weeks and combined Beck's cognitive therapy and Ellis' Rational Emotive Therapy.

The library of the Institute of Psychiatry is undoubtedly internationally oriented; it stocks writings in languages ranging from German to Chinese. As a foreigner one is bound to be on the look-out for texts in one's own language. In my case this search has until now been unsuccessful. After the librarian asked me whether the Dutch write about psychiatry at all, I have actually given up but at the same time I decided that it was my task to increase awareness of Dutch psychiatry among my colleagues. Although it is true that the Dutch have accepted English as the international scientific language more than any other members of the European Community, Flemish and Dutch psychiatrists do continue to publish in their native language by means of the Tijdschrift voor Psychiatrie, a journal which differs from, for example, its British counterpart by the emphasis it puts on case studies, psychotherapy and philosophical/historical issues rather than on research in the internationally accepted format.

The issue of crime and insanity in Victorian Britain is dominated by the 1843 case of Daniel McNaughton. Hounded by paranoid delusions, about which he was relatively unforthcoming despite detailed questioning, he succeeded in shooting Henry Drummond, private secretary to the Prime Minister, Robert Peel. Thinking that it was Peel himself he had shot, McNaughton is quoted by the arresting policeman as stating “he shall break my peace of mind no longer”. The furore over his trial and non-execution filtered down the century, via the McNaughton rules. Daniel himself mouldered in Bethlem and Broadmoor for the rest of his days (West & Walk, 1977, esp. p. 93). But much more prevalent in the public's eye were the seven (at least) serious assaults on the Queen. Not only did they bring about a new criminal charge (vide infra) – but their recurrence tended to promote pro-royalist sympathies as well as pro-custodial attitudes towards “the insane”.

In the wee midnight hours, long ‘fore the break of day In the wee midnight hours, long before the break of day When the blues creep upon you and carry your mind away.

A useful part of the MRCPsych residential revision course at the University of Surrey in Guildford is the mock clinical examination. One of the peculiarities of the mock examination for the Membership course which I attended was that all examinees interviewed patients in one large hall. I found it intriguing to observe the note-taking techniques of my equally nervous colleagues. It seemed to me that there was little organisation in the way candidates wrote down the information acquired from their interviews. Most people left the hall clutching a jumble of disjointed sheets of paper to start a scrambled five minutes of hasty preparation before presenting the case. Much of this precious time was then spent attempting to decipher and organise their notes, when clearly it would have been better employed in thinking and trying to anticipate likely questions.

If three psychiatrists are needed to change a light bulb — one to change the bulb and two to interpret the experience — how many does it need to operate a computer? Judging by the attendance at the 1989 CIPG meeting, held at Keele University in October, the answer is about 54.