The Thorn Initiative was put together by a group of people, most of whom were researchers who had conducted randomised controlled trials on various kinds of social treatments. Isaac Marks had worked on assertive community treatment (ACT), whereas my experience was in family work for schizophrenia, as was that of Nick Tarrier. In addition, Tarrier had carried out a recent trial of cognitive approaches to reducing delusions and hallucinations. It was rather like trying to turn an assemblage of prima donnas into a chorus, and it is a tribute to the personal qualities of Jim Birley that he succeeded in this seemingly impossible task.

Deafness is a common and varied medical, social and psychological construct that affects a significant proportion of the population. Restricted communication and uninformed attitudes have adverse effects on the physical and mental health of deaf people. Clinicians need to know how to recognise and resolve these difficulties.

Clinical research suggests that empathy is associated with better clinical outcomes in various areas of medical care, raising the question of whether a similar effect occurs in psychiatry. The aim of this review is to explore philosophical, neuroscientific and psychological perspectives on the concept of empathy in the context of the day-to-day work of clinical psychiatrists. The definition of empathy is outlined and sociodemographic factors, working conditions and psychiatrists’ beliefs that can potentially affect empathy in clinical encounters are explored; educational and training aspects are also reviewed. The review concludes suggesting that research on empathy is needed to understand contextual, training and relational factors that could benefit mental healthcare as well as the working conditions of clinical psychiatrists, both inextricably linked.

When those whom the law terms ‘secondary victims’ – i.e. the passive and unwilling witnesses of injury, or of the threat of it, to others – seek compensation through the courts for the psychiatric injuries that they have suffered (traditionally but confusingly referred to as ‘nervous shock’ claims), there would in theory be the potential for a virtually limitless number of claims. For this reason, the courts have developed and apply a number of, to a large extent, arbitrary ‘control mechanisms’ as floodgates. This article describes these control mechanisms and other relevant law using recent illustrative cases and with particular reference to the assistance that the courts can expect of psychiatrists as to diagnosis and causation.

Psychiatric expert witnesses instructed to undertake assessments of defendants charged with murder should be familiar with the partial defences of diminished responsibility and loss of control. The Coroners and Justice Act 2009 enacted major amendments to the partial defence of diminished responsibility and introduced a new defence of loss of control to replace the provocation partial defence. In this article, the changes to the law are described with particular focus on the implications for the psychiatric assessment.

This article discusses dopamine partial agonism, which is the main mechanism of action of the psychiatric drugs aripiprazole, brexpiprazole and cariprazine. It outlines the principles of receptor theory and the structure of dopamine receptors; characterises agonists, antagonists and partial agonists; and summarises the dopamine hypothesis of psychosis and the role of dopamine and serotonin in depression.

Balancing risk and safety in long-term care settings can be challenging while providing and respecting patients’/residents’ needs and rights in terms of sexual expression. We look at factors affecting the expression of sexuality, including staff attitudes and reactions, and the lack of policies governing sexuality. We review the various statute and case law, other legislative and quasi-legal provisions governing sexuality and sexual expression. Finally, we consider the need for clear policies and training for both staff and family members.

This article considers the role of experts and their interaction with the legal system to better understand the benefits and potential dangers of expert evidence to fact-finders in trials. Medical experts are indispensable to the administration of justice as litigation ranges beyond what judges or juries comfortably deal with as facts of everyday life. This would render courts, absent expert evidence, vastly under-equipped in making decisions of fact. However, the dangers of surrendering authority to experts or of misunderstanding their role must be considered to ensure that expert evidence is used to benefit the administration of justice.

Draper & Rogers (2005, this issue) have put an important subject under the ethical microscope. They have demonstrated that the current, fairly simple, rules applying to the publication of case studies and dissemination of patient information in teaching are inadequate and need revision. This is particularly important because such forms of communication are likely to increase in the future. Many journals, including the British Journal of Psychiatry, generally frown upon case studies as representing little value to science: case studies unnecessarily focus on the particular; their message is only valuable when it is general. However, they aren't going to go away because their educational value is obvious, as anyone who looks at the handling of almost any scientific subject in the mass media will testify. Experts can pontificate on hypotheses, proportions, means and significance to little effect and the real message comes home from a sufferer or successfully treated patient who adds human flesh to a dry factual skeleton. This need to particularise is necessary in all parts of teaching.

