Mistakes are inevitable in any branch of medicine, but psychiatry is a particularly risky business (Holloway, 1997). When psychiatrists get it wrong there may serious consequences for their patients, the clinical team and the wider public. The Government introduced a series of initiatives in the 1990s: the Care Programme Approach (1990), the supervision register (Department of Health & Home Office, 1994) and supervised discharge (Secretary of State for Health, 1997). One of the main purposes of this legislation was to minimise the risk psychiatric patients pose to the community. Future service provision will be shaped by clinical governance and the National Service Framework for Mental Health (Secretary of State for Health, 1997), and evaluation and management of risk will become increasingly important.

In recent years there has been a marked increase in the proportion of individuals with mental disorders detained in hospital involuntarily, compared to those admitted on an informal basis (Wall et al, 1999). There is also growing concern about legally incompetent patients being treated under the doctrine of necessity (Eastman & Peay, 1998). The rise in the numbers of detained patients may have come about for a variety of reasons. Suggested possible contributory factors include a reduction in psychiatric hospital beds; the move towards community care and the consequent tendency to maintain patients at home for longer; increasing comorbidity and more severely disturbed behaviour on hospital wards; and a greater number of individuals transferred to hospital care from the criminal justice system (Mental Health Act Commission, 1999). Statutory mental health legislation in the UK has remained essentially unchanged, in some cases, for nearly 15 years. There have been additions and amendments during that period, as well as new law. For instance, the Mental Health (Patients in the Community) Act 1995, dealing with the care and treatment of people with mental disorders, and the Criminal Evidence (Amendment) Act 1994, covering specific issues to do with certain groups of those suffering from psychiatric disorders. Despite this there is clear evidence from recent research from various parts of the UK that medical practitioners, most particularly psychiatrists, and even those using the Mental Health Act on a day-to-day basis, do not necessarily possess a detailed knowledge of the law. Among a random sample of Section 12(2) approved medical practitioners in the West Midlands, none of those interviewed was able to define the term mental disorder as used in the Act, and only just over one-third correctly identified the four legal categories of mental illness, mental impairment, severe mental impairment and psychopathic disorder (Bhatti et al, 1999). In similar studies undertaken in Scotland, only one in 10 of a national sample of consultant psychiatrists was able to give the statutory definition of the term mental disorder (Humphreys, 1998) and among a similar non-consultant sample only 28% were able to give the correct title and year of the Mental Health (Scotland) Act 1984 (Humphreys, 1997). It would seem important, therefore, that psychiatrists do not become complacent about their knowledge and use of the Act, even though there has been considerable debate around the issue of how much expertise and precise factual knowledge of specific legislation is actually required.

Community psychiatric teams are an integral part of modern mental health services. The development of such teams has allowed the care of patients to be transferred from institutions to the community. A Cochrane review of community-based programmes showed that community team-based psychiatric services led to a reduction in suicide rates, improved patient engagement and were more acceptable to patients (Tyrer et al, 1999). Community care also reduces the number of days patients stay in hospital, but not the number of admissions (Marshall et al, 1995). However, community mental health teams (CMHTs) have been criticised for their ambiguous and overambitious aims, and their tendency to neglect people with the most challenging health- and social-care needs (Patmore & Weaver, 1991; Sayce et al, 1991). All mental health workers are not necessarily eager, or skilled, to work effectively in teams. Building and maintaining an effective team requires commitment, clarity of purpose, a shared vision and frequent review of team operations. In a previous issue of APT, Burns & Guest (1999) described the adaptation and running of an assertive community treatment team in an inner-city area. Here I examine the attributes of effective CMHTs (Box 1), enumerate barriers and challenges to team-working (Box 2) and suggest strategies for improving team effectiveness (Box 3).

Contextual rating of social adversity has its origins in the work of George Brown and colleagues (Brown & Harris, 1978). This review evaluates its strengths and weaknesses in rating the effects of social adversity on depressive disorder. We write from the perspective of its usefulness for clinical and training purposes both to the consultant psychiatrist and to the community mental health team working in general adult psychiatry.

“Once the patient's biography becomes part of the care, the possibility that therapy will dehumanise the patient, stripping him of what is unique to his illness experience becomes much less likely” (Kleinman, 1988).

“The loss of story making and telling has its impact on failure to care for the long term chronic or incurable patient” (Hunter, 1991).

By the 1980s, one-fifth of all general psychiatrists in England and Wales (Strathdee & Williams, 1984) and one-half in Scotland (Pullen & Yellowlees, 1988) were spending some proportion of their time working in primary care. Rather than limit this process, the growth of general practice fundholding fostered it and developments in general practice total purchasing and extended fundholding have encouraged it further (Lee et al, 1999). At the same time, nationally there has been a gradual increase in referrals directly from general practitioners (GPs) to community psychiatric nurses (CPNs). Referrals from GPs constituted 37% of all referrals to CPNs in 1990 and 46% in 1996 (Brooker & White, 1997: further details available from L.G. upon request), even though there has been a trend away from the primary care service base (21% in 1990 compared with 14% in 1996).

Post-modernism is a term that is omnipresent in the media, academic circles and contemporary culture. It is also a term that has caused substantial consternation among systemic family therapists. Systemic family therapy traces its origins from the 1950s, and there are currently several different models contained within the systemic paradigm. A unifying feature of systemic therapy is the importance placed on understanding psychological difficulties in the context of social relationships. Another point of agreement among systemic therapists is the significance of drawing distinctions and marking ‘difference’ as an aspect of creating change. A third common feature is the practice of working in teams, where one therapist conducts the interview, while a small number of others comment on their observations. The degree to which these models and practices have been influenced by postmodernism varies.

The recent film Boys Don't Cry illustrates in a highly dramatised form the problems that the phenomenon of gender identity disorder can create in an extreme situation. The film is based on the true story of a young person, Brandon, with a female body who perceived himself as a male. In the film we do not know when the issue of his male gender identity first appeared, but we see him living in a male role as a teenager trying to conceal, to his peers, the reality of his female body. (I refer to Brandon as ‘he’ because this is how Brandon presents himself in the film. The dilemma about using ‘he’ or ‘she’ typically confronts professionals in the management of teenagers like Brandon.) The struggles of these concealments are well portrayed, as in the scene when he steals tampons from a shop. He joins in male activities and displays of physical strength as a confirmation of his male role. He is well accepted as a boy within a troubled and troublesome group of young people. He falls passionately in love with a girl, Lana, who accepts him as he is without much questioning, and a close intimate relationship develops, which the peer group seems to accept. The reality of his body is eventually revealed. His girlfriend can accept the new situation, but had she really not known or had she turned a blind eye? Unfortunately, two young men become more and more disturbed by this realisation. It stirs a primitive violence in them, which leads first to Brandon's rape and then to his murder.

It is Government policy that increased attention should be given to the quality (as well as the quantity/efficiency) of clinical care. To achieve this, it has set national standards through the National Service Framework for Mental Health (NSF–MH; Department of Health, 1999a) and the National Institute for Clinical Excellence (NICE).