Risk assessment is in vogue clinically and politically. The term is used in two ways. It refers to a method of balancing probable consequences of decisions which formalises the decision-making process. In psychiatry, it usually refers to the same method focused on the current clinical practice of assessing the risks of harm to self or others.

This paper explores the range of expectations of psychiatrists held by those in general management in the health service.

In most Western countries, including the UK, comprehensive mental health services are predominantly funded from State resources. The role of the psychiatrist has changed in the past 20 years and will without doubt change further in the next 20 years. Expectations of psychiatrists have changed and will continue to do so. We take the position that psychiatrists should continue to have the major leadership role in mental health and in so doing must become increasingly responsive to the changes taking place in health care planning and provision.

In many ways cognitive and behavioural therapies represent the acceptable face of psychotherapy for the general psychiatrist. They are brief, focused, problem-oriented treatments, which take symptoms seriously. They show an affinity for the medical model in their acceptance of diagnostic categories and their commitment to effective evaluation of treatments through randomised controlled trials. The wide applicability of these therapies is also attractive to the general psychiatrist. Cognitive and behavioural techniques are of major importance in the treatment of anxiety disorders, depression, eating disorders, and sexual dysfunctions, and beyond this core group the methods can be applied to enhance coping and change unwanted behaviours in conditions as diverse as cancer, chronic pain, substance abuse, anger control, schizophrenia, and challenging behaviours in people with learning disabilities.

Electroconvulsive therapy (ECT) is a long established form of treatment for specific, serious mental disorders, but one which is still surrounded by much misunderstanding and fear. The use of electrical current administered to the brain to ‘treat’ illness remains a barbaric concept to many people. Much research has been conducted to establish the efficacy of ECT, which is now widely accepted. However, the working principles of the ECT machine itself are little understood, and more research remains to be done to establish, more scientifically, which is the ‘best’ way to administer the electrical stimulus. With the recent introduction of the concept of “stimulus dosing” (for a review see Lock, 1994), the need to be aware of the ECT machines available and their abilities and limitations is important.

For centuries the conditions existing in institutions have been a cause of concern. Accompanying this has been a drive to improve the quality of care in such places. Until the second half of this century younger patients constituted the majority of the mentally ill residing in institutions. Now the balance has shifted and considerable numbers of elderly people, particularly those suffering from dementia, are residing in institutions (hospitals, nursing and residential homes). Perhaps never before has the question “What makes a good environment for the demented?” been so important.

This review considers the place of psychiatry in the complex area of management of the sexually abused child. A model is described in order to guide psychiatric perspectives in the field of child sexual abuse, before describing an approach to management in mental health teams.