There has been considerable progress in recent years in developing psychosocial interventions for people who experience persistent psychotic symptoms. However, it is sometimes difficult to generalise these findings into routine clinical practice. Long-term, psychodynamically informed, supportive psychotherapy is a valuable approach for working with individuals for whom current psychosocial interventions are ineffective or where unhelpful team reactions are obstacles to care. Its principles are used to inform a multiaxial formulation, which is shared with the treatment team and guides treatment, promoting good-quality comprehensive routine care. The benefits of this approach can best be seen at the individual case level using a subsequent multiaxial reformulation.

Critical incident reviews are an integral part of modern psychiatric practice. The issue is central to the clinical governance agenda in the UK, yet there is widespread debate about their usefulness. There is a lack of systematic research into their impact on clinical outcomes, with most authors commenting on their form, their political implications, and whether they should exist at all. This article explores the historical basis to incident investigation, outlines an ‘ideal’ method of review and discusses the concepts of the learning organisation and root cause analysis. Further discussion focuses on what the objectives of critical incident review might be and whether organisations as a whole can learn from them.

Vocational rehabilitation for people with severe mental health problems is poorly developed in the UK. Although there is a clear evidence base indicating the effectiveness of approaches to helping people with severe mental health problems gain and retain employment there is generally a lack of awareness of this evidence. As a result there has been a lack of implementation within routine clinical practice of the most effective approaches to improving employment outcomes for such individuals.

In 1951 Asher described chronic factitious disorder characterised by dramatic presentations, histories and recurrent admissions. Asher initially described three types of presentation – acute abdominal (laparotamophilia migrans), haemorrhagic (haemorrhagia histrionica) and neurological (neuropathica diabolica). Factitious disorder is now included in both DSM–IV and ICD–10. Numerous case reports exist but the evidence base for effective management strategies remains relatively sparse. It is an uncommon disorder most often encountered in liaison psychiatry that remains difficult to manage and characteristically stimulates strong countertransference reactions in the teams involved. Psychiatric involvement remains vital in such cases although poor engagement is often a significant obstruction. As an illustration, we present a vignette based on case of a previously unreported variant of the neurological category involving Guillain-Barré syndrome.

Recovery is an increasingly important concept in mental health services research and policy-making. However, despite burgeoning interest in the concept, no overarching theoretical or empirical framework has been offered to support its key ideas. Further, it is often unclear how recovery ideas translate into routine practices of mental health programmes and practitioners. In this article, a theoretical framework for recovery ideas is derived from self-determination theory, a widely researched and empirically validated theory of human need fulfilment. I discuss the conceptual overlap of self-determination theory and recovery ideas, and, using key motivational concepts, develop a typology of recovery-oriented practices for three hypothetical programme types (controlling, traditional/paternalistic and recovery oriented). I describe existing measures of recovery-oriented practice and consider the implications of self-determination theory for measurement of and research on recovery-oriented practice.

We have developed this succession of articles as a series of iterative steps, each seeking to uphold the recovery values of co-working and collaboration, looking for agreement and commonality but valuing equally diverse viewpoints and difference. Our conclusion is that this is the beginning of a creative dialogue on choice as a route to recovery for people who are psychiatrically detained. We commend our method of engaging with the inevitable tensions and dilemmas by: clarifying the story behind difficult interactions, identifying the relevant guiding principles and jointly working to explore from different viewpoints what can be done to promote recovery.

It has been clearly established as a matter of legal principle that the duty of expert witnesses is to the court, and not to the cause of those who instruct them. I will suggest that many experts fail to maintain this neutrality, for both conscious and unconscious reasons. If this is so, there may be real dangers in the use of single joint experts, even if there is the benefit of lower costs. In England and Wales, expert witness practice is now seen as part of medical practice by the General Medical Council: the whole profession needs to engage in a debate about how this should be scrutinised and regulated.

Heavy drinking poses a significant risk to public health in the UK. Opportunistic screening and brief interventions offer a cost-effective method of reducing the harm related to excessive alcohol consumption at both an individual and a public health level. Given the high prevalence of alcohol misuse among patients attending mental health services and its impact on behaviour and health, professionals need to be skilled in identifying and treating these problems in all areas of mental health. There is also a need for effective joint working between mental health and specialist addiction services. This article describes the principles and evidence base for brief alcohol interventions, and methods of implementation in health settings.

