Introduction

This was one woman’s reaction to the death of her baby in the first half of the nineteenth century. Her grief and despair are timeless. However, the understanding and compassion shown to miscarriage and perinatal death is now very different.

Although such loss does not respect age, previous fertility or wealth, women living in poverty are at most risk.² The impact on the mental health of parents depends on a number of variables, including prior mental health, relationship between partners, culture, gender identity, medical and social support and religion. This chapter explores how the support provided to those experiencing loss reflects many of the seismic societal changes taking place on a broader canvas from the 1960s onwards.

Contribution of Legislation in Marking Change

Legislation in the last fifty years has marked both advances in medical science and changing attitudes towards pregnancy, parenting and the loss of a baby. It continues to do so. Stillborn babies had no legal existence prior to 1927 in England and 1939 in Scotland. ‘The stillborn were thus treated as if they had never existed, and registered as neither a birth nor a death.’³ The Stillbirth (Definition) Act 1992 extended the definition of stillborn from lost after the twenty-eighth week of pregnancy to lost after the twenty-fourth week. Those born earlier are not registered and there is no legal requirement for burial or cremation. Attitudes, however, continue to change. ‘In recent years, with greater understanding of the significance of the death of a baby at any stage of pregnancy, more babies born before 24 weeks have been formally buried or cremated.’⁴

Medical terminology and its wider use have evolved; abortion originally described pregnancy loss without clarifying whether it was spontaneous or induced. Change began with the Abortion Act 1967, allowing women greater legal access to abortion services and the Guidance on the Act was updated in 2014.⁵ Women who experienced a spontaneous miscarriage were thus able to talk to their doctor without fear of being criminalised and those seeking terminations could be referred to expert and safe clinical services. It was not until the 1980s with the development of ultrasound, enabling the foetus to be seen, that doctors consciously began using the term miscarriage to refer to early pregnancy loss.⁶

Prevalence of Pregnancy and Perinatal Loss

The rate of conception in England and Wales has, over the past half century, shown considerable variation. In 1969 conception was estimated to be 832,700 for women of all ages, falling to 686,400 in 1977 and by 2010 had risen to 909,200. Since then there has been a steady decrease. Scares over the safety of the contraceptive pill between 1976 and 1996 may have contributed to increases in conceptions due to the use of less reliable contraceptive methods.⁷

Not all conceptions lead to a live birth. It is estimated that today one in four pregnancies in England and Wales ends in miscarriage.⁸

A foetus may be lost because of an ectopic pregnancy. The recorded incidence increased between 1966 and 1996, ‘probably due to a sexually transmitted agent’ and has remained stable since.⁹ It currently accounts for around one in every ninety pregnancies in the UK.¹⁰ Some women decide to terminate their pregnancy. The recorded abortion rate increased from 6 per 1,000 resident women in England and Wales in 1970 to 20.8 per 1,000 in 2010. Of these, 1 per cent were performed in 2010 because of a substantial risk of foetal abnormalities.¹¹ The rate of perinatal mortality in the UK has been declining, falling from 11.8 deaths per 1,000 total births in 1981 to 7.5 deaths in 2011.¹²

There is now greater interest in monitoring and understanding pregnancy and perinatal loss. MBRRACE-UK undertakes regular perinatal surveillance reports to identify trends in stillbirth, neonatal and perinatal mortality rates.¹³ The reports have informed the NHS Long Term Plan covering maternity and neonatal services, aimed at reducing stillbirth, neonatal mortality and serious brain injury.¹⁴

Attitudes to Motherhood and Fertility

It might be expected that widely held views on the imperative of motherhood would have undergone major changes over the last fifty years, thanks to family planning, the development of medical fertility techniques and greater economic independence.

Post-war advertisers targeted women as mothers and homemakers, mirroring the prevalent view in society. Women were expected to bear children and, in the mid-twentieth century, ‘doctors who believed that female infertility was a psychosomatic condition recommended adoption as a “cure”’.¹⁵ Even now, the prioritising of motherhood continues. The results of a recent UK survey are surprising. ‘Around four in five British women say being a mother is “more important” than having a career, while only 6% put having a career first’.¹⁶

Although women are expected to become mothers, there has been a major change in the public response to pregnancy. In the 1960s and 1970s, it was often seen as a rather embarrassing condition and any evidence was disguised. Today the stigma and shame are disappearing, pregnant women can remain in the workforce, they are featured and celebrated in the media and clothes are designed to emphasise the baby bump. Fertility is also no longer seen as the prerogative of young women: ‘Fertility in the over-forty age group has trebled since the 1980s, and there are now more women giving birth in their forties than in their teens.’¹⁷

Views on single parenthood have gradually been overturned. In the 1960s and 1970s, secrecy and shame surrounded unmarried motherhood,¹⁸ attitudes perhaps reinforced by John Bowlby’s influential work on attachment, which stressed the two-parent family and the stay-at-home mother as the bedrock of social stability. Change started in the 1970s with the wider availability of oral contraception and continued in 1984 with the licensing of the ‘morning-after pill’. This meant that to have a baby as a single woman became largely a matter of choice. Language has also changed; terms such as ‘bastard’, ‘illegitimacy’ and ‘living in sin’ are now rarely used except by the fiercely religious. Yet policy progress has been slow and remains dogged by political and media rhetoric of ‘the feckless poor’ and ‘problem families’.¹⁹

Attitudes towards same-sex partnerships and members of the LGBT community have shifted radically; the number of people who think same-sex relationships are ‘not wrong at all’ has gone from 17 per cent in 1983 to 65 per cent in 2018.²⁰ The many changes in the law around same-sex relationships since 1967, when sex between two men over the age of twenty-one in England was decriminalised, have kept pace with public opinion. Views on the LGBT community continue to shift, including their equal rights to parenthood (see also Chapter 34). A discussion on the impact of pregnancy and baby loss must take a broader perspective on parenthood than would have been assumed fifty years ago.

Fear and Hope in Pregnancy and Perinatal Loss

Pregnancy evokes a variety of emotions: for some, it will produce feelings of joy, excitement and hope for the future; for others, anxiety, dread and guilt; but for many the emotions will be mixed. Women’s reactions will be predicated on whether pregnancy was wanted and planned and the underlying mental health of the parent – issues that will subsequently shape their reaction to losing the pregnancy or baby.

Until relatively recently, many women still feared childbirth, knowing a mother or baby who had died in the process. Today most women trust that technology will minimise risk and they will have a problem-free pregnancy and give birth to a perfect child. Once the pregnancy is established, many women start to plan their future with the yet unborn child and a bond is formed stimulated by foetal activity.

In the mid-twentieth century, the pervasiveness of eugenic beliefs and fear of an ‘abnormal’ child led to couples being advised to feel fortunate if they experienced a miscarriage because the foetus would have been malformed. Although parents’ unhappiness was recognised, grief was not emphasised; what was stressed was the possibility of future success. ‘Doctors and science writers exuded confidence in medicine’s abilities to give all women babies … Follow directions and there is no reason you should not have a fine, full-term baby’.²¹ To achieve medicine’s promise of a healthy baby, a woman might have been required to submit to repeated examinations, long stays in bed, abstaining from all physical activities and ingesting pharmaceuticals.

The medical advancements of the 1960s strengthened the belief that women who miscarried would give birth to a healthy child if they followed their doctor’s advice. Yet this is not always the case; 1–2 per cent of women have three miscarriages in a row, classified as recurrent miscarriage.²² Half of these result from chromosomal anomalies where the embryos would not survive; others are due to a wide variety of issues such as anatomical defects, infections and haematological disorders.²³ Nonetheless, three-quarters of women who experience recurrent miscarriage go on to have a successful pregnancy, and there is no evidence that ‘lifestyle adaptation’ increases the likelihood of success.²⁴

Impact of Loss on Women’s Mental Health

In the mid-twentieth century, miscarriage was a private affair that was rarely spoken of. Attitudes are changing due to the campaigns of vocal groups such as the Miscarriage Association and Mumsnet with its Miscarriage Care Campaign. Baby loss is now treated with greater sensitivity and parents are offered choices, including funerals and other types of ceremonies, for a foetus that would previously have been quickly removed for disposal.

