The National Health Service has entered a period of substantial change. The impending reform of local government (1974) will coincide with considerable reforms in the administrative structure of the N.H.S. (1). In addition, our subject matter—the mental health services—has been the subject of various Government White Papers and policy decisions (2). These reforms are an attempt to increase the efficiency of the service, and throughout their pages reference is made to the need for scientific management and administrative efficiency.

In England, public intoxication has been a criminal offence ever since an Act of Parliament was passed in the reign of James I, somewhat over three and a half centuries ago. Edwards (1970) compiled some figures on these offences for the last two hundred years, showing that the rate of arrest was much higher in the nineteenth century than at present. For example, in 1878 there were 70 arrests per 10,000 of the population, compared with a comparable figure for 1968 of 16. Nevertheless, the latest available figures from the Home Office (1971) show that 82,961 persons were found guilty of simple or aggravated public drunkenness in 1971. In the U.S.A., with its apparently much larger alcoholism problem, there were nearly one and a half million arrests for this group of offences in 1966 (Pittman, 1969); this accounts for one third of all arrests in that country (Chafetz, 1971).

People who kill themselves are grouped together as suicides on the basis of that one action, yet they can hardly be considered to be a homogenous class. Attempts to define sub-categories among suicides can be made in a number of different ways, none by itself entirely satisfactory. Differentiation by psychiatric diagnosis is one possibility, but is difficult to achieve and throws little light on the undoubted contribution of social factors. Sociological studies have usually persisted in regarding all suicides as intrinsically similar, and have sought to relate variations in rates between different sections of the community in terms of general social variables such as status integration, social isolation, anomie and the like. Yet suicides are not a uniform group, and relatively little can be achieved while this fact is ignored.

Family studies of schizophrenia have indicated familial differences between paranoid schizophrenia and other Kraepelinian subtypes of schizophrenia. Kallmann (1938) noted the lower morbid risk for schizophrenia in the families of paranoid probands as compared to the families of hebephrenic and catatonic probands. This finding was confirmed for siblings by Hallgren and Sjögren (1959).

Numerous studies of the reliability of psychiatric diagnosis have been published in the last twenty years, but most have been based either on a comparison of the diagnoses made by two or more raters at a single joint interview, or separate interviews a few days apart (the observer agreement model), or on a comparison of the overall spectrum of diagnoses assigned to two comparable series of patients (the frequency agreement model). Comparisons between the diagnoses assigned to patients on successive admissions, or at other widely separated points in time (the consistency or stability model), have been carried out less often, in spite of the fact that the usefulness of our diagnostic categories is just as dependent on temporal stability as on reliability in an observer agreement situation.

The psychiatric anamnesis is a lengthy enquiry based on the Meyerian principle that most aspects of a patient's past and present history are relevant to the diagnosis and management of psychiatric disorder. Despite widespread use by both clinicians and research workers, the anamnesis has been the subject of few investigations regarding its reliability and validity. The studies reported have not encouraged confidence in traditional history taking (Haggard et al., 1960; Wenar and Coulter, 1962; Beckett et al., 1967). The present study was carried out to investigate the reliability of the family and personal history.

In a previous study (Liss, Welner and Robins, 1973), the hospital records of 212 patients who received a diagnosis of personality disorder other than antisocial personality were studied. The clinical information about these patients was used to arrive at an established psychiatric diagnosis based upon the rigorous diagnostic criteria designed for research (Feighner, Robins, Guze, Woodruff, Winokur, and Munoz, 1972). In 118 cases (56 per cent) the clinical symptoms and the course of the disorder met the required diagnostic criteria for one or more of the established psychiatric diagnoses. The remaining 94 patients (44 per cent) had too few symptoms to meet these criteria.

The token economy is an application of operant conditioning theory which is particularly relevant to the treatment of patients in institutions. The basic idea is to motivate the patient to behave more appropriately and constructively by giving him tokens whenever he behaves in such a way. The tokens have an incentive function, as the patient can cash them in for a number of different things, such as pleasant single room accommodation, cigarettes, magazines, TV viewing, drinks etc., depending upon what is programmed into the token economy. The theory of operant conditioning is that not only does the token motivate the patient to behave in certain ways, but ‘reinforces' his behaviour. Such reinforced behaviour should eventually become an integral part of the ‘way he is', continuing even when the token is removed.

Although phenothiazines have gained acceptance as the standard treatment for the acute episode of schizophrenia (Rathod and Rees, 1953; Cole, 1964), there is much more doubt about their effectiveness as maintenance therapy. Several American studies have reported on the results of maintenance therapy with chlorpromazine compared with placebo, and found phenothiazine treatment to be superior in preventing relapse (Scarpitti et al., 1964; Pasamanick et al., 1957; Ravaris et al., 1967). However, these studies suffer from methodological problems which impair their clarity. First, as emphasized by Leff and Wing (1971), diagnostic criteria are rarely stipulated. This is clearly important if American work is to be compared with British, since Kendell et al. (1971) have shown the wider concept of schizophrenia used in the U.S.A. Secondly, the likelihood of bias occurring in the population meeting trial selection criteria, resulting in a trial population which is unrepresentative of the group as a whole, is not usually defined. Every trial worker knows this ‘shrinking sample’ phenomenon, which appears to result in a sudden scarcity of patients as soon as a trial is contemplated. The trial of maintenance therapy conducted by Leff and Wing (1971) meets this objection by following the progress of patients who met the trial criteria but could not be included for various other reasons.

The investigation had three major aims. We attempted to repeat and extend the findings of the Gelder, Marks and Wolff (1967) study of the comparative efficacy of desensitization and psychotherapy in the treatment of phobic patients. Our second aim was to isolate the effects of various components of desensitization treatment, in the manner employed in laboratory studies of fear-reduction (e.g. Davison, 1968; Rachman, 1965; Rachman, 1968). The third aim was to collect data on the relationships between psychophysiological changes and clinical outcome.

Of the many diverse treatments for impotence (Cooper, 1971) perhaps in some ways the most novel are the various mechanical devices which to date have never been adequately tested; although there are reasons to believe that they would be safer (even if no more effective) than many drugs in present use. A modern innovation of the penile splint (Lydston, 1908) is the Blakoe ‘Energiser’ Ring which is made of ebonite, with five small metal plates on opposite inner surfaces. It opens on a swivel so that the lower half can be placed high up under the scrotum and when the upper part is swung around, closing the ring, the penis, scrotum and testicles are enclosed within it, but hang freely below.