Psychological therapies are a necessary component of any mental health service. Psychiatrists will require a working knowledge of different psychological approaches and many will wish to develop clinical skills to practice at least one model of psychotherapy. Historically, most psychiatry training schemes have offered exposure to psychodynamic psychotherapies, while training in other approaches has been less systematic. The expansion of research into brief psychological therapies and a wealth of recent publications on the subject have led to an increasing awareness of the benefits of training in other models of psychotherapy. The most widely practised and researched brief psychological intervention is cognitive-behavioural therapy (CBT). This paper will outline the principles behind providing training in CBT, and the barriers to successful implementation of a training programme.

Family life in Britain is changing daily to include more stepfamilies, which have widely differing structures with varying histories, losses, transitions and economic circumstances. Of the one in five children who currently experience separation before they are 16, over half will live in a stepfamily at some point in their lives. Of the 150 000 couples with children who divorced each year at the end of the 1980s, a further 35 000 had a subsequent divorce. For some children we need to think of step-parenting within wider processes of transition, which include relationship changes of many kinds. The National Stepfamily Association have calculated that if current trends of divorce, cohabitation, remarriage and birth continue, there will be around 2.5 million children and young adults growing up in a stepfamily by the year 2000. The true pattern of re-ordering of partnership and family life is hard to chart, since many couples second or third time around prefer to cohabit rather than to marry.

The goal of psychoanalytic psychotherapy with a distressed child is to alter the child's psychic structure and function. The technique is based on the same theory as adult psychoanalytic psychotherapy (see Box 1). The unconscious is central, as is the interpretation of defence, resistance, transference, working through and the reconstruction of earlier life. It differs from adult psychotherapy in that the child's age and level of development are at all times central to the work. In young children the focus of interpretation is on free play, while with adults it is free association of ideas. In the treatment of adolescents a combination of techniques, both adult and pre-adolescent, are used, while for late adolescents the technique is basically adult technique with attention to issues relevant to that stage of the life cycle.

Guidelines are statements which help people to decide what to do. Familiar examples include the Highway Code, or the ‘How to Prepare’ instructions on a jar of coffee. Traditionally, clinicians have sought knowledge from their senior colleagues, tutors and mentors, textbooks and published articles. They will continue to do so. However, there has been a recent surge of interest in guidelines on specific clinical topics. This has been driven by interest in unexplained variation in patterns of care, concern that some care is inappropriate, and the growing demand for routine, clinically effective practice. Because clinicians have limited time and resources, it can be helpful to summarise evidence for effectiveness where it is available and provide it in a concise format (see Box 1).

The Government white paper ‘Health of the Nation’ set a target for reduction of suicide rates by 15% by the year 2000. Although the document did not make specific reference to adolescence, it is no less important an issue in this age group than in adulthood since, along with accidental death and malignancy, suicide is one of the most common causes of death in late adolescence and early adulthood and there is an upward trend (Diekstra, 1993; McClure, 1994; Diekstra et al, 1995). How the reduction should be achieved is not clear, since suicide is a rare event which is the culmination of complex processes, and present knowledge does not give a firm foundation for evidence-based practice (Gunnell & Frankel, 1994).

We describe the case of a child presenting with what initially appeared as a pervasive developmental disorder (ICD F84.1) associated with, and in our view, induced by, schizophrenic illness in the mother. Important issues are raised for both adult and child psychiatry, in particular that the failure of the Mental Health Act (1983) to address the mother's needs adequately, left the child vulnerable to her untreated illness.

In 1961 Parkes and his colleagues followed 100 people with schizophrenia for a year after their discharge from hospitals in south London and found that the general practitioner (GP) was the professional most frequently in contact with people. Only 56% attended as psychiatric out-patients, most being seen fewer than five times in the year, while 70% were in regular contact with their GPs, and when problems developed it was usually the GP who was involved first (Parkes et al, 1962).

The concept of positive and negative symptoms in schizophrenia can be traced back to Hughlings Jackson (1889) who taught that disease does not create, it sets free, and accordingly positive symptoms could be seen as ‘release’ phenomena resulting from ‘dissolution’ of the highest cerebral centres of the nervous system. Crow (1980) revived the dichotomy and proposed a Type I syndrome, characterised by positive symptoms, and a Type II syndrome, characterised by negative symptoms. He thought the latter was due to cortical atrophy and responded poorly to antipsychotic medication. In their review of the distinction, Walker & Lewine (1988) found a stronger relationship between premorbid dysfunction and negative symptoms than with positive symptoms. They also found there was a stronger influence of genetic factors on negative symptoms than positive symptoms.