This commentary questions whether the usual ethical and legal requirements for maintaining confidentiality of individuals who fabricate illness should be breached in order to prevent further harm to themselves as well as cost to society. A case report of an individual with Munchausen's syndrome submitted for publication in Advances in Psychiatric Treatment provoked considerable Editorial discussion regarding the absence of written informed consent from the individual described. It is hoped that this commentary will widen the debate regarding the requirement for confidentiality in the exceptional circumstances of patients with Munchausen's syndrome.

This article focuses mainly on issues regarding doctors' clinical performance (capability) and behaviour (conduct), and is aimed at medical managers who deal them. It covers identifying problems and how to manage them, describes typical underpinning (disciplinary) frameworks and sets out the role of the UK's National Clinical Assessment Service and other external bodies in more serious cases.

Recent highly publicised events have understandably worried some expert witnesses, including psychiatrists. This commentary seeks to encourage those who have invaluable expertise to offer the courts to continue to act as expert witnesses. The Civil Procedure Rules and the Criminal Procedure Rules are helpful to some extent in allaying any fears that expert psychiatrists may have. They are, however, matters of form. More important, it is suggested, are the principles that operate and that, at least in part, lie behind the Rules. Those principles are often, in fact, not unfamiliar ones. Moreover, some of the most fundamental legal principles applied in the courts operate to circumscribe the role of expert witnesses, thus protecting them, provided that they do not go beyond the limits of their expertise.

Childhood conduct disorder casts a long shadow over adulthood, often leading to antisocial personality, drug misuse, increased rates of psychosis and earlier death. This article reviews a range of effective treatments, and shows what is ineffective. The common theme underlying interventions that work is that they change the environment around the young person, with parent training emerging as the most effective. Medication is largely ineffective. The task now is to enable more of these interventions to be available at a reasonably early age.

Self-determination theory has been offered as a potential theoretical framework for recovery. It has been argued that a concept as wide-ranging as recovery seems likely to require a number of theoretical frameworks, including self-determination theory, which appears to be particularly applicable to the clinical and social dimensions of this concept. With its emphasis on social competence and environmental support, self-determination theory may be particularly useful as a framework for considering recovery in client groups with higher levels of service need associated with disability or risk.

There has been little systematic study of personality disorders in older people (65 years of age and above). However, with an ageing population worldwide we should expect to find increased numbers of people with Axis II disorders surviving into old age. We undertook a qualitative review of the recent literature concerning personality changes and disorders in older people, their prevalence and possible amelioration.

It takes courage, leadership and planning to successfully implement a smoke-free policy in mental health settings. The content of the policy is crucial in setting parameters for implementation. Management and clinicians should work closely together to develop and coordinate the implementation strategy, ensuring that resources are effectively used and deadlines are met. Key success factors are effective management at both central and local levels, as well as consultation with service users, carers and staff to gain support for the policy and obtain suggestions for improvement. Other important factors are advance planning, recruitment of experienced staff, effective communication and extensive training of staff in smoking cessation support. Local teams should develop appropriate procedures based on the policy. They should work closely with the central management team. The resources developed and obtained by local teams should be shared throughout the organisation and should be tailored to meet the needs of particular services.

The second half of the 20th century witnessed a number of serious miscarriages of justice that resulted from improper police interviewing of suspects and unreliable and false confessions. To prevent miscarriages of justice involving people with mental disorder or particular mental vulnerabilities, psychiatrists have a role in determining the fitness to be interviewed of persons suspected of criminal offences. In this article, the role of the psychiatrist in assessing fitness to be interviewed is set against the background of the latest revisions of the Codes of Practice of the Police and Criminal Evidence Act 1984 and relevant case law in England and Wales.

Workplace-based assessment (WPBA) is becoming a key component of post-graduate medical training in several countries. The various methods of WPBA include: the long case; multisource feedback (MSF); Mini-Clinical Examination (mini-CEX); Direct Observation of Procedural Skills (DOPS); case-based discussion (CbD); and journal club presentation. For each assessment method, we define what the approach practically involves, then consider the key messages and research evidence from the literature regarding their reliability, validity and general usefulness.

Multicultural societies offer a significant challenge to mental health services. Different groups have different rates of illness, illness models, ideas of what a suitable pathway of care is and what suitable care looks like. Trying to set up services to meet all these needs can be difficult. There may need to be modifications in clinical practice, service configuration and the way services are commissioned. Ethnic minority communities face complex problems and, consequently, strategies to deal with them can be complex, requiring support from the non-statutory sector, social services and other branches of medicine. Service development often needs research, staff training, race-equality schemes and sufficient funding to make change possible. I offer here a scheme for considering how to think through service development in this area as well as introducing the government strategy, Delivering Race Equality.