The 1959 Mental Health Act represented, by any standard, a ‘paradigm shift’ in the way in which mental illness was construed, not just in Britain but anywhere.

Homelessness and mental health problems have been historically associated – but before the 1980s this connection was not generally recognised. For many people with mental health problems, the large hostels for the homeless formed a parallel system of institutionalisation to that of mental hospitals. Unlike mental hospitals, they were generally situated within working-class areas of housing. Attitudes and practices changed significantly between 1960 and 2010. Both homelessness and mental illness became increasingly matters of concern – and the high levels of mental disorder among homeless people were recognised. In 1990, homelessness and mental illness became a political issue because of the increasing numbers of people visibly sleeping out in London. Although it was linked to psychiatric deinstitutionalisation, the evidence suggested that it had more to do with the closures of the large hostels in the 1980s. From the mid-1980s, increased recognition of the problem produced a range of high-quality and effective projects which provided better access to mental health care for homeless people.

The practice of military psychiatry is, in part, a function of the size and role of a nation’s armed forces. The end of National Service in 1960 and cuts to defence budgets saw the British Army contract by two-thirds, with reductions to its medical services. Despite suffering psychological casualties in the Falklands War and the sustained challenge of counter-insurgency operations in Northern Ireland, no research was conducted into PTSD experienced by British forces until the mid-1990s. The focus on Gulf War syndrome diverted attention from common mental illnesses towards hypotheses of toxic exposure. A Strategic Defence Review conducted by the Labour government in 1998 defined a broader global role for the UK military to enhance the country’s international influence, and deployments to Iraq and Afghanistan followed. Women, integrated within all three services from 1992, joined in rising numbers but reported elevated rates of mental illness and may have been exposed to greater risk of military sexual trauma. A class action for negligence in the detection and treatment of PTSD in 2002 encouraged the Ministry of Defence to fund research into psychological illness and develop services for trauma-related injury.

Psychiatry has never been without vociferous critics. Anti-psychiatry raised legitimate, albeit irritating, concerns about psychiatric practice. Clinical psychologists in Britain now outnumber psychiatrists, with an enormously expanded clinical remit. Lead psychologists are now as experienced as consultant psychiatrist and vie for leadership. To pretend that all is well in the world of professional mental health practice and relationship is dangerous.

Changes in mental health law in England and Wales between 1959 and 2010 are reviewed – from the earlier Lunacy Act (1890) and Mental Treatment Act (1930) to the Mental Health Act (1959), Mental Health Act (1983) and the Mental Health Act (2007) amending the 1983 Act. The implications of early twenty-first-century developments – ‘decision-making capacity’–based law (including a ‘Fusion Law’) and the influence of the UN Convention on the Rights of Persons with Disabilities (2006) are discussed. The social, economic, ideological, clinical and legal contexts for changes in the law are examined. These include the paradigmatic shift from the ‘legalism’ of the Lunacy Act to the ‘medicalism’ of the 1959 Mental Health Act and, later, less dramatic shifts, to the ‘new legalism’ of the 1983 Act and then the ‘new medicalism’ of the 2007 Act. The departures from the English model in Scotland in 2003 and later in Northern Ireland are briefly considered.

Services were first based on providing mental deficiency colonies, then called hospitals by 1960. The 1970s saw the start of a recognition of a right to live in the community as equals. It took thirty years to close the old hospitals and develop an entirely community-based service. This needed changes to policy, funding agencies and the benefit system. This also involved changing the skills of previous staff and changing skills and attitudes in mainstream services. We now have a rights-based system, which is more fragmented and more challenging for people with learning disability to negotiate.

The number of patients resident in many hospitals had begun to decline several years before antipsychotics arrived on the scene. The population of asylums did shrink significantly throughout the 1960s and 1970s, though mental hospitals did not begin to vanish from the scene until the 1980s under Margaret Thatcher. Deinstitutionalisation was no accident. It was a consciously chosen neoliberal policy, pursued relentlessly over many decades. Welfare ‘reform’, in Britain as in the United States, has become a term of art disguising repeated assaults on the social safety net and the demonisation of those dependent upon it. ‘Community care’ in the era of neoliberal politics has turned out to be an Orwellian euphemism masking a nightmare existence for all too many of those afflicted with serious psychoses and for their families.

