The size of the field in which psychiatry claims expertise has expanded dramatically since the nineteenth century when alienists only dealt with madness (renamed psychosis after the 1860s), epilepsy and some organic disorders. Social history possesses methodologies apt for the exploration both of the world of concepts and values and of the dark forest of economic interests. This book may be pointing to another useful way of doing history of psychiatry. Its findings should add to the periodic documentation required by British psychiatry. There is a need to explore how values and economic interests affect neuroscientific research as well.

In this chapter, life in UK psychiatric hospitals during the long 1960s is described. Based on oral testimony from a witness seminar, the chapter reveals perspectives which are not readily available in written sources. The authors outline how changes in treatments, the Mental Health Act 1959, multidisciplinary teams and ideals of community care provided opportunities to improve the lives of patients but that wide contrasts existed in the pace and extent of these changes and in clinical standards and practices between, and even within, hospitals. The chapter also addresses how some institutions were characterised by individual charismatic – and often ideologically dogmatic – leaders and the risks that this entailed. For many, their experiences had a lasting impact. Individual senior staff – ‘good’ or ‘bad’ – were role models who had profound effects on the course of junior clinicians’ future careers, while the memory of a tragedy, such as the suicide of a patient, could haunt involved staff members lifelong.

The user/survivor movement represents a most significant development in mental health and therefore demands careful and serious examination, particularly in its broader social, political, policy, cultural and economic contexts. Generations of psychiatrists have not been educated about the activism and achievements within the user/survivor movements, which left many practitioners ignorant of the autonomy and agency achieved over the past fifty years. The UK mental health service users/survivor movement is one of the ‘new social movements’, including black civil rights, women’s, LGBTQ and grey power that emerged globally in the second half of the twentieth century, largely based on shared identity and common experiences of oppression. The survivor movement, like other service user movements, was facilitated by the political shift to the right from the late 1970s which was associated with a renewed emphasis on the market, devaluing of the state and growing government rhetoric for consumer rights in public services.

Many scientists, academic and clinical psychiatrists have contributed to the search for the biological basis of mental illness, leading to many notable discoveries and advances in understanding schizophrenia. Randomised controlled trials (RCTs) have established beyond reasonable doubt the efficacy of antidepressants, electroconvulsive therapy (ECT), antipsychotics and mood stabilisers. The most striking diagnostic advances have been made in identifying the genetics of learning disability and in developing neuroimaging and blood-based biomarkers of dementia. Polygenic risk scores and machine learning of neuroimaging and other data have real potential to impact upon clinical practice and improve patient care. Psychiatrists and indeed all those affected by mental illness should call for increased funding to identify biomarkers, develop new treatments and improve services.

The Mental Health Act 1959 and A Hospital Plan for England and Wales in 1962 set a direction for mental health services away from inpatient and towards outpatient and community care which enjoyed support across the political spectrum. There has been a shift of focus over time from rights and recovery to marketisation, to risk and safety to modernisation and, finally, to well-being. There has been greater coherence in policy and consensus among staff in child and adolescent mental health than its adult counterpart, but service developments were hampered by chronic underfunding. Though, overall, it is probably fair to judge that mental health services in 2010 were both substantially more effective and significantly more humane than those prevailing in 1960, they have not fulfilled the aspirations held widely at the beginning of the period.

Psychiatric (mental health) nursing is a relatively young profession that developed with great speed over this fifty-year period. In 1960, nearly all nurses were employed in large mental hospitals. While education and training were improving, nurses’ roles in the 1960s largely involved the care and supervision of institutionalised patients. The pay and status of nurses were low, with nursing at the bottom of a medically led hierarchy. However, the 1970s saw a great expansion in community psychiatric nursing, the development of nurse therapy training and the gradual emergence of multidisciplinary teams. The education and training of nurses improved, as did pay conditions and status and, by 2010, nursing was becoming an all-graduate profession. The end of the era saw nurses becoming independent prescribers and skilled clinicians. Changes in the Mental Health Act meant that nurses could assume additional roles by becoming ‘responsible clinicians’ or ‘approved mental health professionals’.

