This paper attempts to address the question, “What is higher training for?”. It then tries to explain some of the principles which have guided the work of the Joint Committee on Higher Psychiatric Training (JCHPT) up to now, and which are sometimes misunderstood by trainers and trainees, and finally, discusses some current problems. The views expressed should not be taken as reflecting the future policy of the JCHPT.

The controversy concerning psychotropic drug use in children has waged over several decades. The recent trend in treatment has moved towards problem-orientated, eclectic and flexible approaches to disturbed children and their families, away from specific “pure” therapy models. Erstwhile over-use of medication in certain conditions, for example psycho-stimulants in hyperactive children in the USA (Werry et al (1980), has handicapped the development of paediatric psychopharmacology.

Case registers can provide useful data for research and service planning, but the older manually maintained registers were expensive and required special accommodation, staffing and support. Turning raw data into useful information was a laborious process and most systems could not accommodate ad hoc reports. Partly as a result of these shortcomings, and partly because of spending cuts, a number of case registers were closed in the 1980s (for example, see Hassall, 1991).

People with a mental handicap may have a variety of behavioural symptoms, and according to DSM-III-R those commonly seen include passivity, low self-esteem, low frustration tolerance, aggressiveness, poor impulse control, and stereotyped self-stimulating and self-injurious behaviour. There is, however, no diagnostic subclassification of these in DSM-III-R.

Psychiatric patients have had the right to see their notes from 1 November 1991. The ‘Access to Health Records Act (1990)’ makes provision for certain parts of the record to be exempt, including information which may cause serious mental or physical harm to the patient or anyone else. In addition, patients should not have access to information given by third party informants unless appropriate consent has been obtained. The legislation only applies to records made after 1 November 1991. It does not cover informal arrangements where written application for access is not made.

Occupational therapy as a discipline (Finlay, 1988) has grown and matured with time. It has moved away from an ill-defined, imprecise and informal discipline to one which, while treating the patient as a whole being, nevertheless attempts to identify an individual's unique problems and treats them through purposeful activity. It strives to attain the qualities of a holistic, goal-orientated objective process.

Electroconvulsive therapy (ECT) is reported the most effective treatment for severe endogenous depressive illness but may also be useful in the treatment of mania and schizophrenia. It seems that the seizure is a necessary component of the overall treatment but it is undecided what constitutes an adequate duration of seizure activity.

While the term quality is not much used explicitly in clinical medicine in general and mental health services in particular, quality is implicit in much that guides us. Indeed it is at the very foundations of our health care practice – the ethical codes with their emphasis on beneficence, non-malevolence, respect for autonomy, justice and fairness.

Much of a typical general practitioner's time is spent dealing with people who present with “psychological” problems. Of those people who are detected as suffering from a mental health problem, most are then dealt with by the GP without recourse to specialist services. There is a wide variation in referral rate, and a recent review (Wilkinson, 1989) suggests that GPs are most likely to refer a patient to a psychiatrist when he/she has failed to respond to previous GP treatment, an opinion about diagnosis is sought, or there is some specific request either by the patient or another person involved. One of the reasons why GPs are disinclined to refer is their perception of stigma associated with attending a psychiatric clinic, although they do not appear to be unduly perturbed by aspects of the referral process itself, such as a waiting list. Overall, it appears that around 95% of patients in general practice presenting with mental distress are not referred to a psychiatrist. As well as being concerned about the stigma associated with traditional psychiatric services, we hypothesise that another concern of GPs may be a lack of liaison and consultation between primary and secondary care services.

An understanding of research methodology and design including the appropriate use of statistics is considered by the Royal College of Psychiatrists to be an essential part of the education of psychiatrists. The report of the working party for the review of the MRCPsych examination emphasises this by mentioning statistics and research methods as one of the major areas that will be examined as part of the sciences basic to psychiatry (Royal College of Psychiatrists, 1985). They point out that over recent years there has been an increase in the number of questions devoted to this subject, and state that this trend should continue. Pre-membership psychiatric trainees are often encouraged to undertake or participate in research (Sims, 1988), but many commence projects which never come to fruition (Hollyman & Abou-Saleh, 1985); lack of adequate supervision seems to be the cause (Royal College of Psychiatrists, 1991). The Royal College of Psychiatrists is unique among the Royal Colleges in that it enables candidates for the membership examination to be exempted from the essay paper by submitting a dissertation in advance based on a piece of original research. This is known as the research option.

Skill in physical medicine is an often neglected area in psychiatric training. It is nonetheless very important, particularly in the care of the elderly. The need for reciprocal training in geriatric medicine and old age psychiatry was highlighted in Care of Elderly People with Mental Illness (1989), the Joint Report of the Royal College of Physicians and the Royal College of Psychiatrists on services for the elderly and medical training. It recommends that, “Higher professional training for specialisation in the psychiatry of old age should include at least two months experience in geriatric medicine”, and suggests that this previously optional experience should become an obligatory part of specialist training. It indicates the alternative ways of gaining such experience: a short secondment, a weekly sessional commitment or a direct exchange of posts.

Psychiatry is much more community based than ten years ago. Despite this there is little specific research published on out-patient electroconvulsive therapy (ECT) and there is a lack of well-defined guidelines for its administration.

A trainee in psychiatry soon realises that one of the great differences between working in psychiatry and in other specialities is the presence of different working models, each with its own boundaries, which are often kept quite separate in clinical practice (see, for example, Straus et al, 1964). This naturally presents the newcomer with many dilemmas. In this paper I want to explore my own experiences in using psychodynamic approaches within the setting of a routine (medical model) psychiatric out-patient clinic.

Recent public concern about prisoners with psychiatric disorder, the deliberations of the Department of Health and Home Office Review of Health and Social Services for Mentally Disordered Offenders (the Reed Review) and the allocation by HM Government of funds for magistrates' courts to pay for duty psychiatrist schemes like the experimental scheme at Clerkenwell Magistrates' Court (James & Hamilton, 1991) are raising the profile of the mentally disordered offender and focusing attention on a group of people not only handicapped by mental disorder but also caught up in the criminal process. Probation officers have a key role in the care of many mentally disordered offenders and in the recent Home Office circular (1990) Provision for Mentally Disordered Offenders a reference is made to two courses for probation officers run by the Regional Staff Development Organisation for the Northern Region of the Probation Service. These courses are ‘Working with High Risk Offenders’ and ‘Working with Psychiatric Problems in Probation’. The former is run by Professor Herschel Prins and the latter by me. Judged by the number of applications, these are the two most popular courses run by RSD, but, as part of the process of evolving training to local probation areas, RSD closed in November 1991 and it has now organised its last course ‘Working with Psychiatric Problems in Probation’. This therefore seems an opportune time to describe the aims, format and evolution of the course and promote discussion concerning its implications for psychiatrists.

The Psychiatric Unit at Wexham Park Hospital has served a population of 230,000 with no entry to long-stay beds since 1972. There have been between 45 and 60 available beds for all types of mental illness except dementia. Various group homes and unstaffed halfway houses have been started, but the accumulation of more disabled patients showed the need for both a staffed group home, and rehabilitation to fit them for it. There was no separate ward or building in the hospital which could be used, and so rehabilitation had to be arranged on an acute ward. The staffed group home has a lower staff-patient ratio than a hospital hostel.