Although miscarriage is now more openly discussed, it could be argued that only certain voices are heard. Miscarriage is expected to evoke grief and trauma. Yet for women who were distressed rather than delighted at becoming pregnant, a miscarriage may be seen as good news. Other would-be parents, particularly those who have experienced recurrent miscarriage, may suffer intense grief that will not be resolved for years. When a much-wanted pregnancy is lost, women tend to be at risk of depression, anxiety, post-traumatic stress disorder, guilt and self-blame.²⁵

Research for the Stillbirth and Neonatal Death Society (Sands) found women who had experienced intrauterine death or stillbirth shared similarly profound emotions. The parents expressed a sense of ‘overwhelming loss of what might have been. This was felt not only in relation to the baby as a physical presence, but also the loss of joy, of celebration, of parenthood and, in some cases, of their sense of self’.²⁷ Redshaw and colleagues’ study of the impact of neonatal death and stillbirth showed similar results, practically a third of women reported symptoms of anxiety and a quarter reported depression.²⁸ These findings were substantiated by a meta-analysis of the negative psychosocial impact of stillbirth.²⁹

There is general agreement that terminating a pregnancy is associated with increased risks of mental health problems,³⁰ with some groups of women at greater risk of negative outcomes.³¹ When the termination is for reasons of foetal abnormality, it can have a profound impact on both parents because of the existence of choice and the potential for self-blame.³²

For same-sex partners, losing a pregnancy or baby may be amplified because of the complex processes involved in becoming pregnant and the emotional and material investment. They may also face heterosexism and prejudice from health professionals. ‘Some health professionals seemed unable to understand my partner’s distress at losing her child … I don’t think they understood what it meant for my partner, that she was a parent and she had lost her baby too.’³³ Lesbian partnerships experience loss in similar ways to heterosexual women, but the impact on mental health appears to last for longer.³⁴

Perhaps most devastating is when a baby is lost due to failures in clinical practice, systems or culture. There have been several investigations into preventable perinatal deaths at maternity units over the past few years.³⁵

Silent Partners in Grief

Masculinity has been characterised by emotional detachment, silence and rationality. Traditionally, men have been excluded from all aspects of pregnancy and childbirth. Popular media portrayed their role as the ‘anxious father’ allaying his fears in the company of friends (often in the pub) while waiting to toast the arrival of a healthy baby. Changes began in the 1970s with more women giving birth in hospital and the belief that they should be allowed to choose whether to have their partner with them. By 2010, would-be fathers were expected to accompany their partner for the ultrasound, take an active role in antenatal classes and be present at the birth. Public recognition of fathers’ more active parental role was marked finally by the introduction of paternity leave of up to two weeks in 2003.

Recent research has focused on men’s experiences of baby loss. Qualitative studies reinforced by meta-studies have identified key themes.³⁶ This body of work suggests men react in similar ways to women, experiencing guilt and blame, regret, fear and grief as well as shame, stigma and post-traumatic stress disorder.³⁷ ‘I will never forget what I saw. I can’t. It’s burned into my mind forever’.³⁸

Many men felt grief and a deep sense of loss not only for their baby but also for their lost dreams of fatherhood. Because the woman experienced the event biologically, men felt less entitled to feel or to communicate their emotions. Many assumed the traditional role of protector, putting aside their own emotions to support their grieving partner; others buried their grief by taking on practical tasks. They ‘expected themselves, and were expected by others, to be unaffected by the loss: yet, they recounted feelings, uncertainties, and desire for support beyond anything they would have anticipated’.³⁹

Parenting after Miscarriage or Baby Loss

Awareness that the experience of losing a pregnancy or baby can affect parents’ relationships with existing or future children is being acknowledged. Losing a pregnancy is associated with an increased likelihood of women experiencing sadness, low mood and excessive worry during any subsequent pregnancy, emotions that subside once the baby is born.⁴⁰ However, the arrival of a healthy baby may cause conflicting emotions as parents struggle to bond with their new baby while still grieving for the baby lost. A widely held misconception is that pregnancy and baby loss are far more prevalent for first-time mothers. The evidence suggests otherwise; just under half of neonatal deaths and 41 per cent of stillbirths occur following a previous successful delivery.⁴¹

The Missing Sibling

Following a miscarriage or stillbirth, a proportion of women will experience mental health problems that affect their capacity to care about themselves and their existing children. Men may deal with their grief by an increased use of alcohol or drugs, a coping strategy that makes them less available to their children.⁴² Children will be directly affected by the loss and their reactions may be complicated as jealousy may have vied with excited expectation.

A Swedish study identified several themes that helped parents and children deal with such loss. These include making the stillborn baby and the loss a reality for the sibling: providing honest, age-appropriate information, creating memories, recognising and acknowledging the child’s grief and being able to show how they feel themselves.⁴⁴ When parents are unable to provide the support and understanding children need, children will self-interpret the loss of their sibling and the risk of pathological reactions can be high.⁴⁵

Research suggests that, by supporting parents through the grieving process and facilitating the sharing of the loss within families, the emotional well-being of children can be better protected.⁴⁶ The debate has now moved into the political arena in the UK. The impact on children was acknowledged and fundraising for counselling applauded in the government’s debate on baby loss in 2017.⁴⁷

Professional Practice in Response to Baby Loss

Fifty years ago, all evidence of miscarriages and stillborn babies was immediately removed from the labour ward and parents had no opportunity to see or hold their baby.

It was generally believed at the time, both within the medical professional and wider society, ‘that parents could, and should, forget their babies, and that it was best to carry on as though nothing had happened. Expressions of grief were discouraged.’⁴⁹

While stillborn babies have been registered since 1927, even as late as the 1960s and 1970s many parents were not provided with a death certificate and few knew what happened to their baby’s body. The 1970s heralded a gradual change in attitudes and practices, changes led by the work of Sands and other similar organisations. As a result, since the mid-1980s parents of a stillborn baby are consulted about funeral arrangements.⁵⁰

The remains from a miscarriage continue to be classified as ‘medical waste’ and the Human Tissue Act 2004 made no distinction between the disposal of pregnancy remains and that of other tissue from a living person. Attitudes are beginning to change. The Guidance provided by the Human Tissue Authority in 2015, although acknowledging that parental consent is not required for the disposal of pregnancy remains, stresses that hearing the wishes of the parents ‘are of paramount importance and should be respected and acted upon’.⁵¹

The NHS review identified the different responses of parents who suffer pregnancy loss, ‘some wanted to remember their baby whatever the gestation and should have the opportunity to do so’.⁵² The review found that ‘compassion and attitude of the staff have a lasting impact on the experience’ but that high workloads and competing priorities could hamper this important work.⁵³ The review also identified the relevance of the environment:

Health professionals are more aware of the impact of losing a baby and parents are offered opportunities to see and hold the baby, to take photos and collect keepsakes. Research on the impact of making memories is nuanced. For example, Crawley and colleagues found no direct relationship between maternal mental health and memory making, but the sharing of memories with partners, families and friends, along with the time since the baby died and professional support, were factors associated with improved mental health.⁵⁵ Watson’s autobiography provides an illustration of the difference support can make to grieving parents. Recorded on a thank-you card in a neonatal intensive care unit was the following message:

