Julian Leff (1938–2021) was Professor of Social and Cultural Psychiatry at the Maudsley’s Institute of Psychiatry and Director of the Medical Research Council’s Social and Community Psychiatry Unit. He worked in Africa and contributed to the World Health Organization’s International Pilot Study of Schizophrenia. Alongside Anthony Isaacs, Consultant Psychiatrist at the Maudsley and Bethlem Hospitals, he co-authored Psychiatric Examination in Clinical Practice, whose three editions tracked my professional development: 1978 (entering clinical training), 1981 (medical graduation) and 1990 (consultant psychiatrist post).

When I joined the Middlesex Hospital Psychiatric Training Scheme in 1982, Jaspers’ Psychopathology (1913) overwhelmed me and Fish’s General Psychopathology (1967) felt as inert as a textbook on rocks. Leff and Isaacs, by contrast, offered a training sanctuary with their ordinary practically oriented language and compact format (141 pages). Not much changed between the second and third editions except a brief mention of AIDS. It explicitly leaned on John Wing’s ‘Present State Examination’. The content covers history-taking, mental state examination (MSE), psychosis, neurosis, ‘organic’ states, children, difficult patients and case formulation. In the cognitive section, I chuckled nostalgically when I was reminded of the Babcock sentence: ‘The one thing a nation needs in order to be rich and great is a large and secure supply of wood.’ ADHD is absent, autism mentioned only under children, ‘trauma’ is nowhere in the index. Times have changed since, therefore.

The tone is both humane and paternalistic. There’s a quiet modesty: ‘Our bias needs to be assessed…’ Indeed! That the patient is ‘ill’ is taken for granted. People are either ‘normal’ or not. The reifying instinct remains: ‘Phenomena of mental illness are comparable to abnormal heart sounds…’ Patients with ‘less education or medical sophistication’ tend to express their depression or anxiety in more somatic symptoms. In relation to self-neglect it is stated that women may wear no make-up, ‘although this may be currently fashionable’. To investigate the presence of ‘hysterical personality disorder’ (mostly female) patients should be asked, ‘Are you sometimes overemotional?’ Sexually, men may be impotent, women ‘frigid’. There is no reference to race.

Some ideas and practices may have aged well but others not. The sacredness once attached to ‘first-rank symptoms of schizophrenia’ has been exposed. And certain assumptions feel darker in the light of cultural shifts post-1990. The real lesson, however, is how deeply our thinking is shaped by the language and power structures of our time. Even our most basic tools – clinical interviews, MSEs – are not neutral.

Despite it all, I remain attached to the book. I met Leff once and admired him. He wasn’t a crusty traditionalist. Born to Communist parents, married to psychoanalyst and anthropologist Joan Raphael-Leff, father to political radicals – he understood complexity. He is quoted in his BMJ obituary saying: ‘The future of psychiatry… lies in understanding relationships.’ And it is his progressive and psychosocial orientation that underlines how we are all, even the best, inevitably caught in our times, and it behoves us, therefore, to develop the habit of thinking and, where necessary, speaking against the grain.