Cognitive linguistics is a new development in one of the basic sciences of psychiatry. It takes a novel approach to metaphor that is having an impact on philosophy and cognitive neuroscience, offering a perspective on questions about the development of language and the embodiment of mind that may have an impact on psychiatry. Likewise, our expertise in mental pathology may be required for further development in cognitive linguistics (Lakoff, 1997).

Suicide may be defined as intentional self-killing, although the definition has been the subject of critical review (Fairbairn, 1995). As the determination of whether intent was present at the time of death by suicide can be difficult, coroner's inquests tend to underestimate the number of suicides. At the time of suicide, the vast majority of people are suffering from some form of mental disorder, although there may, exceptionally, be a few rational suicides. Suicide is a relatively uncommon event, but the possibility of suicide by those with mental disorders is always a potential hazard faced by health and allied professionals responsible for their care. Detention of a patient in hospital under mental health legislation is often precipitated by concern regarding risk of self-harm and/or risk of harm to others and potential for absconding and, at times, admission to a locked or secure facility is necessary. Detained patients in secure facilities include both offender patients, admitted through the courts or transferred during sentence from prison, and patients on civil orders under sections 2 or 3 of the Mental Health Act 1983. The relationship between suicidal behaviour and that which is violent or homicidal is complex but relevant to an understanding of the phenomenon of suicide in secure conditions.

Humans have attempted and successfully committed suicide since time immemorial. The reasons for killing or harming oneself vary with cultures and societies and in urban or rural settings.

It is a sign of the progress we have made in the field of learning disability that it is possible to consider three previously taboo subjects in one paper. Before 1979, there was no published English clinical or theoretical paper which looked at either talking treatments for people with learning disabilities, treatment for those who survived physical and sexual abuse or, specifically, talking treatment for survivors of abuse who also have learning disabilities. Such steps forward bring hope for the future, but also pain concerning the past. How often have emotional and behavioural communications of betrayal and violation been ascribed to ‘disability’ and not been properly considered because there was no social intellectual context to help us to consider that there might be a reason for them? This also illustrates the need for continuing professional humility and toleration of uncertainty. What painful experiences and communications of our patients are we missing today because of internal and external taboos? How will we feel when we become aware of them in another 10 or 20 years' time?

The syllabus for higher training in forensic psychiatry requires knowledge of the therapeutic uses of security, although there are no references to this in standard texts. Similarly, the process of mapping a mental health service is an essential first step in planning, audit and needs assessment. All mental health services, not just forensic services, are organised to stratify patients according to the risk they present so that they can be cared for in an environment that is safe but imposes the minimum necessary restrictions and intrusions. Forensic mental health services differ from other mental health services mainly by including subsystems which are at higher levels of security than those necessary in local services. Although they have a general orientation towards risk awareness and risk management, they remain integral parts of the mental health services for the populations they serve.

Multi-sensory therapy is an activity which usually takes place in a dedicated room where patients experience a range of unpatterned visual, auditory, olfactory and tactile stimuli (Baker et al, 1997). These rooms are designed to create a feeling of comfort and safety, where the individual can relax, explore and enjoy the surroundings (Fig 1.).

In the first three papers of this series (Williams & Garland, 2002a, b; Wright et al, 2002), we looked at the different areas of human experience that alter during times of mental illness. The Five Areas Assessment model (Williams, 2001; see Williams & Garland, 2002a, Fig. 1) provides a clear summary of the range of problems and difficulties faced by individuals in each of the following domains:

1. 1 life situation, relationships, practical problems

2. 2 altered thinking

3. 3 altered emotions (moods or feelings)

4. 4 altered physical feelings/symptoms

5. 5 altered behaviour or activity levels.

Homeless families are defined as all adults with dependent children who are statutorily accepted by local authorities (housing departments) in the UK, and are usually accommodated for a brief period in voluntary agency, local authority or housing association hostels. This period varies from a few days to several months, although the target for rehousing is usually around 4 to 6 weeks. Some housing departments, particularly in London, also use bed and breakfast accommodation.

The terms ‘clinical audit’ and ‘clinical governance’ elicit a variety of responses, including boredom, frustration, incomprehension and, rarely, enthusiasm. This paper sets out to persuade the reader that clinical audit, as an integral component of clinical governance, will be reborn as an activity that clinicians will find interesting, developmental and a useful part of their everyday clinical practice. Under clinical governance, clinical audit will at last be able to achieve important and measurable improvements in patient care as a matter of routine.