Developments in Perinatal Mental Health and Community Services

How individuals experience losing a pregnancy or baby is personal and it would be wrong to assume that one type of response would suit everyone.⁵⁷ The type of support available can depend on the stage of pregnancy. Busy health professionals who deal with early pregnancy loss on a regular basis may normalise the event and fail to recognise its possible profound psychological impact. Women are routinely discharged quickly from hospital and often return home in a state of shock: many mothers and fathers may leave with undetected and unresolved psychological symptoms.⁵⁸

Our understanding of the process of grieving over the last fifty years has influenced the development of preventive and community mental health services. Some parents will not need or want professional or community support while for others it will be a lifeline. For a few women, a stillbirth will have long-lasting effects. A better understanding of the experience and access to psychosocial support may benefit some women and their families to deal with the impact.⁵⁹ Gaps in the provision of maternal mental health services have been identified,⁶⁰ as has the lack of accessible support services for men that acknowledge and validate their experience of grief.⁶¹

As in the nineteenth century with child welfare services, charitable organisations have played an instrumental part since the 1970s in changing the landscape through campaigning; working with health professionals; raising funds for research; promoting good practice; providing information and advice; and, above all, supporting grieving parents and their families. Their role underpins the advances made in the last fifty years, and they are often founded by bereaved parents, devastated by their own loss and the lack of understanding of its significance and impact on their lives. Each with their own distinctive missions, these organisations have shown drive and resilience and continue to be strongly active. Bliss, Sands, Miscarriage Association, Tommy’s, Lily Mae Foundation and Mariposa Trust are among many organisations providing new models of bereavement care and support. They engage with the NHS to bring about much-needed specialist and expert resources to help parents in their contact with the NHS and at home in the community.

Parliamentary engagement in the issues and NHS England’s action plan are more recent advances. The All Party Parliamentary Group on Baby Loss made a commitment to providing high-quality bereavement care through their initiative Safer Maternity Care.⁶² The Parental Bereavement (Leave and Pay) Act 2018 provides for the first time in the UK’s history a legal right for bereaved parents to have leave from work, bereavement pay and employment protection. NHS England is engaged in improving women’s access to perinatal mental health support through the establishment of new services and targeted funding.⁶³

Conclusion

Advances in medical science and major changes to the law have influenced and reflected wider society’s changing attitudes to pregnancy and parenthood. Consequently, single parents draw less condemnation and same-sex partnerships are legal. Attitudes towards miscarriage and perinatal death have benefited from these changes. What was previously a very private affair is talked about more openly, revealing the profound and long-term impact such loss can have on the mental health of would-be parents and existing children. This has resulted in health professionals managing miscarriage and stillbirth with greater compassion, enabling parents to have the opportunity to hold their baby and create memories. Fifty years ago, parents were sent home from hospital to cope with their grief alone; charities and voluntary groups, working in conjunction with health professionals, now fill the gap and provide information and a range of support. Although much has been accomplished, there is certainly scope for further advances.

Key Summary Points

• Any discussion on the impact of pregnancy and baby loss must take a broader perspective on parenthood than would have been assumed fifty years ago.

• Loss of a baby can affect any woman, irrespective of age, previous fertility or wealth, although those living in poverty are most at risk.

• Grief and despair for women at the loss of a baby were historically seen as a private affair. The need for health services to offer sensitivity and choice in coping with loss is now better recognised.

• The consequences of loss are far-reaching for all family members, including existing children. Some may not cope, which can have a profound effect on their mental health and well-being, if not addressed.

• Community mental health and voluntary organisations offer greater compassion and support to grieving families but the need for easily accessible and responsive local services remains.

Introduction

Work or, more broadly, activity has been of interest to medical practitioners over the centuries.

Activity or exercise, rest, relaxation and leisure have been seen as health promoting and a core part of medical practice, from the Graeco-Roman tradition, Ayurveda and Chinese medicine to modern times. The place of work as physical labour in medical regimes is a more recent development, emerging towards the end of the eighteenth century and playing a significant role in the daily lives of inmates of the large asylums.¹ For psychiatric practice and the study of mental health/ill health in the twentieth century, the focus has been on the role of work in rehabilitation and the health risks associated with unemployment and the conditions of employment. In this chapter, we focus on these two areas.

Work, Employment and Leisure

What we mean by work is not easy to define; it is a shifting and contradictory concept that has varied over history and with the development of more complex societies.² Our contemporary view of work has its origins in the development of capitalism and the creation of a free labour market. This has dominated our conception of work and differentiated it from leisure and the home. It has allowed for the distinction between the employed and the unemployed (and children and retired people) but has also raised questions about work that does not receive renumeration, particularly that of housework and the work of carers. In practical terms, we may see ‘work’ as an activity that involves the exercise of skills and judgement, taking place within set limits prescribed by others.³ It is something you ‘do’ for other people, whereas in most leisure activities you can ‘please yourself’. ‘Employment’ is seen as work you get paid for, thus clarifying that many activities (childcare, housework, looking after elderly or sick relatives, for example) involve ‘work’ but do not usually attract formal payments and so are not ‘employment’.

The Benefits of Work

Work may be viewed as being a uniquely human quality, essential not only for our material subsistence, growing needs and the wealth of nations but also for our psychological needs and sociability. It is a normative concept defined by the customs of society, but it is fundamentally relational and assists in defining who we are and our relation to others. It plays a central part in personal identity, gives a structure and purpose to the day and provides opportunities for socialisation and friendship. The social networks established in the workplace often extend beyond it and are a core component of social capital.

The potential magnitude of these beneficial effects (and by implication their ill effects) is brought home to us when we consider that our working lives represent the single longest period of the human lifespan, amounting to some forty to fifty years. This is the greater part of our adult lives, a time when many are raising families with the consequent responsibilities of dependents and effects on subsequent generations.

Employment, Worklessness and Their Ill Effects

Changes to the working life of Britons brought about by the industrial revolution revealed dangers of work on physical health in the hazardous conditions of the factories and mines during the nineteenth and into the twentieth century. During the twentieth century, however, the effects of unemployment and working conditions on our mental health emerged.

Economic cycles and crises during the twentieth century brought with them periods of high unemployment. During the Great Depression in the late 1920s and 1930s we saw the social and psychological effects of mass and long-term unemployment. These were documented in the classic studies of Marie Jahoda and colleagues examining the effects of the closure of the ‘Marienthal’ factory on the population of the Austrian village of Gramatneusiedl in 1929 and the subsequent studies of mass unemployment in the United States.⁴ The morale of people suffers during periods of prolonged unemployment, and those without employment experience emotional instability, depression, hopelessness and apathy. These psychological effects can, in a vicious cycle, reduce social engagement and the likelihood of future employment and may blur the distinction between those who are unemployed and those removed from the job market for health reasons.⁵ They also contribute to other social and interpersonal problems, including family and domestic discord.

The rising rates of unemployment in the UK during the 1980s prompted a revival of studies on the health effects of worklessness. These provided further evidence of the link between unemployment and poor mental health.⁶ Studies typically find higher rates of anxiety and depression, alcohol and substance use and alcohol-related deaths among the unemployed than among those in work, even after taking account of age and sex. Suicide rates, especially among the long-term unemployed, are greater than among those in work. This association between unemployment and poor mental health seems to be bidirectional – being made unemployed can be a direct cause of poor mental health but mental illness or poor mental health can result in loss of employment. Continuing poor mental health can be a barrier to regaining employment, but re-entry into employment can result in an improvement of mental health.

The recognition of a link between suicide rates and rapid social change and economic depression has been noted since the nineteenth century.⁷ By now, we can be confident about the association between unemployment and suicidal behaviour and the tendency for suicide rates to increase during economic crises.⁸ The longer the duration of unemployment, the greater the risk of suicide or suicide attempts.⁹ There is evidence for a direct causal relationship between unemployment and suicide, although most of the effects are related to the presence of mental health conditions.¹⁰ This relationship is complicated and, like many psychosocial phenomena, dependent on a range of socioeconomic factors, including the strength of social safety nets and the degree of social fragmentation.¹¹

The mental health conditions associated with unemployment are predominantly those that have become known as ‘common mental health’ disorders (or the studies used a measure of mental well-being). That these disorders were ‘common’ has been revealed by many population and primary care studies carried out since 1945. The emerging relationship between poor mental health, suicide and joblessness exposes the role of broad social, economic and political factors in determining the nation’s health.