Either side of the Second World War, social psychiatry had emerged in the United States, influenced by Adolf Meyer’s work, the ecological wing of the Chicago School of sociology and subsequently the development of the biopsychosocial model by George Engel. The sociological imagination in British social psychiatry was sparse but not always absent. Most of the work in UK is derived from the Institute of Psychiatry in London, augmented by a minority of studies from Scotland and the English provinces. By the turn of this century, the taken-for-granted diagnostic categories used by social psychiatrists were subject to critical questioning. The weak construct validity of schizophrenia was conceded and a broader notion of psychosis as the medical codification of madness (i.e. socially unintelligible conduct) emerged. No discipline has a monopoly of understanding about this topic and so the interdisciplinary potential of social psychiatry, broadly conceived, remains an opportunity for all. However, for its potential to be realised, the principle of interdisciplinarity needs to be fully respected by all.

The recession of the 1970s saw the advent of financialised capitalism and a renewed focus on cost containment in health care. At the same time, new identity politics had displaced the old politics of distribution associated with the welfare state. The political contraction of the welfare state, together with the spread of ‘precarity’ in employment via zero-hours contracts, and the undermining of work conditions, sick pay and pensions have been facilitated by a recasting of personal responsibility. Strong flows of biological, psychological, social, cultural, spatial, symbolic and, especially, material asset flows are conducive to good health and longevity, while weak flows are associated with poor health and premature death. Ideological assaults on the welfare state have been major contributors to growing material and social inequalities. Financial capitalism has witnessed an accelerating rate of mental as well as physical health problems in line with the fracturing of society. The period 1960–2010 set the scene for what many at the time of writing (2020) see as a severe crisis in welfare care.

In the period from the 1960s to the 2010s, there are six major shifts in encounters between these professionals and their patients. They are deinstitutionalisation, changes in diagnostic nomenclature, anti-psychiatry, patients’ movements, evidence-based medicine and the privileging of psychopharmacology, neurochemistry and neurobiology. These themes overlap to varying degrees. Linked to these changes are major shifts in the care of elderly people with mental health issues, the ‘treatment’ of homosexuals, debates about informed consent, the ‘medicalisation’ of everyday complains and shifts from psychosocial models of psychiatry to biomedical ones.

Miscarriage and stillbirth are not rare events and losing a baby can have an overwhelming and long-term impact on parents, on existing and subsequent children and on wider family. Potential parents’ feelings of devastation, intense grief, anxiety, guilt and self-blame and loss following such a death have been identified in literature written over past centuries. Fifty years ago, miscarriage and stillbirth were a private matter and unspoken of, leaving parents to manage their grief alone. This chapter aims to shine a light on the changes in attitudes and the support available to those who have experienced miscarriage and perinatal death since the 1960s. A review of relevant research, policy and practice identified significant advances in medical science and major changes to the law – changes that have influenced attitudes to abortion, same-sex parenthood and single mothers. Medical advances have made childbirth safer and the use of IVF has extended the opportunity of motherhood to a wider group of women. The campaigning of numerous charities has led to far greater understanding of the impact of baby loss on parental mental health and parenting capacity.

From the 1960s to the 1980s, in parallel with societal changes from welfarism to the counterculture, the legacy of the child guidance and psychodynamic approaches gave way to more active, transparent and fast-moving therapies. Family/systemic therapy involved the whole family, training practitioners from all disciplines. Cognitive behavioural therapy (CBT) was developed as an alternative effective psychological treatment. A variety of longitudinal and epidemiological research approaches developed, providing a variety of ways of measuring the presence and impact of mental health problems. Conditions such as anorexia of childhood, self-harming and neurodevelopmental disorders – autism and attention deficit hyperactivity disorder (ADHD) – have been identified. Despite attempts to ‘shrink the state’ in the 1980s, a continuing theme has been the recognition of the hidden yet pervasive traumatic impact of maltreatment many children suffer. There is a lifespan impact of adversity on mental and physical health and the need for a trauma-informed care approach.