When Ken Clarke (KC) became Secretary of State he was concerned to try and make the service much more accountable to its patients, and to stop it being so borne down by bureaucracy and dominated by industrial relations problems. The idea of NHS Trusts was to give more autonomy to the local users of services so they could answer for their performances to their local public. KC states that before the purchaser/provider discussions nobody really knew what the NHS was spending its money on, and the idea that the money given might be linked to the outcomes was never contemplated. He found that the old ‘asylums’ were absolutely shocking places so it was perfectly sensible to introduce this policy of care in the community, provided it was integrated with hospital care by psychiatrists and others in a coherent way. Regrettably, the public believe that whenever there is extra money in the health service it ought to be spent on cancer patients or children, not on mental health, and populist Secretaries of State in populist governments accede to these requests, especially on cancer, a subject that terrifies the public so they feel if politicians spend more it might go away.

We want to celebrate the resilience of refugees. We therefore dedicate this chapter to all those who came to the UK seeking protection and have made a life in the UK against the odds. Past mental health work has been disproportionately focused on post-traumatic stress disorder (PTSD) as a diagnosis. This imbalance has improved in more recent years. Refugees are now known to have a higher rate and wider range of mental health problems as well as psychosocial stress. Refugees need their basic needs met as well as addressing mental health problems. Interventions that have helped have been social such as access to employment, combating discrimination and fostering inclusiveness. Resolving asylum uncertainty has been central to a reduction in mental health distress. The importance of the culture of the refugee cannot be underestimated in assessing and managing their health needs. One difficulty has been refugees’ access to mental health services. Mainstreaming was the main approach, but some specialist services enhanced access during this time. Some specialist services developed within the voluntary sector.

There remains a gap between needs, aspirations and delivery in psychiatry and mental health. To close this gap there is a need to attend more intensely to social science and mad studies, as well as neuroscience, in professional formation in psychiatry and mental health. Further strengthening of the nursing profession and greater engagement of action therapies will also help close the gap in practice. To be effective, such efforts must be underpinned by a commitment to pluralism.

There is an association between unemployment, poor mental health and suicidal behaviour. There is a modulating effect of the strength of national social security programmes: countries with the weakest welfare states showed a greater impact of unemployment on rates of suicide.

While employment may be beneficial to health, exposure to a range of psychosocial hazards can also put workers at risk of poor mental health. People with mental health conditions now represent the largest group receiving out-of-work sickness benefits. In the UK, rates of employment of people with schizophrenia may have fallen. Supported employment is significantly more effective than pre‐vocational training. The initial business case for IAPT (Independent Access to Psychological Treatment) assumed that the receipt of cognitive behavioural therapy (CBT) would result in people returning to work, but few did. More recently, we have seen a shift from ‘work’ as therapy to ‘work’ as a human right. Annual surveys conducted in England between 2004 and 2008 repeatedly showed that, of those who use mental health services and were unemployed, more than half would have liked help in gaining employment but mental health services had not offered such help.

By the 1960s, some psychiatrists had begun to specialise in work with mentally disordered offenders but the term ‘forensic psychiatry’ was not used anywhere except at London’s Maudsley Hospital. In the UK, such work has demonstrated a highly developed capacity for inter-agency working. In 1978, the first UK professorial chair was established and in 1988 an independent Department of Forensic Psychiatry was created at the Maudsley Hospital. Between 1990 and 2002, seven forensic psychiatry chairs were created around England, almost invariably funded by the NHS; but British universities were becoming business-oriented and their core funding was decreasingly available for developing academic subjects, like forensic psychiatry, which did not attract large grants. Psychological damage to victims of miscarriage of justice adds to the social turmoil and is particularly difficult to treat in the face of constant re-traumatisation as inquiries follow. Forensic psychiatry and psychology in England became concerned with false confessions. In general, recognition of the importance of work with victims of harmful behaviours has grown in terms of respect for their wishes and needs and from the perspective of preventing further harms.

This chapter will review the societal and political context in which there was an evolution of approaches to address the mental health needs of children and young people.