While employment may be beneficial to health, what emerged in the late twentieth century was evidence that the exposure to a range of psychosocial hazards can also put workers at risk of poor mental health.¹² Jobs can be poorly paid or provide people with insufficient or overly long working hours. They may be temporary or insecure or place people at risk of job loss or redundancy. They may also provide exposure to conditions of low psychosocial quality that affect the mental health of workers. Several large population studies of workforces in Europe and Australia have contributed to this body of evidence and the two British Whitehall studies conducted on populations of UK civil servants showed that adverse psychosocial conditions were associated with less satisfaction and well-being, a greater prevalence of mental health conditions and predicted poor mental health over a five-year period.¹³ Low psychosocial quality includes conditions of a ‘high-strain’ working environment where the high demands on workers are combined with conditions of low control, such as little autonomy and reduced decision-making or conditions in which the effort to perform the job is not met by commensurate rewards in terms of money, esteem, career opportunities or job security.

UK Health and Social Policy since 1945

The cross-national studies on unemployment (or recessions) on mental health and suicide have noted 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.¹⁴

The provision of services and income transfers by the state to meet the welfare needs of the UK population and the concomitant expenditure grew in the twentieth century. These provisions include personal social services; services for health, education and housing; and income transfers such as pensions and out-of-work payments. Following the Second World War, the UK established reforms to create a more comprehensive and universal welfare state with an increase in resources to extend benefits and coverage which were associated with a commitment to economic growth and full employment (see also Chapter 3). These were accompanied by improvements in provisions for people with disabilities, including those for people with mental health conditions and intellectual disabilities. These welfare state developments facilitated the rundown of the large asylums and the development of community-based facilities for people with severe and long-term mental health conditions and improved access to primary care for those with common mental health conditions (see also Chapters 23 and 30).¹⁵

The golden age of the UK’s welfare state declined in the 1970s, and the 1980s saw a period of retrenchment and recalibration with an abandonment of full employment and cuts to welfare provision, despite continuing growth in public expenditure. This was set against a background of increasing income and wealth inequality. In the late 1990s and 2000s, the New Labour government’s vision for welfare was for a system that enabled rather than provided. The challenge was to reduce worklessness and introduce new benefits and tax credits as well as work support schemes. The recession in 2008 and the election of the coalition government in 2010 brought in a period of austerity and the introduction of further welfare reforms in 2012. The squeeze on expenditure and the roll-out of the new benefits continue to this day.

Contemporary Changes to Conditions of Work and Employment

In high-income countries, the labour market has changed dramatically over the past seventy years. In Britain, many traditional, large national employers such as the coal mining and motor manufacturing industries that were at the heart of the economy are long gone, radically reduced in scale or have been sold to global corporations. These dominant industries have been largely replaced by financial, service and hospitality industries, with many manual labour tasks replaced by automation.

In more recent years, there has been a movement away from the standard employment model in which workers earn wages or salaries in a dependent employment relationship with their employers, jobs that usually offer a stable contract and employment as well as labour law and social security protection.¹⁶ In high-income countries, including the UK, while the standard employment model is still dominant, there has been a move towards increasing labour market flexibility and a weakening of regulations and protective policies. Associated with this has been an increase in forms of ‘precarious’ employment which may include ‘flexible employment,’ ‘temporary work’, ‘casual work’, ‘zero hours contracts’ and ‘gig economy work’. In the UK, before the 2007 recession, we began to see an increase in ‘underemployment’ (employed persons who have not attained their full employment level) and a rise in ‘in-work poverty’ (households with incomes below the poverty line) which, along with precarious employment, has since increased. Working in insecure employment has a detrimental effect on psychological well-being and somatic health,¹⁷ as does living below the poverty line.¹⁸

The labour market and the conditions of work or lack of work reflect and reinforce health inequalities and can have knock-on effects for future generations. High-pay conditions are protective of health, but poor-quality conditions in the workplace are more likely to be experienced by people from disadvantaged socioeconomic groups.¹⁹ Certain jobs are more likely to expose people to these poor working environments, including elementary jobs, sales and customer services, plant and machine operatives and caring, leisure and other service occupations.²⁰ People who are in danger of unemployment are those who are looking for (or have previously worked in) jobs which carry the greatest risk to their health. There are stark regional differences in poor-quality work in England with the north of the country faring worst.²¹

Employment in People with Mental Health Conditions

People with mental health conditions are more likely than others in the general population to be out of work. Across the Organisation for Economic Cooperation and Development (OECD) countries, the employment rate of people with a mental disorder is between 55 per cent and 70 per cent, 10–15 per cent lower than for people without a mental disorder.²²

While many people with common mental health conditions are in work, about 300,000 people with a long-term mental health condition lose their jobs every year in the UK and do so more frequently than those with physical health conditions.²³ People with mental health conditions now represent the largest group receiving out-of-work sickness benefits. One reason for this labour market disadvantage is that many people experience their first episode of a mental health problem in their teens or early adulthood, with serious and often enduring consequences for their education and employment prospects. Stigma and discrimination also contribute to these reduced employment opportunities (see also Chapter 27). In addition, they have a lower re-entry rate into the labour market, particularly in economic downturns.

Employment rates in people with common mental health conditions, while lower than the general population, are much higher than those with psychoses.²⁴ In the UK, between 10 per cent and 20 per cent of people with schizophrenia are in some form of employment.²⁵ These rates may have fallen over the years, as before 1990 employment rates of 20–30 per cent were reported.

Developments in Vocational Rehabilitation for People with Mental Health Problems

The view that occupation was an integral part of treatment and the subsequent development of vocational rehabilitation were influenced by the rise of ‘moral treatment’ in the early 1800s. However, despite the growth of patients working within the confines of nineteenth-century asylums, this was less about moral therapy and rehabilitation but more a matter of filling the patient’s day, reducing idleness and providing free labour for the hospital farm, kitchens and laundry, with a view to reducing costs and raising funds for the running of the institution.²⁶

This changed during the early-to-mid twentieth century as work became seen as enabling, valuable to good physical and mental health and part of a patient’s rehabilitation. We saw the development of industrial workshops and creative therapies as well as the profession of occupational therapy.²⁷ The reforms after 1945 facilitated the idea that hospital-based work might be a stepping stone to eventual resettlement and were supported by research findings.²⁸ In the industrial workshops, which attempted to provide realistic conditions of employment, patients were paid for their labour and their work exceeded the expectations of staff. However, as the asylums diminished, the hospital workshops relocated to the community, patients’ earnings were capped and workshop numbers dwindled. It became obvious that few people from these settings went on to get paid ‘open’ employment in the labour market.

In the United States, during the late 1970s, a new conceptual model emerged for the development of community-based treatment programmes for patients with mental health problems who would typically have been inpatients in large psychiatric hospitals. This took a multidisciplinary team approach and delivered integrated community-based treatment, rehabilitation and support services to help people with severe and persistent mental health problems to avoid psychiatric hospitalisation as well as to live independently in natural community settings. This approach gave patients sustained and intensive assistance in finding a job or a sheltered workshop. When in the job, staff retained contact with patients and their supervisors or employers to help with on-the-job problem-solving. Those who received this new approach spent significantly less time unemployed, spent more time in sheltered employment and earned a significantly higher income in open employment than those receiving the control intervention.²⁹ These new models of community-based treatment programmes seemed radical at the time but have since evolved into one of the most influential service delivery approaches in community mental health. Regrettably, when these new models of community-based treatment programmes were implemented in the UK, the presence of supporting people with longer-term mental health problems into work did not translate into practice.