Most individuals who have lived in foster homes, residential care or adoptive families for substantial periods (‘people affected by public care or adoption’) show normal psychological adjustment as adults, although rates of mental disorders, hospital admission and suicide are increased. Research focusing on the experiences of this group of people can help professionals better understand their behaviour and attitude towards help. Psychiatric symptoms can be multifaceted, including complex trauma presentations. The specific mental health needs of this population are increasingly being recognised in child and adolescent mental health services but less so in adult services. In this article we describe life experiences of people affected by public care or adoption, examine the lifelong impact of these experiences on mental health and functioning, and offer practical suggestions for clinical work with them.

Post-traumatic stress disorder (PTSD) is a complex, heterogeneous mental health problem that can be challenging to identify, assess, understand, diagnose and treat. This article provides an overview and critique of key topics, literature and principles to inform comprehensive and meticulous assessment of PTSDs. Although expert witnesses are the target audience, this article will have relevance for identifying, assessing, understanding and diagnosing PTSDs in all clinical contexts. A range of topics relevant to assessment are discussed, including: the complex relationship between trauma and PTSDs; DSM-5-TR PTSD and ICD-11 PTSD and complex PTSD diagnoses and the similarities and differences between them; the clinical presentation of PTSDs; psychological models of PTSDs; how to approach assessment and differential diagnosis; the impact of PTSD on neuropsychological abilities and functioning (disability); causation, reliability and assessing PTSDs when this is being considered as a legal defence; evidence-based interventions (medication, psychological therapy, when is the ‘right time’ for therapy, contraindications); and prognosis (if untreated, how long therapy/change takes). Given ongoing debate, the article proposes that trauma exposure is best defined in future iterations of the DSM and ICD as exposure to one or more psychologically threatening or horrific experiences that are overwhelming.

The Defence Mental Health Services (DMHS) provide an occupationally focused service for the UK armed forces when deployed and when at home. Although much of the work is similar to that carried out by National Health Service community mental health teams, there are many unique aspects to working with the military. Although carrying out operational duties is a key function of the armed forces, the majority of cases managed by the DMHS are not related to traumatic exposures; instead, adjustment, mood and substance use disorders form the bulk of the case work. However, DMHS personnel carry out a considerable amount of psychological education and command liaison functions to support the concept that the psychological welfare of troops is primarily a chain of command responsibility. This article outlines the structure and function of the DMHS and its approach to risk management.

The humane treatment of prisoners has long been considered a mark of a civilised society. Early prison reformers such as Elizabeth Fry and John Howard campaigned vigorously for the improvement of conditions for inmates and for institutions to be focused as much on reform and rehabilitation as on punishment. This progressive improvement in conditions for those imprisoned has been further advanced by the European Convention on Human Rights and its incorporation into UK law. The Human Rights Act 1998 is playing an ever-increasing role in determining the standards of treatment of those detained by the state. Article 3 of the Act – freedom from torture and inhuman and degrading treatment – is of particular importance for those detained in prisons, hospitals and other institutions. As Article 3 case law has evolved, so its interpretation has broadened to include a thorough scrutiny of prison conditions, prison healthcare and the treatment of prisoners in general.

Currently, network meta-analyses (NMAs) are the only technique that allow us to compare and rank numerous treatments across trials. Evidence produced by NMAs relies on pooled data from both direct and indirect comparisons within studies. Consequently, NMAs are invaluable tools for informing clinical guidelines.

As the arsenal of antidepressant drugs increases with time so, concurrently, does the list of caveats that must be considered when using these agents in patients with other physical illnesses and using other medications. MacHale's (2002, this issue) overview of the management of depression in physical illness serves as a crucial update for clinicians providing psychiatric services for patients with comorbid physical illnesses. Appropriate emphasis is placed on the usefulness of non-pharmacological treatments in such patients, although the reality of modern practice is that drug treatment is most often considered first-line owing to limited psychological service resources.

When a patient in an in-patient psychiatric setting allegedly commits a crime, psychiatrists are sometimes asked to assess their fitness to be interviewed by the police. This article describes how to conduct this assessment, outlines the criminal justice process leading to police interviews (with particular reference to the legal system in England and Wales) and highlights practical issues to consider when assessing fitness to be interviewed in this context.