Shame and self-criticism are transdiagnostic problems. People who experience them may struggle to feel relieved, reassured or safe. Research suggests that a specialised affect regulation system (or systems) underpins feelings of reassurance, safeness and well-being. It is believed to have evolved with attachment systems and, in particular, the ability to register and respond with calming and a sense of well-being to being cared for. In compassion-focused therapy it is hypothesised that this affect regulation system is poorly accessible in people with high shame and self-criticism, in whom the ‘threat’ affect regulation system dominates orientation to their inner and outer worlds. Compassion-focused therapy is an integrated and multimodal approach that draws from evolutionary, social, developmental and Buddhist psychology, and neuroscience. One of its key concerns is to use compassionate mind training to help people develop and work with experiences of inner warmth, safeness and soothing, via compassion and self-compassion.

There are many potential pitfalls in the identification and enlistment of suitable candidates for psychiatric research. The challenges of recruitment are highlighted, detailing impact of study design, characteristics of participants, including demographics and personal preferences, investigator characteristics and collaboration with clinicians. Techniques used in recruitment are discussed, including financial incentives, assertive tracking and communication methods. Ethical issues, methods of data collection, and control participants are also considered. Key issues are: early consideration of the impact of study design on the recruitment process; the participant's perspective; close collaboration with colleagues; the investigator's good interpersonal, communication and organisational skills; and feedback to collaborators, associated clinicians and participants.

Stigma is defined as a sign of disgrace or discredit, which sets a person apart from others. The stigma of mental illness, although more often related to context than to a person's appearance, remains a powerful negative attribute in all social relations. Sociological interest in psychiatric stigma was given added vigour with the publication of Stigma – Notes on the Management of Spoiled Identity (Goffman, 1963). More recently, psychiatrists have begun to re-examine the consequences of stigma for their patients. In 1989, the American Psychiatric Association's annual meeting's theme ‘overcoming stigma’ was subsequently published as a collection of articles (Fink & Tasman, 1992), and last year saw the launch of the Royal College of Psychiatrists' five-year Changing Minds anti-stigma campaign.

The World Health Organization has described poverty as the greatest cause of suffering on earth. This article considers the direct and indirect effects of relative poverty on the development of emotional, behavioural and psychiatric problems, in the context of the growing inequality between rich and poor. The problems of children in particular are reviewed. Targets to reduce inequality have been set both nationally and internationally.

Writing about traumatic, stressful or emotional events has been found to result in improvements in both physical and psychological health, in non-clinical and clinical populations. In the expressive writing paradigm, participants are asked to write about such events for 15–20 minutes on 3–5 occasions. Those who do so generally have significantly better physical and psychological outcomes compared with those who write about neutral topics. Here we present an overview of the expressive writing paradigm, outline populations for which it has been found to be beneficial and discuss possible mechanisms underlying the observed health benefits. In addition, we suggest how expressive writing can be used as a therapeutic tool for survivors of trauma and in psychiatric settings.

Trauma-informed approaches emerged partly in response to research demonstrating that trauma is widespread across society, that it is highly correlated with mental health and that this is a costly public health issue. The fundamental shift in providing support using a trauma-informed approach is to move from thinking ‘What is wrong with you?’ to considering ‘What happened to you?’. This article, authored by trauma survivors and service providers, describes trauma-informed approaches to mental healthcare, why they are needed and how barriers can be overcome so that they can be implemented as an organisational change process. It also describes how past trauma can be understood as the cause of mental distress for many service users, how service users can be retraumatised by ‘trauma-uninformed’ staff and how staff can experience vicariously the service user's trauma and can themselves be traumatised by practices such as restraint and seclusion. Trauma-informed mental healthcare offers opportunities to improve service users' experiences, improve working environments for staff, increase job satisfaction and reduce stress levels by improving the relationships between staff and patients through greater understanding, respect and trust.