Changes in the Emphasis of Vocational Rehabilitation

During the 1980s, also in the United States, new forms of vocational rehabilitation were being developed. These models of vocational rehabilitation were based on a ‘train and place’ approach – people with longer-term mental health problems would typically go through a stepwise approach of skills training and development in a segregated and sheltered environment, with a view that these new skills would enable them to gain and retain jobs in the open labour market. A variety of different models were developed ranging from pre-vocational training programmes through to clubhouses which were developed alongside other models of community mental health rehabilitation for people with longer-term mental health problems. The choose–get–keep model of rehabilitation began the shift from viewing work solely as a form of therapy to one that viewed it as a personal goal of the patient.³⁰ This approach defined the process both from the mental health practitioner’s point of reference and from that of the person served. The practitioner’s role was to facilitate rehabilitation: choosing, getting and keeping were what the individual did to attain their goals.

In 1993, Becker and Drake published the first manual of the Individual Placement and Support (IPS) approach to vocational rehabilitation.³¹ The IPS approach is a form of supported employment and differed from previous approaches to vocational rehabilitation. Moving away from ‘train and place’, it adopted a ‘place and train’ approach, in which the primary goal of the approach was to directly find a job and then provide continued support. Its approach was fundamentally ‘person-centred’. In 1996, the first randomised controlled trial (RCT) of the IPS approach was published and showed that people with longer-term mental health problems could be directly supported to gain and retain open employment without the use of pre-vocational training.³² By 2001, a Cochrane systematic review of vocational rehabilitation for people with severe mental illness found that supported employment was significantly more effective than pre‐vocational training,³³ and there are now twenty-seven RCTs supporting the efficacy of IPS compared to standard vocational rehabilitation.³⁴

The ten-year plan of the National Service Framework for Mental Health contained several targets in which work was important, including ‘action needed for employment, education or training or another occupation’ (Standard 5) and the requirement of health and social services to ‘combat discrimination against individuals and groups with mental health problems and promote their social inclusion’. The associated development of early intervention teams in the early 2000s provided a focus for vocational rehabilitation to support young people with a first episode of psychosis in education, training and employment.³⁵

In 2003–4, the UK government undertook a cross-government review into mental health and social exclusion. The term ‘social exclusion’ was initially used as a simile for poverty but grew to acquire a wider interpretation. It encompassed unemployment, poor-quality housing or homelessness, limited social networks and restricted participation in social, economic and political life. The Mental Health and Social Exclusion report examined the connections between mental health problems and social exclusion.³⁶ It noted that mental health problems often led to and reinforced social exclusion, stigma and discrimination, owing to low expectations of what people with mental health problems can achieve; lack of clear responsibility for promoting vocational and social outcomes; lack of ongoing support to enable them to work; and barriers to engaging in the community. This report provided a catalyst for the development of vocational rehabilitation services for people with longer-term mental health problems and for the promotion of the IPS approach.

Two important developments occurred during this time. First, the Convention on the Rights of Persons with Disabilities was adopted on 13 December 2006. Rather than viewing persons with disabilities as ‘objects’ of charity, medical treatment and social protection, it saw persons with disabilities as ‘subjects’ with rights, who can claim those rights and make decisions based on their free and informed consent as well as being active members of society. The Convention dealt with the right to work and employment, stating that priority should be given to participation in the open labour market and all efforts should be done, through reasonable accommodations, to achieve this. The other development was the emergence of the recovery approach within mental health services in England.³⁷ At its heart, the recovery approach is a set of values about a person’s right to build a meaningful life for themselves, with or without the continuing presence of mental health symptoms. Recovery is based on ideas of self-determination and self-management. It emphasises the importance of ‘hope’ in sustaining motivation and supporting expectations of an individually fulfilled life. Many of the ideas underpinning the recovery philosophy were not new. The main impetus came from the consumer/survivor movement in the 1980s and 1990s. The emergence of the recovery approach brought a renewed focus on the personal goals that were important to those with longer-term mental health problems and a focus on functional outcomes for mental health services.

Yet, despite these developments, 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.³⁸ By 2010, there was evidence that the IPS approach could be effectively implemented within mental health services in England.³⁹

Conclusion

This brief look at work and mental health perhaps tells us more about developments in psychiatry and its relation to history and social and economic factors than is immediately obvious.

First, it reflects the change in what has come under the psychiatric gaze during the twentieth century. The predominant interest in the nineteenth century was in severe mental illness located in the asylums. In the twentieth century, particularly after 1950, this shifted to include those with more prevalent conditions, common mental health disorders. In the development of mental health services, this extended gaze has increased the tensions related to the planning of services, particularly when we consider the size of the financial cake and its apportioning.

Second, the predominant emphasis for those with severe and enduring conditions has been on vocational rehabilitation, viewing work as part of therapy. Historically, this has been based on a more optimistic view of outcomes for this groups of people, from moral therapy to post-war enthusiasm and the recovery movement. More recently, we have seen a shift from ‘work’ as therapy to ‘work’ as a human right. Recent developments in vocational rehabilitation, notably IPS, have a firm and well-established evidence base but remain poorly implemented.⁴⁰ For those with common mental health conditions, the realisation of their increasing costs to the welfare benefit bill led the New Labour government (and subsequent UK governments) to adopt a series of welfare reforms to move these groups back into work. The evidence for the efficacy of these approaches has been poor but they continue. 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 (see also Chapter 11).

Third, we see how economic cycles or crises and changes in labour markets have significant effects on the mental health of populations and on rehabilitation services.⁴¹ Improvement to vocational services for people with serious mental illness (SMI) may mean increased spending on community rehabilitation services; but improving the quality of the working environment and alleviating the effects of unemployment require improvements to occupational health services and a public health or preventative approach to reducing health inequalities to ‘create fair employment and good work for all’,⁴² as well as wider employment and welfare benefit reforms. This means taking action to reverse the fundamental causes, prevent the harmful environmental influences and mitigate the negative impact on individuals.

Key Summary Points

• 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) for common mental disorders 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.

Introduction

While the stories of sexual diversity did not begin in 1960 there is no doubt that the fifty years that followed saw radical changes in thinking about sex, gender and sexual practice. To be alive now is to live in interesting times, ones in which new categories of meaning about sexuality and gender are proliferating. These provide individuals with innovative ways of explaining themselves to each other and to themselves. That idea of self-definition, rather than definition by experts, including psychiatrists, is a key shift; much of that movement happened between 1960 and 2010. This was a period in which UK psychiatry was part of the wider debate about gender and sexuality but also a period where its contribution to the evolution of thinking about sexual diversity and its capacity to provide appropriate services to sexual minorities came under considerable scrutiny.

The premise of the chapter is that what happened within UK psychiatry and mental health did not do so in a social vacuum. So it documents key changes, judged in terms of what does or does not and should not constitute a mental disorder as well as corresponding amendments to legal rights and restrictions, as they relate to different genders, sexual identities and practices. Yet that is only part of the story. Psychiatry between 1960 and 2010 has been practised largely within the NHS with a smaller number of mental health practitioners operating psychiatric or psychological services either privately or within voluntary sector groups. Practitioner views are important in shaping care and they have not been static. Equally, both research and practice over this period of time have led to a broader understanding of the mental health issues encountered by individuals from sexual minorities and to a prevailing view that many of these difficulties stem from the negative responses of the wider community (including family and school) rather than being intrinsic to the minority identity. Research has, perforce evolved, so that it has investigated the nature and frequency of mental health problems within what is now, but was not earlier, the LBGTQI community. This new focus could be characterised as a move from being the problem to having problems. This forms a local, UK-centred, backdrop to the patchwork quilt information on the experiences of those accessing services for mental health difficulties, be that voluntarily or involuntarily, be they statutory services or from voluntary sector or private providers.

