Effective processes of change generally begin with a trigger event, a period of reaction and uncertainty, and finally a tipping point. This is no less the case in the field of mental health, where major change has frequently come about as a consequence of failures or crisis in service delivery. Too often when this happens the reaction is to seek immediate solutions based on a need to be seen to act. However, this encourages an oversimplification of complex problems and a tendency to deny uncertainty and the limits of existing knowledge. The result can be decision-making driven by the immediate reaction to events and the need to resolve public and political anxieties. The best evidence base has not always been the key determinant of policy established in this way and any impact on outcomes for either public or patients has not always been that expected.

It is rewarding, therefore, to find that in one area of policy, the national concern about dangerous offenders has generated a momentum in research, practice and training and has resulted in a positive tipping point for policybased practice on learning.

The long history of public prejudice, clinical ambivalence and the associated exclusion of patients with personality disorder from health and social care treatment services has been a troubling one. Too often our lack of knowledge and skills has been concealed by an underdeveloped judgement on the treatability of patients. Mainstream psychiatry has struggled with the absence of appropriate practice skills for complex psychological conditions and, although work on improving the treatment of severe and moderate mental illnesses has made significant progress in the past half-century, interventions for personality disorders have been harder to crack. The development of social therapies, in particular therapeutic communities, has been one of the few areas of optimism. However, this has been undermined by the difficulty of research into complex dynamic relational models of treatment and the sheer complexity of cases and measurable outcomes. In consequence, there has been a widespread need for improved practice skills underpinned by sound research.