In politics some things can happen very quickly when a sufficient head of steam has been built up, as we have seen in the recent European Community election results. The message from the medical profession about the proposed changes in the NHS may now have been understood by politicians but we should never assume that governments will withdraw foolish or damaging proposals, so the time is ripe for renewed pressure for their withdrawal.

Working for Patients and the subsequent Working Papers mention psychiatric services explicitly only twice. The proposals have been formulated for patients requiring tests and treatment for elective surgical conditions. They are the conditions which are believed to be predictable and therefore the most receptive to contractual specification and pricing. The health care contract is to be central to the new NHS. It is the device by which the Department of Health hopes to produce a fundamental change in attitude by both doctors and managers. Kenneth Clarke seems much more concerned with this attitudinal shift than with the detail of what the NHS might resemble a decade from now. This omission of overt consideration of psychiatric services does not allow us to ignore the White Paper. I intend to focus on the potential implications of the proposed themes for psychiatric services, particularly in the context of what they might indicate about the Government response to Community Care: Agenda for Action.

Huntington's disease is associated with a considerable psychiatric morbidity and mortality. These risks are not confined to the sufferer. The relations of victims, both biological and legal, are also at high risk for significant psychosocial dysfunction (O'Shea & Falvey, 1988). Despite recent advances in genetic research, there is still no cure for this chronic choreodementia syndrome. Medical management is confined to palliation of symptoms. The doctor and the patient's family, in the face of this unpleasant disease, are wont to exercise a variety of psychological defences which may hinder the delivery and receipt of adequate support (Martindale, 1987).

In each of three mental handicap hospitals I have observed an institutional disorder. From consideration of these I have suggested a classification. I have analysed the aetiology and pathogenesis of some of these disorders and discuss the treatment and prognosis.

There is increasing recognition that people with a mental handicap who also suffer from psychiatric disorder will need specialised services. Those with major psychiatric disorders may need periods of hospital in-patient care but treatment as out-patients or day-patients may be more appropriate for those with neurotic disorders, behaviour or conduct disorders, problems of adjustment or personality problems. Many such psychiatric difficulties are amenable to treatment by therapies commonly used in general psychiatry. However, the treatment process can be prolonged and may need modifying so that there is always a ‘concrete’ or ‘practice’ base for handicapped persons who may have limited or no ability to conceptualise abstract ideas, although able to gain insight and modify their behaviour when taught appropriate skills and strategies.

It is now widely recognised that families represent a hidden and largely unacknowledged resource to the NHS in the day to day management of long-term disabilities, particularly severe mental problems like schizophrenia. It is most likely that 50–60% of first admission schizophrenic patients will return to some type of family environment and a significant number will remain with the family for a considerable time. The current trend towards community management of mental illness, hampered by the lack of community provision, almost inevitably means discharge to families and is likely to continue and increase further.

From the plethora of articles examining the role of individual disciplines within the community mental health team, one discipline appears almost conspicious by its absence. How has occupational therapy become the forgotten speciality?

The following is a descriptive study of Willoughby Ward, a psychiatric intensive care unit, opened in Parkside Hospital, Macclesfield, in July 1986. It provides a moderately secure facility for the treatment of psychiatric patients within both Crewe and Macclesfield Health Authorities. The unit has 15 beds, of which two are funded and used by Crewe area, where, unlike Macclesfield, the psychiatric unit is located in the district general hospital. Managed as a locked ward, the patients are admitted under the provisions of the Mental Health Act 1983. As well as being mentally ill as defined in the Act, the patients were disturbed to a degree as to be unmanageable in open conditions.

Consultation is a term that can have many different meanings. In this paper, it is used in the sense that Caplan (1964) defines as mental health consultation, to describe the interaction between a consultee and consultant who meet to facilitate some area of mental health work in which the consultee is involved. By working with workers instead of directly with clients, the consultant aims to offer a service to a greater number of people than would otherwise be possible and to have a preventive role with earlier detection and management of mental health problems.

The topic of homosexuality has often aroused strong opinions among the public and professionals alike. In a study organised by the journal Modern Medicine in 1969, 17, 741 physicians in the USA responded to a questionnaire. Of those who stated their speciality, 8% were psychiatrists, 26% general practitioners and 10% general surgeons. Questions sought opinions on abortion, legalisation of marijuana, legalisation of homosexual practice and other topics; 92% of psychiatrists [n 2,041] were in favour of legalising homosexual practices. The three specialities least in favour were general practitioners 59% [n 6,927], general surgeons 59% [n 2,580] and orthopaedic surgeons 58% [n 731]. The sample was self-selected and this may have introduced a respondent bias. The data were collected nearly 20 years ago when homosexuality was still seen as a psychiatric illness in the American Psychiatric Association's Diagnostic and Statistical Manuals I and II.