This contribution is limited in scope but necessarily draws on work describing events in other countries but known to those of us living and working in the UK. Social historians in the UK have set the wider scene in which the changes described here occurred and it would be absurd not to acknowledge the relationships between psychiatry, liberalisation in public attitudes, campaigning, legislative change and the ongoing internal conflicts within major religions on their position in relation to sexual minorities. The presumption here is that these do relate to the overall impetus within psychiatry to keep abreast of changing thinking rather than to direct it.

Nor are these essentially social debates confined to single jurisdictions. The social situation of sexual minorities varies in the West and internationally. In July 2020, Poland re-elected a president opposed to gay rights. There are a number of countries in the world with records of state violence against gays, some with legislation that allows for the death penalty for consensual same-sex sexual expression between adults. The Royal College of Psychiatrists has members from all over the globe and this issue continues to challenge it even as the UK basks within a socially liberal atmosphere, albeit one that is only recently acquired. The delicacy of the position of the College is that it risks a neocolonialist position when speaking to an international audience, in which old tropes about the hegemony of Western-inspired categories of meaning can be dusted off. At the same time, as the rest of the world dances to its own tunes,¹ indigenous concepts of gender identity and sexual expression can be and are reworked for modern times by those for whom such identities are their life, often drawing on historical models of multiple genders.²

Writing about sexual diversity in earlier decades could incur the wrath of the censors.³ This remains the case. The judgements of the next generation on today’s thinkers may be unkind. The previously radical figure Germaine Greer and, more recently, the internationally renowned author J. K. Rowling have found out that, regardless of their intent, it is easy to invoke opprobrium.⁴ This chapter will attempt to tread carefully, speaking about, not for, but it enters a hot debate, most obviously today in relation to transgender politics and health care.

Sexual Diversity: Concepts, Categories and Contemporary Currency

Underpinning this discussion is the tricky issue of categories. What constitutes sexual diversity has long been contested. Central to this chapter is the balance of power between those who have been heavily pathologised by prevailing psychiatric concepts and the institution of psychiatry and its practitioners. The real story of the last sixty years is the reclaiming of autonomy and the move to self-definition by those of us who do not find ourselves sitting comfortably in a heteronormative, gender binary culture. What has not changed is the penchant, indeed enthusiasm, for categories. Sexual diversity continues to provide many conceptual categories, functioning as coat hangers on which individuals can hang their own experience of themselves, or not.

In the 1960s, the main focus in the UK was homosexuality, to use the term of the day. The Wolfenden Committee had reported on homosexuality (and prostitution, strange bedfellows from the perspective of 2020) in 1957.⁵ The history of the word ‘homosexuality’ is instructive. Weeks argues that it was only one of a number of terms emerging in the late nineteenth century as writing on sexual preference emerged from private diaries into a public spotlight.⁶ Despite its centrality to Wolfenden, he suggests it was not owned by those who saw themselves as ‘queer’. Lesbianism and Sapphism had an obvious connection to the island of Lesbos and the poetry of Sappho, invoking a notionally golden past of communities of women with same-sex desires. These terms were superseded in time in part by the word ‘gay’, a word adopted by both men and women but which has never entirely replaced the word ‘lesbian’. Medical discourse on same-sex sexuality stuck firmly to homosexuality, often ignoring women.⁷ The British Journal of Psychiatry currently contains 127 papers on homosexuality, 17 on lesbians and a rather confusing 35 thrown up by ‘gay’ in the search engine, many of the latter being nothing to do with sexuality.

The messy history of vocabulary, where words have currency in different and overlapping social arenas, says much about what happened as political activism, both male and female, took private struggles to a visible, political front line. Events such as the Stonewall riots in 1969 and the abseiling of women into a TV studio to protest against Section 28 of the Local Government Act 1988, derived and owed much to a motley crew of local and national groups campaigning and creating safer social spaces for what was increasingly, but not necessarily accurately, called a community.⁸ Derogatory terms, or words that indicated some degree of self-loathing, such as ‘dyke’ or ‘poof’, became at least contested and in part reclaimed as the voice of the ‘community’ grew louder and more confident. While explicitly gay organisations, such as Gay Liberation Front (GLF), did much to support the daily life of often isolated gays and lesbians, this was more true for men than women who also found a home in the women’s movement. There, concepts such as lesbian feminism and compulsory heterosexuality were debated alongside lesbian motherhood, men’s use of pornography and other aspects of the patriarchy.⁹

The arrival of AIDS in the early 1980s both contributed to this public identification of an emerging gay community and vilified gay men. It can be understood, however, as a turning point, not only for AIDS but also for medicine as demands to be involved in treatment trials in a different way paved the way for greater patient involvement in care and research.¹⁰ An era of sexual experimentation and hedonism turned to personal tragedy for many and this sobering experience also highlighted the absence of basic rights within gay relationships.

It is salutary to note that the voice of bisexual and transgender people was noticeably absent for much of this period. The pioneering academic work of Charlotte Wolff is one of few attempts to document the experiences of bisexuals at that time.¹¹ The subjectivity of trans individuals was publicly aired intermittently or privately rehearsed over decades.¹² It is only in the twenty-first century, partly assisted by campaigning organisations such as Stonewall and Mermaids,¹³ that trans issues have come to the fore really. The cinderellas of sexual minority activism have perhaps had their territory invaded by the plethora of new subjectivities emerging which challenge conventional understandings of both gender and sexuality. Non-binary, gender queer, gender fluid and third gender contest the concept of binary gender and themselves may or may not sit under a transgender umbrella, all with a range of sexual expressions. This is happening now and will in time generate its own history when the extent to which a significant portion of the population will adopt and amend these understandings of themselves will be clearer.

Sexual Diversity: Counting Changing Concepts

Estimates of the presence of individuals from sexual minorities in the overall population have been problematic. Methodological concerns about individuals’ willingness to disclose stigmatised identities to the state or to research are reasonable in the context of identities that in sixty years, less than the average lifetime of a UK citizen, have gone from being illegal or pathological or both to being at least intermittently celebrated.¹⁴ The government could find no recent reliable estimate of LGBT numbers in the population in 2018.¹⁵ ONS experimental statistics indicate 2.3 per cent of the population are LGB, with many more young people identifying as such.¹⁶ As terminology changes and new categories achieve prominence, historical comparisons become harder. Older studies from the 1990s have generated range of figures, for example 5–12 per cent men and 3–5 per cent of women in the UK as gay,¹⁷ 5 per cent of the UK population gay, lesbian or bisexual.¹⁸ Data on transgender are not collected as part of the annual population surveys, but the consultation on the Gender Recognition Act reported an estimate of between 200,000 and 500,000 and it is anticipated that the 2021 census will include a question on gender identity.¹⁹

The advent of civil partnerships (2004), legislation allowing same-sex couples essentially the same rights as heterosexual marriage, resulted in 53,415 couples (roughly equal numbers of men and women) using the legislation by 2011, five times the original government estimate.²⁰ Only a small percentage (2.2 per cent for men and 4.6 per cent for women) of these partnerships are dissolved.