Throughout the 1990s, there had been concern in the UK about the number of homicides carried out by people with severe mental health problems. The frequency of homicides was alleged to be increasing but analysis of official data showed the opposite; homicides had been reducing at the rate of 3 per cent per annum over many years. The Dangerous and Severe Personality Disorder (DSPD) legislation and richly funded associated ‘treatment’ programme were introduced in the late 1990s by the then Labour government and aimed at the use of a contrived psychiatric ‘diagnosis’ and ‘treatment’ to enhance public protection. The exact origin of the concept of the Dangerous and Severe Personality Disorder (DSPD) programme remains an enigma but Jack Straw, secretary of state for the Home Office, and his Department played the leading role. The programme started at HMP Whitemoor and Broadmoor Hospital in 2001 and subsequently extended to HMP Frankland in County Durham. The initial cost was £128 million, with operational costs amounting to £40 million per annum, and by 2010 had cost £480 million in total. The legislation and ‘treatment’ programme were vigorously opposed by the Mental Health Alliance.

Robairt Clough was a long-term patient at Holywell Psychiatric Hospital in Antrim (Northern Ireland). In the Christmas 1972 edition of the patients’ magazine, he wrote the following verses

Between the late 1960s and early 1980s, at least ten major and many smaller inquiries were held into neglectful, abusive and violent practices in a number of psychiatric and ‘mental handicap’ hospitals. Many of these institutions, or certain wards inside them, had become professionally isolated and severely under-resourced. Deeply ingrained cultures of harm and neglect had evolved over years, causing untold suffering to many of society’s most vulnerable people, including those with severe learning disabilities and older people. This chapter provides an overview of shifts in the understanding of institutional environments in the post-war period and the subsequent emphasis on moving care for acute conditions into the community, leaving long-stay wards more isolated than ever. It explores the social, cultural and political mechanisms that facilitated the exposure of harmful practices by the press and campaigners, compelling politicians to order inquiries. Finally, it examines how the inquiries helped to bring about change to the provision of long-term care in the 1970s and contribute to the widespread closure of the old Victorian asylums from the 1980s.

The period 1960–2010 was a time of marked immigration into the UK from Commonwealth countries, either to fill employment gaps in the UK or to escape hostilities and conflict as many Commonwealth countries secured independence. The political climate of the UK; attitudes to immigration and cultural integration; the evolution of mental health sciences, including British psychiatry and the Royal College; the emerging research evidence; and the controversies around why migrants and minorities appeared to have higher incidence rates of severe mental illness and poorer outcomes were, and are still, all interrelated and contribute to the lives of minorities. In the 1970s, as a community, Black African Caribbean people of the Windrush generation were concerned about their children getting police attention, which occurred in a racist and political climate of oppression. More than sixty years later, the situation has escalated and diversified so that illegal drugs, gangs and violent crime are now stereotyped as ‘Black culture’. Inequalities generated by the education and criminal justice systems, early years care and employment practices are a backdrop against which the mental health systems are positioned to respond to societal harms to the marginalised.

The closure of the old hospital asylums in Britain was driven by psychiatric optimism, moral outrage at overcrowding and poor quality of care as well as by concerns about the cost of maintaining the old buildings. Initial results were promising: patients discharged from the asylum experienced a better quality of life with few adverse outcomes. At the same time, mental health care became more multidisciplinary and reached out to people with less disabling conditions. Problems emerged when the asylums could no longer accept new referrals of people with enduring disability whose needs for care were publicly visible and who were stuck on acute wards. Community residential facilities were unwilling to accept people with challenging behaviours and the prevailing social model was one of a progressive movement towards independence that spoke against the provision of long-stay accommodation. This left ambulatory mental health teams to provide intensive support that nevertheless failed to prevent tragedies including suicide and homicide. The media and politicians claimed community care had failed and demanded more powers to enforce treatment.