‘Recovery’ is usually taken as broadly equivalent to ‘getting back to normal’ or ‘cure’, and by these standards few people with severe mental illness recover. At the heart of the growing interest in recovery is a radical redefinition of what recovery means to those with severe mental health problems. Redefinition of recovery as a process of personal discovery, of how to live (and to live well) with enduring symptoms and vulnerabilities opens the possibility of recovery to all. The ‘recovery movement’ argues that this reconceptualisation is personally empowering, raising realistic hope for a better life alongside whatever remains of illness and vulnerability. This paper explores the background and defining features of the international recovery movement, its influence and impact on contemporary psychiatric practice, and steps towards developing recovery-based practice and services.

Catha edulis (khat) is a plant grown in the countries around the Red Sea and on the eastern coast of Africa. Its leaves are chewed by the local people for their stimulant action. Its principal active constituents are cathinone and cathine, which have sympathomimetic actions. Migration of Africans from these countries has spread the habit of khat chewing to the West. Chewing khat has a number of important psychological and physical sequelae. ‘Khat-related’ psychosis is very similar to that seen following use of amphetamines.

Subscribers to the medical model of the causation of madness and distress emphasise the role of genes and can severely underestimate the impact of traumatic events on the development of the human mind. This bias persists despite the worldwide popular wisdom that mental illness arises when bad things happen to people. Childhood physical and sexual abuse and neglect are extremely common experiences among those who develop serious mental health problems. Unfortunately, victims are typically reluctant to disclose their histories of abuse and practitioners are often reluctant to seek it. We explore the nature and extent of the problem and the apparent reasons for the pervasive neglect of this important area of care. Then, on the basis of our experience in New Zealand, we provide guidelines on asking patients about childhood abuse and describe an ongoing initiative in the UK to further advance our understanding of the impact of abuse and our skills to detect it and treat survivors.

Patients miss about 20% of scheduled appointments for mental health treatment, almost twice the rate in other medical specialties. Up to 50% of patients who miss appointments drop out of scheduled care. Many who miss appointments because of slips and lapses later rearrange their appointments without adverse consequences. Those that do not are at risk of further deterioration, relapse and hospital readmission. Predictors of non-attendance are complex and linked with the predictors of missed medication. Service barriers and administrative errors are common but are often overlooked in the absence of feedback from patients. Of prime importance are the therapeutic alliance and degree of ‘helpfulness’ of the clinician but again these are rarely measured routinely. Useful markers of engagement include patient-rated trust, satisfaction and degree of perceived participation in treatment decisions. Much can be done to improve attendance in most services. Simple measures such as offering prompt, convenient appointments, offering reminders and augmenting with telephone contact have a reasonable evidence base. Scales to assess therapeutic alliance are now available. Complex interventions need to be evaluated carefully in order that the overall benefits outweigh costs. We suggest that clinicians consider accessibility, discharge policies and patient feedback when examining local rates of non-attendance.

Human beings have moved from place to place since time immemorial. The reasons for and the duration of these migrations put extraordinary stress on individuals and their families. Such stress may not be related to an increase in mental illness for all conditions or to the same extent across all migrant groups. In this paper, we provide an overview of some observations in the field of migration and mental health, hypothesise why some individuals and groups are more vulnerable to psychiatric conditions, and consider the impact of migration experiences on provision of services and care.

It is increasingly recognised that pharmacological treatments for dementia should be used as a second-line approach and that non-pharmacological options should, in best practice, be pursued first. This review examines current non-pharmacological approaches. It highlights the more traditional treatments such as behavioural therapy, reality orientation and validation therapy, and also examines the potential of interesting new alternative options such as cognitive therapy, aromatherapy and multisensory therapies. The current literature is explored with particular reference to recent research, especially randomised controlled trials in the area. Although many non-pharmacological treatments have reported benefits in multiple research studies, there is a need for further reliable and valid data before the efficacy of these approaches is more widely recognised.

This article summarises the current research evidence base on user involvement in mental health services from both policy and practical perspectives. We begin by examining the many meanings of the term ‘mental health service user’ and the policy imperatives for user involvement, to provide a context for later examples of good practice. We then discuss what is meant by ‘involvement’ and the reasons why user involvement is particularly important in mental health services. Finally, we describe some of the traditional barriers to involvement and a number of examples of positive practice across a range of different aspects of mental health service development and delivery.

