The development of psychiatric care in Ghana since the colonial era in the 19th century, up to the present, is described. Distorted planning and limited accessibility to psychiatric services in many parts of the country, coupled with shortage of trained staff of all grades (including psychiatrists and nurses) plus inadequate funding, have adversely affected the establishment of a fully comprehensive psychiatric service. Suggestions for improving services into the 21st century are briefly discussed.

On the evening of 23 February 2000 at the Maudsley Hospital in London the motion ‘This house believes that compulsory community treatment is not justified’ was debated in front of an audience of mental health professionals, carers, service users and other members of the general public. Peter Campbell, a mental health system survivor, and Dr Frank Holloway, consultant psychiatrist at the South London and Maudsley Trust, supported the motion. Cliff Prior, Chief Executive of the National Schizophrenia Fellowship (NSF), and Professor Tom Burns, professor of community psychiatry at St George's Hospital Medical School, opposed it.

We visited St Petersburg in the autumn of 1999 as the guests of Professor Leonid Shpilenya, Director of the city's addiction services, and Dr Olga Khvognova, Director of Nurse Training, College Number Three. This was part of an exchange programme financed by the Know How Fund – Health Sector Small Partnerships Scheme (Russia). Two of the authors (P.F. & A.G.) have been involved in these exchanges for a number of years. The current project is a joint one, involving medical and nursing staff (Green et al, 2000).

I became a Divisional Public Education Officer (DPEO) for the College's External Affairs Department in 1990. My first media training day was most informative. I learned how to disseminate information; how to inform journalists about issues pertinent on the day; and ways to challenge stigma. I learned that it was safest to assume that most journalists do not usually understand the complexity of mental health issues. The health correspondent for the BBC at the time showed how adequate preparation – making written information available in a helpful question and answer format – and development of personal relationships with journalists through understanding how they work, their deadlines, pressures, etc., are important factors in trying to do the job properly. I also learned the golden rule: never say anything off the record.

My first encounter with the media was about 17 years ago when Marjorie Wallace turned up at a College meeting. As the conference organiser, I was told by the then secretary of the College, Natalie Cobbing, to ensure that Marjorie was not admitted, as our meetings were closed to the press. In fact, the fear of God was instilled in the staff at that time about the press – no staff were to talk to the media. Disobedience could be seen as a sackable offence. Ironically, Marjorie Wallace is now an Honorary Fellow of the College in recognition of the work she has done in mental health, both as a journalist and campaigner.

“And when life has no more meaning in old age, the will to meaning is lost; when life no longer seems to be worth living, some people who have experienced disasters and are unable to cope, may throw their lives away.” (Wilson et al, 1988) There continues to be a great deal of interest among psychiatrists, psychologists and sociologists about post traumatic stress disorder (PTSD) related to war crimes and experiences. Twentieth century studies of Holocaust victims and Far East prisoners of war, Korean and Vietnam veterans and the recent experiences of people in Bosnia have honed the diagnosis and increased awareness of the gradations of these disorders. Almost every conceivable variable has been examined in attempts to explore the motivating and resulting behaviours. Initially most studies dealt with the immediate impact of the event, but more recently articles have focused on the longer-term effects on relatives and the next generations of the earlier events (Sigal, 1998). Time has allowed this. The passage of time has also established that post-traumatic stress symptoms can be reactivated as much as half a century after the original trauma (Krasucki et al, 1995). Reactivation of events from 40 or 50 years previously may occur via current stressors such as social isolation and upheaval. Equally perceived helplessness precipitated by the somatic process of ageing could reactivate previous feelings and a delayed onset or exacerbation of clinical PTSD may emerge during the process of ageing. Institutionalisation itself could re-awaken feelings associated with incarceration or victimisation (Aarts & Op den Velde, 1996; Sadavoy, 1997). Late-life PTSD is more often associated with sleep disturbance, nightmares, intrusive ideation and avoidance of reminders of the original events (Kuch & Cox, 1992).

I can vividly remember my first exposure to psychiatry as a medical student in the USA. By drawing the short straw, I won the privilege of night call on my first day on the service. It was February and by early evening it was black and cold outside. To avoid the night, I took a seldom travelled tunnel between the hospital and the state mental facility. Alone, and frequently passing broken-down equipment from a bygone era, I felt as if I were entering another world. I took an elevator to the sixth floor. The elevator was operated by a middle-aged pale woman who wore a calf length skirt that blew around in the wind generated by the elevator's ascent. She said nothing. To this day I remain unconvinced that she was not an apparition. My patient was a severely cognitively impaired woman who was said to have neurosyphilis. My task was to replace her nasogastric feeding tube, which she had pulled out despite wrist restraints. Her nose was bleeding and she was spitting blood between attempts to bite anyone who came near her. It was a sad and dehumanising interaction for both of us. When the psychiatry resident came to help, at my request, she displayed only callousness and incompetence. The night nurse was certain to tell me this after the house officer had left. This event, among others during my training more than a decade ago, froze the worst stereotypes of psychiatry into my mind. Subsequent positive experiences in out-patient psychiatry were too weak to thaw the negative perceptions.

Like many countries in Asia, Singapore has its own system of postgraduate training and specialist accreditation in psychiatry. Psychiatry trainees are strongly encouraged, but not required, to receive supervision in psychotherapy with patients during the 6-year period of basic and advanced training since the inception of the Masters of Medicine in Psychiatry (MRCPsych equivalent) in 1985.

A postal questionnaire survey of a sample of members and fellows of the College listed as retired revealed that 56% are still engaged in some work, but only 11% are registered for continuing professional development (CPD). Thirty-eight per cent intend to apply for revalidation to remain on the Specialist Register. Their CPD needs are, therefore, important.

One of the best collections of links to USA psychotherapy sites is at Mental Health Directory (http://www.mental-health.net). In the UK, two good starting points are: the Centre for Psychotherapeutic Studies at the University of Sheffield (http://www.shef.ac.uk/-psysc/) and Chris Evans' website (http://www.psyctc.org/).

There is a recognition that doctors require management skills and many are now studying for formal qualifications in management. This article describes a Masters degree in Business Administration (MBA) with the Open University.

Workshops at the College's Edinburgh Annual General Meeting (AGM) in July proved to be very popular, attested by the fact that nearly 1000 delegates attended 27 of them, which were distributed over the 5 days of the conference. The College has only recently introduced this format into their AGMs, although faculties and sections have long been including them into their residential meetings, again with positive feedback from those attending. As a result, the Edinburgh Organising Committee asked me to take on the job of Workshop Director for the conference, for which I had no real track record, although I had been previously involved in organising conferences and workshops for the Rehabilitation and Social Sections.

Many trainees, like myself, are so daunted by the prospect of working with patients within a psychodynamic framework that their anxieties can overcome them, and their experience of psychotherapy suffers. As a result they can end up deeply sceptical of this style of treatment. Later in their career, when they are more confident of their general skills, they may wish to return to psychotherapy to try to understand at a deeper level the interaction between individuals, in particular between doctors and patients. Often though, there is too little time to develop these skills at this stage.