The organisation of psychiatric emergency services varies widely in the UK. These can usefully be viewed as a spectrum. At one end are traditional services where the GP acts as the primary filter to admissions. At the other extreme are crisis intervention teams aimed at managing the patient in the community. Somewhere along this spectrum of service provision lie the emergency walk-in clinics. There have been few studies on how effective these different arrangements are.

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 conditions endured by mentally disordered defendants remanded in custody have been the subject of mounting concern in England. The Home Office has issued guidelines which encourage the diversion of the mentally disordered from the criminal justice system whenever possible. In an attempt to reduce the number of custodial medical remands, new schemes have been set up which target the magistrates' court, instead of the remand prison, as the site for psychiatric assessment (Joseph & Potter, 1990; James & Hamilton, 1991). These schemes are in their infancy and currently suffer from a lack of funding and have yet to find general acceptance from hospital based psychiatric services.

Our countrymen, including ourselves, share numerous prejudices.

We are sexist, racist, ageist, chauvinist (an un reasonable patriotism), and classisi (by birth, wealth or education). We also share that fear, dislike and rejection of the mentally disordered, which I would like to call the prejudice of ‘psychiatrism’. Not only those who suffer are stigmatised – but so are their carers.

The boundary between neurology and psychiatry has never been sharply defined. It remains the case that a number of conditions (e.g. epilepsy, head-injury sequelae, dementia, and conversion hysteria) are seen by both neurologists and psychiatrists (Reynolds & Trimble, 1989). Few neurologists would dispute that there may be a marked psychiatric element to the presentation of multiple sclerosis, and it has long been noticed that even unmedicated chronic schizophrenic patients sometimes exhibit abnormalities of movement and so-called “soft” neurological signs such as dysgraphia and clumsiness (Lishman, 1988). These and other conditions may all on occasion present to the neuropsychiatrist.

On a recent study trip I was able to examine approaches to health care, in particular, mental health services in what was West Germany. I visited a range of facilities and met a wide range of professional workers.

The main body of Jelgava Psychiatric Hospital, in which I spent my week, consists of 14 or so adult and psychogeriatric and two child psychiatric wards. It was built about ten years ago. An alcohol and drug abuse unit, an out-patient department, and a small day hospital catering mostly for the ‘neuroses’ are found near-by.

There can be no doubt that schizophrenia is associated with a variety of neurophysiological disturbances and disordered cognitive functioning. But we are only beginning to identify which brain areas are involved and to discover how abnormalities in these areas are related to abnormal psychological processes. This symposium, organised by Drs David and Cutting, offered an opportunity to learn about the work of both psychologists and psychiatrists in this field. Diverse research presented ranged from PET studies to the analysis of home videos, from epidemiological work to studies of cognitive performance.

Guardianship Orders (GOs) are being applied more often in care of people suffering from mental illness (Hughes, 1991) and the elderly may have problems particularly suited to their use. Since many individual psychiatrists have little experience of GOs, we decided to examine our use of them. One of us had been involved in six orders over seven years working as a full-time consultant in the psychiatry of old age.

The rotational training scheme now forms the basis of psychiatric training. The advantages include the provision of experience in a wide variety of posts, while permitting educational continuity as well as the stability that accrues from having a job over a long period of time. Achieving a Balance threatens to change the structure of the rotation and thus the very nature of psychiatric training. The main consequences are the division of combined rotations into separate senior house officer and registrar rotations, competitive interviews for registrars, and the expansion to multi-district rotations.

In recent years registrars on psychiatric training rotations have been encouraged to begin their research careers early. Most of them are in such (training posts) for three and a half years. A few with extensive previous experience in other areas of medicine will be in post for less than this. The usual pattern of work with such schemes is to change both posts and accompanying routine every six months. At no point during this time will they have time allocated for research per se unless they are a fortunate member of some of the training rotations which include this in the weekly timetable. Such time has to be begged, stolen or borrowed from the hapless consultant who is all too aware of the service shortfall in his or her own area. If the registrar is fortunate enough to find an accommodating senior, this may not be the situation in his or her next post, which renders long term research well nigh impossible.

Two theoretical positions in psychiatry, the psychodynamic and the biological are explored, as seen in a discussion at the conference mentioned. It is argued that they form part of a wider philosophical debate between idealism and materialism, which is explored with reference to ideas about substance and then using psychodynamic and biological theories of depression. Double aspect theory is presented as a pragmatic solution adopted by the profession.