Doctors’ typical reaction to patients’ suffering is to alleviate it when clinically appropriate. This has been described as a negative model of suffering, in contrast to the positive model of suffering. In the positive model, suffering can contain an important message of needed change, indicate a response to a psychosocial predicament or be a route to spiritual enlightenment. This approach is briefly critiqued, and circumstances where patients might prefer this approach are described. Doctors can work alongside professionals using this approach while also trying to alleviate suffering if indicated (such as if a patient wishes less suffering or if risk is involved).

Professional statements suggest that psychiatrists engage in media work to supply a general audience with medical knowledge informed by relevant professional expertise. However, media work may be motivated by interests other than disinterested service to the well-being of the public, such as fame, money and a platform for one's wider views. The role of media psychiatrist is also crucially shaped by the unpredictable needs of a complex media ecology and marketplace. Furthermore, the properties of the media, and different forms within them, bring implicit meanings such as the wider authorisation of therapeutic self-reflection or the promotion of para-social intimacy. Finally, the media psychiatrist may function as an entrepreneur, converting the currency of celebrity into new forms of cultural, social and political capital. Professional guidelines for media work should be updated in light of such observations.

Gender disappointment can be defined as subjective feelings of sadness when discovering that the sex/gender of a child is the opposite of what the parent had hoped or expected. Wanting a boy (or ‘son preference’) has long been noted in many cultures, particularly in South and East Asian communities, but it is now becoming more recognised in the UK, Europe and North America. This article aims to improve understanding of gender disappointment by exploring medical and social sciences research; it also discusses the clinical and risk implications of assessing and managing gender disappointment (or not doing so) when individuals present to perinatal and/or community mental health services.

Ayn Rand is known as an advocate of rugged individualism and unregulated capitalism, which has led to a scholarly focus on her influence on neoliberal and right-wing politics. This article focuses on the psychologically unrealistic conceptualisation of self-esteem in Rand's ethics, which arguably prevails in today's self-help culture. Rand endorsed Nathaniel Branden, her acolyte and lover, as official therapist for her circle. In this role, he promoted the positive effects of living according to Randian principles on mental health. Rand's so-called objectivism therefore provides not only a questionable philosophical framework for neoliberal politics but also, and perhaps predominantly for its followers, a set of guidelines for the project of self-optimisation. The fact that Rand's ideal of radical self-sufficiency is ultimately psychologically unliveable makes its use in applied psychotherapy ineffective and harmful. The article offers a cultural-historical case study about the ideological entanglements of philosophy and pop-psychological concepts and of clinical malpractice.

In Continental Philosophy of Psychiatry: The Lure of Madness Alastair Morgan surveys the contributions of a loosely conceived school of psychiatrists, philosophers and social theorists to understanding and responding to madness during the years 1910–1980. Taking my cue from him, I highlight some of the contributors discussed in Morgan's book and reflect that although madness may be difficult or even impossible to articulate effectively in discourse it remains a ‘limit experience’ which demarcates and illuminates the contours of other thinking and being, including reason and activism. I discuss social and cultural factors that have dulled clinicians’ sensitivities to the sounds of madness in recent decades and advocate the need for a reappraisal of our expertise and for a new activism today. What may at first appear as a failed clinical-philosophical tradition remains of professional relevance in today's rapidly transforming circumstances of practice both as inspiration and as cautionary tale.

Building a culture of conceptual inquiry in psychiatric training requires the development of conceptual competence: the ability to identify and examine assumptions that constitute the philosophical foundations of clinical care and scientific investigation in psychiatry. In this article, we argue for the importance of such competence and illustrate approaches to instilling it through examples drawn from our collective experiences as psychiatric educators.

This is an article about exclusion. We might not like to admit it – even fail to realise it – but National Health Service (NHS) mental health service structures have become increasingly focused on how to deny people care instead of help them to access it. Clinicians learn the art of self-delusion, convincing ourselves we are not letting patients down but, instead, doing the clinically appropriate thing. Well-meant initiatives become misappropriated to justify neglect. Are we trying to protect ourselves against the knowledge that we're failing our patients, or is collusion simply the easiest option? Problematic language endemic in psychiatry reveals a deeper issue: a culture of fear and falsehood, leading to iatrogenic harm. An excessively risk-averse and under-resourced system may drain its clinicians of compassion, losing sight of the human being behind each ‘protected’ bed and rejected referral.

We must remain open to revising and expanding the important but incompletely understood philosophical categories of agency and responsibility in light of what can be learned from atypical states and behaviour. A reflection on images – here, Goya's great Madhouse scene, and photographs of Mad Pride events since the 1980s – is shown to provide assistance towards this end.

The Scaling-up Health-Arts Programme: Implementation and Effectiveness Research (SHAPER) project is the world's largest hybrid study on the impact of the arts on mental health embedded into a national healthcare system. This programme, funded by the Wellcome Trust, aims to study the impact and the scalability of the arts as an intervention for mental health. The programme will be delivered by a team of clinicians, research scientists, charities, artists, patients and healthcare professionals in the UK's National Health Service (NHS) and the community, spanning academia, the NHS and the charity sector. SHAPER consists of three studies – Melodies for Mums, Dance for Parkinson's, and Stroke Odysseys – which will recruit over 800 participants, deliver the interventions and draw conclusions on their clinical impact, implementation effectiveness and cost-effectiveness. We hope that this work will inspire organisations and commissioners in the NHS and around the world to expand the remit of social prescribing to include evidence-based arts interventions.