Family composition is varied in the UK. Official estimates suggest that in 2012 there were 18.2 million families of which 69,000 were same-sex cohabiting couples (of which 6,000 had dependent children) and 60,000 civil partnerships (of which 6,000 had dependent children). In 1996, prior to civil partnerships (and now gay marriage) there seemed to be far fewer, only 16,000 same-sex cohabiting couples (and 1,000 with dependent children).²¹ Gay couples have been able to adopt since 2002 and account for a rising percentage of adoptions.²²

Legislation in the UK: From Crime to Weddings

It is tempting to see the half-century of change, post-1960, in which this linguistic, conceptual and real-life journey has taken place, as moving inexorably in the direction of liberalisation, de-pathologisation and openness. In fact, it is more complex.²³ Many legal changes took decades to materialise and were fought for every step of the way. Equally, there was a hardening of attitudes towards homosexuality in the 1980s. In 1987, only 11 per cent of the population thought same-sex relationships were ‘not at all wrong’, a figure that had changed to 47 per cent in 2012 and 64 per cent in 2016,²⁴ which allowed for the introduction of Section 28 in the Local Government Act . This effectively censored sex education in schools, arguably making it harder to counteract homophobic bullying and jeopardising the local groups supporting LBGT individuals in local communities by restricting the activities of local authorities. The extent to which statute law has changed is striking and indisputable. The sheer volume of legislation in this area, as opposed to legislation about women or those from black and minority ethnic groups, is remarkable (see Chapters 15 and 35).

Psychiatry and Diagnostic Indecision

Much of the thinking and many of the changes in the understanding and experience of sexual diversity since 1960 have occurred independent of psychiatry but the concepts within mental health and associated practices within mental health care have also been profoundly affected. Drescher has documented the evolution of diagnostic thinking within both the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM) over the second half of the twentieth century to the present day.²⁶ As a gay psychiatrist who has lived and worked through many of the changes, it is a relief no longer to be a diagnosis. The self-belief of a profession which viewed the application of terms such as ‘sexual deviation’ or ‘pathological personality’ to gay individuals as reasonable jars with modern sensibilities.²⁷ The individuals have not changed but the profession and the terminology certainly have.

In 1973, the American Psychiatric Association (APA) removed ‘homosexuality’ from DSM-II. This was done on a vote, a democratic approach rather than a scientific one, and based on a small constituency, few of whom were gay.²⁸ ICD dragged its feet in comparison. In 1965, ‘lesbianism’ and ‘sodomy’ were added to the ICD-8 collection of sexual deviations already featuring homosexuality. ICD-9, in 1975, hedged its bets and, while ‘homosexuality’ was still a diagnosis, it was less clear that it was construed as a mental disorder.²⁹ Not until 1992 did ‘homosexuality’ per se finally disappear, with ICD-10 featuring ‘ego dystonic sexual orientation’ instead. ‘Gender identity disorder’ appeared for the first time, having been in DSM since 1994.³⁰

The tension between wanting to help someone with a problem and pathologising them is evident in the history of psychiatry and all things LGBT.³¹ Access to health care can depend on having a diagnosis. While being a diagnosis resulted in gay men and women being sent to doctors (notably to psychiatrists) for help in what could and can be a hostile world, the sense of negative difference engendered by the diagnostic process is unavoidable. This is now being played out in the UK more markedly in relation to transgender individuals where the role of medicine in the current Gender Recognition Act is very clear and constrains a person’s capacity for positive self-definition.

Mental Health Problems and Sexual Minorities

It was not until 2003 that the first robust UK-based study was able to suggest that some mental health problems were more common in lesbian and gay individuals than in straight counterparts,³³ echoing research done in north America. Gay men and lesbians had higher levels of psychological distress, greater exposure to recreational drugs and higher rates of self-harm and were more likely to have consulted mental health professionals as a result. These findings have persisted over time and now include similar information on bisexual, non-binary and transpeople.³⁴

The uncoupling of distress from identity and the identification of an external set of societal stressors – for instance, LGBT hate crimes and bullying at school – is an important paradigm shift and echoed what gay people had been saying themselves.³⁵ King and colleagues argued that both societal prejudice and restricted lifestyle opportunities contributed to their findings.³⁶ Hunt and Minsky had earlier argued persuasively that, for the LGBT community, simply considering sexual orientation was inadequate and the intersectionalities with age, disability, youth issues and membership of a BAME community also mattered.³⁷ The salience of this observation is evident in the later work that highlights the increased rates of mental health difficulties among LGBT young people, BAME individuals, disabled individuals and within lower-income households.³⁸ Only with this more nuanced grasp of health needs and their origins can health services meet needs appropriately.

Professional Practice with Sexual Minorities

Medicine has an overt obligation to try and meet the health needs of the whole population without prejudice and LGBT people use health care like everybody else, perhaps more so.³⁹ Unlike visible difference, LGBT status may not always be recognised by health care practitioners, regardless of their own sexual orientation or gender identity. There is substantial evidence that health services in general and mental health services in particular have historically failed to live up to the General Medical Council (GMC) standard. Patients perceived staff as holding negative views about their sexuality and connecting it with their mental health problems as well as responding negatively to self-disclosure by the patient. Bisexuals in particular reported negative experiences.⁴⁰ In this context, a reluctance to be ‘out’ to health care professionals, an avoidance of health care and a wish to see LBGT clinical staff are understandable.

Treatment issues have compounded this for LGB individuals and now in a related but also different way for transpeople. The history of the treatment of ‘homosexuality’ and its current manifestation as conversion or reparative therapy of LGBT people, endeavours which have involved mental health services but which are by no means confined to them, have caused pain and generated mistrust over much of the twentieth century.⁴¹ Psychodynamic theory and practice were often directed to changing sexual orientation in men and women, using a model of compulsory heterosexuality.⁴² With the same aim, behavioural theory and practice,⁴³ for instance aversion therapy using electric shocks, was principally directed at gay men, sometimes those who had fallen foul of the courts. Individuals sought treatment mainly because of negative social or family attitudes towards their sexuality. More recently, there was further evidence, from a survey of 2,000 psychiatrists, psychologists and psychotherapists, that 4 per cent of these professionals were still prepared to offer treatment directed at altering sexual orientation from gay to straight where clients requested this and 17 per cent had done so previously.⁴⁴ In 2018, 5 per cent of a large sample of LGBT individuals had at some earlier point in their lives been offered reparative therapy and 2 per cent had undergone it (half within faith groups but one in five from health care professionals).⁴⁵ A systematic review of psychological therapies in the UK and elsewhere found that early studies revealed that concern about LGBT identity precipitated contact with therapy but that was less true in recent studies.⁴⁶ LGBT affirmative therapy was becoming ordinary and therapy was positively experienced unless an attempt to change sexual orientation was attempted.

A proportion of transpeople will seek help from primary care and specialist services for a number of aspects of their gender identity, including hormone treatment and surgery. Much recent material on transpeople’s experience of care falls outside the historical scope of this chapter but suggests that specialist services are hard to access, transpeople will often avoid general health care and they often do not feel understood by health care services.⁴⁷ Given the need for access to specialist services for a person’s gender recognition, their long waiting times are unhelpful.

UK Psychiatry and Sexual Minority Issues

Sporadic work in the UK on attitudes in psychiatry to LGBT issues suggested that psychiatrists were influenced by disease models of sexual preference more than GPs.⁴⁸ Bhugra and King found the opposite in a survey undertaken just before the AIDS crisis.⁴⁹ Both these studies predate the removal of homosexuality form ICD-10. Current attitudes are un-investigated. It is also far from clear how rigorous the approach is taken within either basic medical training or psychiatric training such that practitioners are culturally competent with LGBT patients. Without this information, it is debatable whether psychiatry knows enough about lifestyle, sexual practices and contemporary identity to provide an inclusive service for an LGBT patient; material from patients suggest that problems remain.