The syllabus for higher training in forensic psychiatry requires knowledge of the therapeutic uses of security, although there are no references to this in standard texts. Similarly, the process of mapping a mental health service is an essential first step in planning, audit and needs assessment. All mental health services, not just forensic services, are organised to stratify patients according to the risk they present so that they can be cared for in an environment that is safe but imposes the minimum necessary restrictions and intrusions. Forensic mental health services differ from other mental health services mainly by including subsystems which are at higher levels of security than those necessary in local services. Although they have a general orientation towards risk awareness and risk management, they remain integral parts of the mental health services for the populations they serve.

Epidemiological studies measuring prevalence rates and factors associated with mental health problems in adults with learning disability have produced very different and sometimes contradictory results, mainly because of methodological problems. Consequently, much of the epidemiology of mental health problems in this population is still unknown, although improved methodology and additional information are emerging. This article describes the methodological difficulties of studies, the reported prevalence rates in the context of these difficulties and what is currently known about the factors associated with mental health problems in this population.

Over the course of a year, about three-quarters of patients prescribed psychotropic medication will discontinue, often coming to the decision themselves and without informing a health professional. Costs associated with unplanned discontinuation may be substantial if left uncorrected. Partial non-adherence (much more common than full discontinuation) can also be detrimental, although some patients rationally adjust their medication regimen without ill-effect. This article reviews the literature on non-adherence, whether intentional or not, and discusses patients' reasons for failure to concord with medical advice, and predictors of and solutions to the problem of non-adherence.

In recent years there has been much debate regarding the evaluation of treatments in medicine. The evidence-based medicine (EBM) movement has formed partly out of the realisation that clinical practice is often poorly informed by the best available evidence, and that many widely used treatments are either completely untested, or tested and proven to be ineffective or even harmful. EBM has been characterised as a stick by which policy-makers and academics beat clinicians (Williams & Garner, 2002). However, another side to EBM has been the realisation that research performed to test new treatments has often been of poor quality, or has asked the wrong questions (Hotopf et al, 1997; Thornley & Adams, 1998; Barbui & Hotopf, 2001). We have previously argued that clinicians could justifiably criticise the research establishment for failing to provide answers to relevant clinical problems of everyday practice (Hotopf et al, 1999).

Refugees are not a recent phenomenon. Since the time of the Roman Empire there have been many examples of people fleeing persecution and seeking refuge and protection in other countries. Refugees flee war, internal unrest and persecution by their own governments because of their ethnic origin or their political, religious or social activities. Estimates of the number of refugees and displaced people worldwide range from about 23 million to about 50 million, this latter figure including those who are not officially registered. It is perhaps pertinent to realise that this number is larger than the entire population of Australia and almost the same as the number of refugees resulting from the Second World War. Refugees represent a variety of cultures, races and nations from all over the world. Summerfield (2000) claims that nearly 1% of the people in the world are refugees or displaced persons resulting from about 40 current violent conflicts.

Cognitive–behavioural therapy (CBT) is a shortterm, problem-focused psychosocial intervention. Evidence from randomised controlled trials and metaanalyses shows that it is an effective intervention for depression, panic disorder, generalised anxiety and obsessive–compulsive disorder (Department of Health, 2001). Increasing evidence indicates its usefulness in a growing range of other psychiatric disorders such as health anxiety/hypochondriasis, social phobia, schizophrenia and bipolar disorders. CBT is also of proven benefit to patients who attend psychiatric clinics (Paykel et al, 1999). The model is fully compatible with the use of medication, and studies examining depression have tended to confirm that CBT used together with antidepressant medication is more effective than either treatment alone (Blackburn et al, 1981) and that CBT treatment may lead to a reduction in future relapse (Evans et al, 1992). Generic CBT skills provide a readily accessible model for patient assessment and management and can usefully inform general clinical skills in everyday practice.

A formal therapy for depression, behavioural activation focuses on activity scheduling to encourage patients to approach activities that they are avoiding and on analysing the function of cognitive processes (e.g. rumination) that serve as a form of avoidance. Patients are thus refocused on their goals and valued directions in life. The main advantage of behavioural activation over traditional cognitive–behavioural therapy for depression is that it may be easier to train staff in it and it can be used in both in-patient and out-patient settings. This article describes the theory and rationale of behavioural activation, its evidence base and how to develop a formulation that guides the strategy.