During the last ten years in the UK, service user consultation and collaboration has gradually entered the vocabulary of people providing and purchasing mental health services. However, we are not convinced that much needed change in mental health services will be achieved as a function of increased commitment to market consumerism. We argue here that service user consultation and collaboration should take account of the effects of social inequalities on mental health and on mental health services. This perspective highlights the need for fundamental change in mental health services, and helps us to appreciate the strength of resistance to change, and to understand some of the dynamics involved. We describe here how this perspective has motivated and shaped our own efforts to collaborate responsibly with service users to change mental health services.

In selected adult neurotics, nurse-therapists have a significant contribution to make in giving behavioural psychotherapy to patients who were formerly denied it for lack of trained personnel (Marks et al. 1977). Perhaps 10% of all adult psychiatric outpatients can benefit from behavioural psychotherapy as themainapproach for those categories of problem where established behavioural methods have been found to be superior to contrasting treatments (Marks, 1976).

A young man was followed-up over three years who had severe obsessive-compulsive rituals and ruminations, interpersonal deficits, complicating depression and a history of childhood autism. Intensive behavioural treatment was given in an operant framework, with exposure in vivo, modelling, response prevention and social skills training. Compulsive rituals improved markedly and lastingly, but ruminations and social defects persisted. When intercurrent depression occurred dothiepin facilitated behavioural treatment. Adjustment remained fragile. Minimum maintenance treatment in the community could not be adequately arranged, so that gains made in hospital were partly lost at follow-up, despite continuing improvement in rituals.

Concepts of interviewing skill and of appropriate training and evaluation are briefly reviewed. It is hypothesized that if goals and skills relevant to a specific clinical interview can be identified and modelled in advance then even very brief training can improve outcome. An experiment is described in which three randomly selected general practitioners conducted, separately, test interviews with the same role played 'patient'. These interviews were repeated after a 'goal focusing' exercise and again after a modelling and instruction exercise. All interviews were telerecorded and subsequently blindly rated for impact on the 'patient'. The results suggest powerful training effects. The drawbacks of the study, such as lack of controls, are discussed. The similarity of evaluation raters who were 'behaviour' orientated and those who were 'psycho-dynamics' orientated is noted and it is suggested that agreed concepts of effective interviewing may be within reach.

This paper concerns a new clinical role for psychiatric nurses--as case managers for selected adult neurotics with behaviour problems. The role involves unusual autonomy. The selection and training procedures are unusually rigorous and focus on general case-management as much as behavioural skills. The number of service posts offered these therapists is rising. These developments have wide implications for other personnel, particularly in respect of authority and responsibility boundaries, selection and training procedures, and team structure.