I should like, in the first place, to express my deep and humble appreciation of the honour of your invitation to me to deliver this year's Maudsley Lecture. I am very sensible indeed of the honour, and equally of the responsibility, which you have conferred upon me. In my attempt to carry out that responsibility I should be in total despair, were it not for one sentence in the letter of invitation which I received from your impeccable Secretary. He wrote ‘What we want is to listen to people in other fields talking on their own subject with sufficient of a bridge for some degree of mutual understanding.’ That modest hope seemed to me to be conceivably possible of fulfilment.

Truancy has been called the kindergarten of crime (Healey and Bronner, 1926) and it is very common to find delinquents with a history of truancy (Glueck and Glueck, 1950). Children who truant are also frequently convicted of criminal offences later (Schulman, 1928). It is, therefore, not surprising to find great similarities in the backgrounds of truants and delinquents.

Gambling may be defined as an activity which has the following four characteristics:

1. 1. There is an agreement between two or more persons; the participation of others is therefore essential, although sometimes, as in pools and fruit machine gambling, this is more remote.

2. 2. Certain property is transferred between the persons involved so that some gain at the expense of others; this is usually referred to as the stake.

3. 3. The result is dependent on the outcome of a risky or uncertain situation; it therefore involves risk taking.

4. 4. Participation can be avoided and is typically pursued in an active fashion; the motivation for this is not uniform often being unrelated to the property staked and arising out of various psychological needs.

During the past year the question of lithium prophylaxis has been the subject of lively debate (Blackwell and Shepherd, 1968; Hullin et al., 1968; Houghton, 1968; Baastrup and Schou, 1968a; Lader, 1968; Sargant, 1968; Saran, 1968; Baastrup and Schou, 1968b; Melia, 1968; Fieve and Platman, 1968; Cole, 1968; Kline, 1968; Kerry, 1968; Editorial, 1968; Berlyne, 1968; Silverman, 1968; Laurell and Ottosson, 1968; Lancet Editorial, 1969; Whybrow, 1969; Melia, 1969; Angst et al., 1969c). This discussion has revealed considerable uncertainty about the design and assessment of prophylactic trials, and there have been misunderstandings on important points.

Following the first reports of a prophylactic lithium action in recurrent affective disorders (Hartigan, 1963; Schou, 1963; Baastrup, 1964; Schou and Baastrup, 1966; Baastrup and Schou, 1967), a large number of research projects on this subject have been started. Prophylactic studies yield results slowly, and reports published to date are mainly of a preliminary nature. Some have been negative; the authors found little or no evidence of prophylactic lithium action (Fieve et al., 1968; Zall et al., 1968). Other observations seem to confirm the ability of lithium to prevent manic and depressive relapses (Achté et al., 1968; Blinder, 1968; Christodoulou, 1968; Dyson and Mendels, 1968; Gershon, 1968; Gottfries, 1968; Haastrup et al., 1968; Hofmann and Boleloucky-Bolen, 1968; Hullin et al., 1968; Kerry and Owen, 1968; Lauter, 1969; Levy, 1968; Melia, 1968; Sargant, 1968; Vaadal and Robak, 1968; Annell, 1969; Forssman and Wålinder, 1969; Fries, 1969; Uddenberg, 1969). The reports are based on samples which range from a few patients to about seventy. Few deal with systematic studies.

Prophylactic maintenance treatment with lithium presents a number of features not shared by conventional therapies. Patients suffering from recurrent affective disorders are offered the possibility of avoiding further psychotic episodes (Baastrup and Schou, 1967; Angst et al., 1970), but the treatment also makes demands on doctors and patients.

Lithium was first successfully used in the treatment of mania by Cade (1949), and its efficacy in reducing mania was confirmed in double-blind trials by Schou et al. (1954) and Maggs (1963).