There is increasing recognition of the importance of the humanities and arts in medical and psychiatric training. We explore the poetry of Charles Baudelaire (1821–1867) and its evocations of depression through themes of mood, time and self-consciousness and discuss their relation to images of ‘spleen’, the ‘snuffling clock’ and the ‘sinister mirror’. Following the literary critical commentaries of Walter Benjamin (1892–1940) and Jean Starobinski (1920–2019) we identify some of their roots in the poet's experience of the rapid and alienating urbanisation of 19th-century Paris. Appreciation of the rich vocabulary of poetry and the images it generates adds depth to clinical practice by painting vivid pictures of subjective experience, including subjective experience of the ‘social’ as part of the biopsychosocial constellation.

In the UK, the incidence of schizophrenia appears highest in Black Caribbean and Black African communities (four- to six-fold that of the White British population). The incidence of psychosis in other minority ethnic groups is also raised, but to a lesser magnitude. Although there are numerous environmental confounding factors, the data stresses the importance of optimising treatment in high-risk (minority) groups. Antipsychotic nonadherence is the most common reason for schizophrenia relapse, and is associated with increased rates of relapse, readmission to hospital and suicide. This article examines available literature to discover how culture can affect antipsychotic nonadherence, and considers culture-based solutions that could enhance antipsychotic adherence. Acknowledging the importance of the therapeutic alliance and sociocultural aspects in antipsychotic adherence, I argue that current cultural competence training provided to clinicians is inadequate. Organisational- and system-level approaches are required to reduce oppressive practise and promote culturally competent, person-centred care.

In most countries, social or behavioural interventions are recommended for autism. However, in France, psychoanalysis is still used, despite objections by patients, families and mental health experts. Supporters of psychoanalysis maintain that the choice of therapeutic approach is a matter of cultural preference, and that objections to psychoanalysis arise from misunderstandings. We argue that more deep-rooted problems are the lack of an evidence base for psychoanalysis and its focus on sexual relationships between children and adults, which demonises mothers and can put children at risk of abuse. Furthermore, psychoanalysis in France is protected from criticism by powerful educational and political networks.

Mindfulness-based therapies (MBTs) have shown promising results in non-psychotic disorders. Unlike most other psychotherapy models, which are claimed to be Western in origin, MBTs are firmly based in Indian philosophy and traditions. This paper summarises the concepts of the observer self (sakshi) and attention (dhyana) that underlie the principles and practice of MBT, correcting some erroneous assumptions in the process. It is argued that better understanding of these concepts is beneficial not just for specialist psychotherapists, but for all clinicians interested in the craft of healing.

The author draws comparisons between the subjectivity of interpreting a work of art and that of experiencing anorexia nervosa. She explores her own experiences of anorexia through a portrait depicting the duality of the disorder.

In a volatile world, during a time of multiple crises and amid a projected upsurge in mental illnesses as an aftermath of the COVID-19 pandemic, now is a critical time to consider how art and psychiatry can entangle with each other. Submissions like that of Lily Aston can create new spaces for conversation, reflection and constructive collisions. This can help disrupt and extend the state of psychiatry, management of psychiatric services, and education and training in mental healthcare, and advance how we understand other bodies and minds around us, and how knowledge can be created.

Many people like to perceive themselves as better than previous generations: more knowledgeable, moral, tolerant and humane. Values associated with these aspects of ourselves may affect how we understand our professional forebears. In the early 20th century, some psychiatrists adopted new biomedical theories, including focal sepsis and eugenics, which resulted in inestimable harm. Detrimental clinical practices arose and were perpetuated in the context of societal values, medical ethics and other forces within and outside the medical profession. Historical understanding of the processes by which these things took place may help inform debate concerning current and future challenges of providing psychiatric care. The methods by which psychiatrists consider their predecessors may also have a bearing on how psychiatrists of the future will perceive us, the psychiatrists of the 2020s.

Electroencephalogram-based evidence was accepted in a UK law court for the first time in 1939. This paper gives an account of that case, not previously clinically reported, and the individuals involved. Why it was not published in the literature at the time is explored and parallels with more recent technologies are highlighted.

The fiftieth anniversary of the Royal College of Psychiatrists, and the publication of a detailed multidisciplinary social history of British psychiatry and mental health in recent decades have offered an opportunity to take a helicopter view and reflect on the relation between psychiatry and changing British society. We argue that the time has come to move on from the rhetoric of deinstitutionalisation and community mental healthcare to lead public debate and advocacy for the needs of the mentally ill in the new era of ‘meta-community psychiatry and mental healthcare’. We need to respond effectively to the increasing awareness of mental health problems across society, aiming for a pluralist, integrated and well-funded reform led by joint professional and patient interests which could be unstoppable if we all work together.

The medical humanities may offer an antidote to the unconscious depersonalisation of patients into clinical variables and diagnoses at the hands of physicians, cultivating a patient-centred and individual approach to the management of both physical and mental health conditions. The emphasis on the person behind the diagnosis helps physicians to remain motivated and compassionate in the face of increasing social and organisational pressures that threaten this human connection. As a doctor and the relative of a patient with dementia, I reflect on the way in which poetry has helped to translate my experience as a relative into improving my own practice as a doctor. This article includes one of the poems I wrote during my grandmother's illness to aid reflection on the patient perspective I gained during her time in hospital, and also a brief commentary exploring the influence this process has had on the interactions I now have with my patients.