Since the establishment of a separate Royal College of Psychiatrists and membership examination, psychiatry has been progressively acquiring a special identity of its own that bridges the social and biological sciences. The University of Leicester Psychiatric Training Scheme has responded to the recently revised Membership Examination by developing a two year modular academic programme, which complements the traditional medical (diagnostic) organisation of teaching by incorporating social and psychological views of the subject, which reflect the lessons of modern psychiatric research. It is hoped that the development of a more eclectic approach to the subject and its practice will complement the multidisciplinary and growing community orientation of the profession. We describe here our first attempts to provide an academic programme that responds sympathetically to these important developments.

Mental health services in general are at present receiving a bad press. Recent complaints focus on two main areas: the widespread prescription of tranquillising drugs, and the social consequences of the policy of community care. There is now serious concern, both among the public and in the profession, about the over-prescription of tranquillisers. The legal implications are serious. An article in the Journal of the Medical Defence Union was recently quoted in the Bulletin: “Dr Ashton's article is a timely reminder that the prescription of benzodiazepines is now a high profile activity for the psychiatrist that has been scrutinised much more closely than many of our other functions. It is well to be aware that one of the potential onlookers is a lawyer” (Tyrer, 1988).

Experience in group therapy is recommended by The Royal College of Psychiatrists (1986) as an important aspect of training in psychiatry. However direct experience is unusual. It was reported in the Bulletin that a group formed by trainees in psychiatry to study the group process found a demand for personal therapy for its members (Whewell, 1987). In this paper a group is described which attempted to meet both needs.

Sexual abuse of children by family members varies in its incidence depending on the reports used but its presentation among the adult population has largely been under-reported and unrecognised by mental health workers. Since 1984 we have become increasingly aware of survivors of childhood sexual abuse within our own district service presenting initially as psychiatric cases and more recently seeking help directly for the distress which their childhood experiences have caused them. Gradually we have come to recognise the persistent negative effects of this trauma and have attempted to evolve a model for therapy which deals with this and is suitable for use within a district psychiatric service. The pattern of therapy follows the usual psychotherapeutic rules in that it is on a one-to-one basis at the same time and same place each week. It differs, however, in that the therapist is active and when necessary, directive. Our experience has taught us that each patient will present with certain common basic issues that need to be worked through. We have recognised that to do this work sensitively and efficiently it is important that all the relevant questions are asked and feelings explored. We have evolved a list of themes which we expect each therapist to cover during the contracted sessions. We believe that this ensures work is carried through to resolution. If any of the points on the list are omitted then a patient's ability to be free from the past might be impaired. The majority of our patients have been dealt with as out-patients or in a community setting, but a number may already be within the in-patient unit or day hospital setting, and, for a few, attendance at the day hospital is arranged whilst undertaking individual therapy.

This year, 1989, marks the 150th anniversary of the abolition of mechanical restraints at the Hanwell Asylum. It was, of course, John Conolly who carried out this large-scale experiment in the application of non-restraint at Hanwell. He was in charge of the diagnosis and treatment of the 800-odd pauper lunatics in this, the largest of the county asylums. Most of his patients had been insane for many years before their admission to Hanwell from the parish workhouses. The prospects of curing them were slim: Hanwell had the second lowest cure rate among the county asylums, a meagre 6% for the period 1835–1845 (Conolly, 1847).

As the move towards community based psychiatry gathers momentum, it becomes increasingly important that psychiatrists are adequately trained to take on their changing role in the new model of psychiatric care (Sturt & Waters, 1985; Lancet, 1985). Indeed, it has been recommended that “every psychiatrist should be familiar with the conduct of community psychiatry” (Freeman, 1985). Difficulties arise, however, due to the fact that there is no accepted definition of the practice of community psychiatry (Fink & Weinstein, 1979) let alone well established training programmes designed to equip future community psychiatrists to practise competently. Not surprisingly, few psychiatrists are satisfied with their community psychiatry training. Brook (1981) reported that only 38% considered their community psychiatry to be adequate in quantity and suitably supervised. Even then, their subjective view may not have reflected the actual adequacy of their training. Nevertheless, useful guidelines have been drawn up by the Collegiate Trainees Committee Working Party (Scott, 1988), outlining what would constitute a rounded training programme in community psychiatry. However, there is scant literature evaluating the usefulness of the few existing posts providing such experience