During the past twenty years, the unity of manic-depressive disease as defined by Kraepelin (1913) has been questioned by investigators who have presented clinical and genetic evidence that the disease is heterogeneous and contains at least two discrete groups (Leonhard, 1957; Perris, 1966). In one of these groups mania occurs and patients exhibit both manic and depressive phases during the course of their illness. This group has been designated bipolar by most investigators (Leonhard, 1957; Perris, 1966). In the other group there are only episodes of depression, and this has been designated the unipolar group by some (Perris, 1966) and corresponds largely to the ‘monopolar’ group of Leonhard (1957). In this paper we shall use the term unipolar throughout to designate an affective illness in which only depression occurs.

The idea of a relationship between respiration and mental functioning can be traced back to ancient superstition that the diaphragm is the centre of the soul as well as of emotion.

Amphetamine psychosis and severe amphetamine dependence are now well recognized clinical pictures leading to psychiatric in-patient treatment (Connell, 1964). These pictures, however, are probably seen in only a small proportion of those who take amphetamines. The true assessment of the total incidence of unprescribed amphetamine taking in any group is made difficult by the absence of specific clinical signs (Connell, 1966), denial of drug-taking by the patient (Scott and Willcox, 1965) and the large number of false positives found with the methyl orange screening test (Johnson and Milner, 1966). Gas chromatography for amphetamine substances in the urine (Rowland and Beckett, 1965), though both expensive and time-consuming, provides for the specific detection of amphetamine and many other drugs in the microgram and submicrogram quantities. This paper describes the use of the method to obtain a picture of amphetamine abuse amongst patients in a 20-bedded acute psychiatric ward in a Teaching Hospital.

Blood-borne infection is a common complication of the self-administration of drugs of dependence by the intravenous routes. British drug addicts are notorious for their disregard of even the most elementary hygienic precautions. They will use dirty needles and syringes, which are often being used by other addicts as well. They may use unboiled tap water or even lavatory pan water to dissolve the drug for self-injection. They may not clean the skin before injection and in desperate moments may inject themselves through a number of layers of clothing.

In a previous paper (Pilowsky, Levine and Boulton, 1969) the classification of a group of 200 patients on the basis of their responses to a depression questionnaire and certain other attributes was described. The classification was carried out by using a form of numerical taxonomy based on information theory (Wallace and Boulton, 1968). By this technique the 200 patients were grouped into three classes, labelled A, B and C. Class A was regarded as a mixed group of ‘reactive’ depressions, Class B corresponded to ‘endogenous' depression and Class C comprised a non-depressive group.

In a typical classification problem each subject in a sample of N subjects is allocated to one or other of k exhaustive and mutually exclusive categories. For example, a sample of families may be classified into social-class groupings in accordance with the Registrar General's classification based on the occupation of the father or father substitute. Or a sample of psychiatric patients may be classified into one or other of the diagnostic categories recommended by the W.H.O. Now it occasionally happens that the same sample of subjects is classified, for a given set of categories, independently by two different agents. For example in the Plowden Reports, Appendix 3 Table 29, a sample of children is classified into types of secondary school, Grammar, Comprehensive, Technical, etc., on the one hand according to the parent's ambition for their children and on the other hand according to the type of school in which the children were eventually placed. In situations such as the latter a k k classification table evolves in which, when the categories are arranged in the same order, the matches between the two separate classifications appear in the cells of the main diagonal of the table and the mismatches appear in the off-diagonal cells (see Table I below). The question then arises as to how to compare the two separate classifications and to measure in quantitative terms the degree of agreement between them.

In a recent article (Hope, 1969a) the author has demonstrated the theoretical relations between what psychologists call the analysis of persons and the analysis of tests. The demonstration was illustrated by an analysis of a hypothetical matrix M whose rows were called entities and whose columns were called variables. It was shown that, by combining Slater's (1964) method of spherical co-ordinate mapping with a method of numerical taxonomy suggested by the author, it is possible to perform a comprehensive and self-consistent pair of analyses whose conclusions can be read off three diagrams: a map of variables, a dendrogram of entities, and a profile diagram of the multivariate means of groups of entities.

In a previous paper in this series (Sandier, Holder and Dare, 1970a) aspects of the doctor-patient relationship were discussed under the general heading of treatment alliance. It was pointed out that the concept included features which have been at times referred to as ‘transference’, and the purpose of the present paper is to consider some of the further meanings of the latter term.