The UK's Postgraduate Medical Education and Training Board (PMETB) went live on 30 September 2005. This editorial summarises the state of play and informs members of the Royal College of Psychiatrists and stakeholders of the changes that have taken place in the intervening year and of the College's response. The College has received provisional approval of its core curriculum, and specialty curricula have been submitted for approval. We are in the middle of pilot work on workplace-based assessments and preliminary results should be available in the early part of 2007, when trainees and educational supervisors will begin training in the preparation for and carrying out of these assessments.

Medical practice must be regulated, but the form this currently takes is increasingly based on a ‘technical’ view, which wrongly assumes that practice is straightforward and that error is the result of individual failure. The metaphor of ‘delivery’ is currently used to characterise medical practice but this usage is fundamentally flawed. An alternative is presented, supported by a growing literature, that shows that professional practice generally (and medical practice in particular) is characterised by complexity, uncertainty and unpredictability. Practitioners use their judgement and wisdom, developed in their own practice and in their contacts with fellow practitioners. Often, practitioners choose between options that are not ideal, and may need to decide on what they believe is best for an individual rather than what is ‘right’ in some absolute sense. Doctors must find ways of giving a clearer account of their practice, and in so doing become more truly accountable.

There is much uncertainty in psychiatry, particularly because of conflicting values. Awareness and tolerance of ambiguity are necessary for a psychiatrist, but they do not obviate the need for improved regulation, both at the level of the protocol and for overseeing performance. The professional should not to be free from regulation but should be an active participant in developing and improving it.

Paranoid and suspicious thoughts are a significant clinical topic. They regularly occur in 10–15% of the general population, and persecutory delusions are a frequent symptom of psychosis. In the past, patients were discouraged from talking about paranoid experiences. In contrast, it is now recommended that patients are given time to talk about them, and cognitive–behavioural techniques are being used to reduce distress. In this article we present the theoretical understanding of paranoia that underpins this transformation in the treatment of paranoid thoughts and summarise the therapeutic techniques derived. Emphasis is placed on the clinician approaching the problem from a perspective of understanding and making sense of paranoid experiences rather than simply challenging paranoid thoughts. Ways of overcoming difficulties in engaging people with paranoid thoughts are highlighted.

Machines will replace therapists and counsellors. This was the confident prediction made a decade ago. In this article, I discuss the inherent limitations of machines as conversationalists that have prevented the prediction from coming true. Machines can, however, be exploited to assist therapy and I consider the following digital tools: test administration; managing procedural, symptom-relieving cognitive–behavioural therapies; providing virtual environments for immersive behavioural therapies and for e-learning; and assisting training through automated discourse analysis and the use of cognitive maps.

The physical co-presence of psychotherapist or counsellor and client has been considered essential to the development of the therapeutic relationship. Psychotherapists have often, therefore, been resolutely opposed to anything other than face-to-face therapy. The richness and ubiquity of internet communication is likely to change that. I consider here the circumstances in which internet psychotherapy is indicated, some of the new problems it poses, including boundary-keeping and ethics, along with some solutions to these problems. The potential of the internet has already been exploited by many clients themselves and I conclude with a consideration of the growth of internet-based peer support groups.

Cannabis is the most commonly used illicit drug in the UK and a significant proportion of users have symptoms of dependence. In addition, there are a number of adverse consequences of use, including an association with psychotic disorders. Thus there is a need for effective treatment of cannabis misuse. Psychological therapies have been developed based on principles of motivational interviewing, cognitive–behavioural therapy and relapse prevention. The evidence base for these therapies is explored in this review, and studies targeting both adult users and young people are considered. Possible new pharmacological treatments are also discussed.

Since its original conception by Bowlby to explain an important evolutionary function of the child–caregiver relationship, attachment theory has been supported by much empirical research in a variety of settings. However, although attachment theory began as a clinical enterprise, its wider application to the everyday clinical understanding of adult mental health problems has lagged behind the available research. The theory can afford valuable insight not only into the developmental nature of common psychiatric disorders, but also into the development of the therapeutic relationship. This article gives an overview of (a) the current conceptualisations of attachment and the measurement of attachment for clinical research purposes and (b) the application of attachment theory to different psychopathologies. The importance of attachment to the therapeutic relationship will be discussed in a future article.

Over the years, the number of mentally disordered offenders in England and Wales subject to restriction orders has steadily increased. The Home Secretary, through the Mental Health Unit at the Home Office, is responsible for overseeing the treatment of these individuals. As psychiatrists work in partnership with the Mental Health Unit in the treatment of these patients, it is essential to understand the Unit's role and functions. In this article, we describe the philosophy, structure and functions of the Mental Health Unit and its statutory role in the care of mentally disordered offenders subject to restriction orders.

Srinivas et al provide a comprehensive guide to the law, regulations and practice concerning the management of ‘restricted patients', who are the responsibility of both the clinical services treating them and the Home Office. In doing so, they make the assumption, with apparent approval, that there is a ‘partnership’ between clinicians and the Home Office. However, partnership assumes parties working towards a common goal on an equal footing. Neither assumption is correct here. Although forensic mental health services direct themselves explicitly towards enhancing public safety, they do so in conjunction with treatment aimed at the relief of dysphoria in the patient. The interest of the Home Office in the patient's mental health is solely in terms of its impact on the risk of harm to others. There is therefore no ‘partnership’. Rather, there is constructive tension between agencies working towards differently valued and balanced objectives. Certainly the relationship is not one of equal power.

Psychiatry is the branch of medicine concerned with the diagnosis, treatment and study of psychological disorders. The role of the psychiatrist evolves to reflect developments in medicine, science and society. The scientific knowledge base required for the practice of psychiatry changes from generation to generation, but many of the fundamental principles of practice remain essentially unchanged. We attempt here to identify some of these (relatively unchanging) principles and explore their relevance to contemporary psychiatry. In particular, we focus on the work of some of the more reflective physicians of history (e.g. Sir Robert Hutchison, Sir William Osler) in order to identify and interpret principles of medical practice outlined in the 19th and 20th centuries and we explore the relevance of these conceptual frameworks to the practice of psychiatry in the 21st century.

It is remarkable that any of the advice given to medical students 70 years ago should still be relevant today. But none of it now makes sense without reference to the two-way relationship we share with our patients. We should be asking not what the doctor should be blessed with by the world, but what the patient should require of the doctor. This would include humanity, humility, honesty and especially wisdom.