Liberal ideas about personal autonomy, choice and independence emerged internationally in the 1960s. Changing agendas permitted younger people to make choices, even if risky, but older people were perceived as inevitably vulnerable, and despite their experience of life, their wishes were frequently ignored. For older people, clinically and scientifically, things edged on, albeit slowly. Promises of new services for an undervalued sector of the community were particularly vulnerable to political and economic fluctuations. The leadership had to advocate persistently for older people to receive appropriate levels and ranges of care equitable with those provided for younger adults. Ongoing and ageist themes over the fifty years have included prioritising services for younger patients; the double whammy of stigma of mental illness plus old age; and policy decisions based on short-term economic calculations rather than likely health and well-being outcomes.

I go about my domestic duties in mourning, sighing over the melancholy void that death has made … There sits her empty cradle … I shall never see her sleeping there again.1

The period 1960–2010 has been one of marked change in UK society and mental health services. Prominent changes have included deinstitutionalisation and community care in mental health. These have taken place in an evolving framework of liberalisation, marketisation and globalisation. The global financial crisis of 2008 and the increasing impact of information technology, social media and artificial intelligence have ushered in a new era of meta-community care, which is now affected by the shock of Covid-19. It is timely to look back over the half-century of 1960-2010 to study and learn the lessons from developments in mental health during what has been labelled the neoliberal era, now in retreat.

British psychiatry is almost entirely publicly funded; in the United States, a tradition of well-remunerated private practice has prevailed. Despite similar therapeutics and nosology, psychiatry in Britain and the United States has developed in strikingly different ways. Psychoanalysis once dominated US psychiatry; in a big swing of the pendulum, it has been almost entirely replaced by psychopharmacology. In Britain, the research tradition in the past was weak; in the United States, it has been fuelled by large amounts of government funding. A British hesitancy about embracing large abstract theories has no US counterpart. In terms of training, a progressive agenda has been emphasised in Britain, more defensive postures in the United States.

Substance use and misuse remain a feature of everyday life in the UK today. It is a cause of death and disability and a marker of deprivation and inequality. The health, social and criminal justice systems currently in place are not able to provide the flexible response in which the public can have confidence and to which they can adhere. While much of the debate has centred on younger people, including children and adolescents, attention has recently turned to older people who are misusing cannabis and heroin as well as over-the-counter and medically prescribed medications. The remarkable contributions of neuroscience over the half-century of 1960–2010 have demonstrated the biological basis of substance misuse, which can become a chronic medical condition, much like diabetes and hypertension. There is exciting potential for the development of new pharmaceutical agents for the treatment of substance misuse. An aspiration we have is towards a new public understanding of addiction through education so that people can make informed choices based on realistic policies.

Religion, spirituality and psychiatry share many ideals, such as the importance of a holistic understanding of mental well-being, yet in the past have clashed. The transitions that occurred from 1960 to 2010 have significantly shaped the contemporary relationships between religion, spirituality and psychiatry in Britain. Interest in the intersections between spirituality, religion and psychiatry resulted in the formation of the Spirituality and Psychiatry Special Interest Group (SPSIG) of the RCPsych in 1999. In 2009, an edited volume, Spirituality and Psychiatry, conceived within the SPSIG, provided the first critical attempt by a group of British psychiatrists and mental health professionals to address the implications of spirituality/religion for clinical practice. At the same time as the developing acknowledgement of the importance of religion and spirituality to psychiatry, there were similar developments within several other mental health professions. The General Synod of the Church of England held debates on mental health in 2003 and 2008. The president of the RCPsych and three members of the College were invited to observe the 2008 debate.

The sickness model of LGBT people was dominant within UK psychiatry and its impact was still apparent years later despite the removal of homosexuality from ICD-10 in 1992. Conversion and reparative therapies were important aspects of psychiatrists’ and other mental health practitioners’ approaches to LGBT people, despite the lack of a credible evidence base. More positive, gay-affirming therapeutic approaches have been developed and adopted by mental health practitioners, although many LGBT people report concerns about their experience of mental health care. Social changes (liberalisation in public attitudes and law) were brought about through complex social processes that owed nothing to UK psychiatry. The history of LGBT people in relation to psychiatry raises important questions about the legitimacy of psychiatric power and authority.