Against a background of political change, alterations to the diagnostic systems and anecdotal concern about homophobia against colleagues, support within the membership led the Royal College of Psychiatrists to endorse the formation of a Lesbian and Gay Special Interest Group (SIG) in 2001. In 2012, its remit expanded to include trans issues and it was renamed the Rainbow SIG. The original remit of this group was determined by the membership and was ‘to promote discussion and research, provide expertise within the College and contribute to education’.⁵⁰ Its regular appearance at mainstream College meetings and periodic workshops gave it a profile that allowed isolated psychiatrists to identify its activities and created the possibility of a broader audience for its work. It has provided a forum to discuss patient-focused issues – the broader social context of LGBT life, for example parenting, discrimination and intersectionality – in a clinical context, for instance by working with older LGBT people, and also to provide support to colleagues. Its advisory role within the College led to two position statements: one essentially in tandem with other mental health organisations on the lack of evidence for conversion therapy and another, more recently, on trans issues.⁵¹ This is in some contrast to the earlier work in the United States on diagnosis, perhaps because the College lacked a coherent LGBT voice until the formation of the SIG, long after many of the most difficult discussions on diagnostic entities had taken place. It may be that the NHS is better placed to transform organisations to provide inclusive environments for staff and patients. In 2020, only one mental health services Trust, Central and North West London (CNWL), is in the Stonewall Top 100 Employers list; no other NHS organisations are listed, suggesting that there is more to do; this is in line with recent evidence of experiences of care.

Conclusion

History, whether of psychiatry or not, does not have bookends. The focus of this contribution has necessarily been principally on the experiences of gays and lesbians in relation to psychiatry, as it was those issues that dominated the years from 1960 to 2010. Yet, as identities alter over time, there has been some space to acknowledge the mental health issues and experiences of those with a less well-rehearsed sense of self, for instance bisexual and transpeople, non-binary and intersex individuals whose voices have come to the fore only recently.

The historical period in question has been one of profound change, experienced as such by those of us affected by changing social attitudes, protection in the workplace and the street, public recognition of our relationships and stability for our children. Psychiatry, and UK psychiatry in particular, seems both central and peripheral: central because embedded in its previous way of thinking was a wholesale and widely shared sickness model of LGBT sexuality which has been overthrown; peripheral because it is hard to argue that psychiatry did anything more than follow where the emerging LGBT community and its influencers bravely led, backed up academically by a handful of social scientists, historians and psychologists.⁵²

Questions remain about the proper role of psychiatry going forward. Some may argue that this is a dismal history and in future there is no place for psychiatrists in relation to LGBT matters; but, as mental health services are used by many of the LGBT community, UK psychiatry can play a role, if it chooses to do so. However, if this chapter tells us anything, it is that psychiatry should adopt an unaccustomed humility that sits uneasily with the intrinsic power and authority of the profession.

Key Summary Points

• 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.

Introduction

This chapter examines the experience of black and minority ethnic communities and the way their mental health needs were understood, recognised, prioritised, discussed and tackled by service providers and commissioners in the UK in the period 1960–2010. The chapter begins with the section ‘Doreen’s Narrative and the Research Evidence’, an experiential narrative account from Doreen Joseph, placed alongside research evidence. This attends to black, Asian and minority ethnic (BAME) children, young people and their families in and against the youth (criminal) justice system. The issues are situated within a broader context of racism derived from a legacy of slavery, colonialism and postcolonialism. BAME people have felt this impact on their education, employment, housing, social circumstances, citizenship and health. To understand how these experiences emerged in a historical, social and political context, we then consider responses from practitioners and policymakers to health inequalities.

Doreen’s Narrative and the Research Evidence

Growing up as a teenager in west London in the UK during the 1970s, I noticed the problem of Black youth falling into the criminal justice system. I saw Black youths being slammed against cars while policemen searched them under the ‘sus’ laws. This was the ‘search under the suspicion’ of criminality. This concerned the Black community because of the distress and shame it brought to parents who were law-abiding citizens and its occurrence in a racist and political climate of oppression.

BAME youth in contact with the criminal justice system is one element of a broader context of culture and politics which determines who gets what resources to live in society and how much. Racism is one of the tools that is used to ensure that ‘the rich get richer, and the little that the poor man has is taken away’ in accord with the so-called Matthew effect of cumulative advantage,¹ named after the parable of the talents or minas in the biblical Gospel of Matthew. The inverse of this is cumulative disadvantage and trauma, which lead to cumulative harms, including for health.² Poverty and dispossession drive some Black youth into criminality to survive. However, historical, economic and political factors are major determinants for this outcome, more so than individual ‘bad’ choices or deviant behaviour. Wider issues of immigration, citizenship, (mis- or under)education, (un)employment, housing and detention/incarceration, fuelled by racism, are pertinent. Ultimately, more structural fairness and equity of opportunity and choice would reduce poverty and disadvantage as well as consequent pathways to criminality. Although I look at the experience of the UK, it also applies worldwide where the legacy of slavery and colonialism has continued through racist policies and legislation.

Research Evidence and New Directions

The narratives of oppression are supported by much evidence on ethnic inequalities of incidence and experience of mental health systems in which some black minority groups and migrants experience more coercive care.³⁸ This includes more adverse pathways to care through criminal justice systems, police involvement and use of the Mental Health Act. Part of the challenge is a reductionist approach that sees mental illness as a product of individual failings or exposures to risk factors rather than a dynamic balance of resilience and risk factors over the life course and that in specific social contexts is too simplistic. That is, assets have a positive influence cumulatively and likewise risk factors a negative influence. Indeed generations of traumatic experiences (genocide, slavery, religious, ethnic or racial persecution) continue to have evident impacts on future generations. These are transmitted through narratives of identity and how these are often shaped by histories of persecution. A further problem is the web of causation, including social divisions and status; stratification by poverty, employment and housing; and safety and trust in neighbourhoods. These rarely feature as structural factors that offer potential explanations for why some groups continue to suffer greater adversity, thus leading to poor mental health (see also Chapters 3 and 5).

A historical perspective on life in Britain during the period 1960–2010 therefore becomes important. Historical documents can reveal prevailing attitudes to mental health care and mental illness and attitudes towards migrants and minorities not only in official policy and practice but also in popular culture. Boxes 35.1 and 35.2 present, respectively, British health policies during this time, and as a way of tapping popular culture, situation comedies during the same approximate period. The documents and shows listed in Boxes 35.1 and 35.2 could be examined, interrogated and explored for popular cultural stereotypes and for information on how ethnicity, race and cultural diversity were viewed. The situation comedies openly show racist language, ostensibly to call out bigots but reinforcing common attitudes towards minorities and not considering the power imbalances (e.g. Spike Milligan’s Paki-Paddy from Curry and Chips). More recent decades have seen black actors and comedians reverse this situation by taking leading roles and directing and writing the material for comedies in an attempt to share both the ironies and the realities of their lives (e.g. The Fosters, Desmond’s, The Kumars at No. 42 and Goodness Gracious Me).

Certainly, in the 1960s, we have the incredible movement of deinstitutionalisation, which led to the closure of the asylums and the call for community care, greater social care and support in ordinary places, as well as a recognition of the importance of the environment and social space in both causation of mental illness and recovery. It is ironic that, at the end of the National Service Framework (NSF) in 1999, specialised services to support community care have been stripped back, resulting, ultimately, in crisis-only services with little space for rehabilitation and adequate place-based social care (see also Chapters 23 and 26 ). Health inequalities in general were identified by the Black Report and the review by Michael Marmot; and ethnic inequalities were profiled more recently by the Synergi Collaborative Centre.³⁹ These inequalities persist and have not seen a coordinated set of actions by successive governments.

There is no sustained and consistent action on systems change to impact care practices. At the same time, during the period of interest Powell’s ‘Rivers of Blood’ speech stoked hostility towards migrants and minorities, and the ramifications are still felt today, with contentions around whether racism was and is a helpful term, specifically institutional racism. Furthermore, the legacy of the Windrush generation has not been overlooked, when, even recently, a hostile environment for immigrants under the May government appears to have been repeated and expressed past colonial attitudes. Historical moments lead to products that show an underlying default of hostility towards perceived aliens, often the underclasses and the poorer and most vulnerable in society. The visibility of historical moments, monuments even to British identity, fluctuates and some consider these events as irrelevant to modern life in Britain, contrary to the lived experience of being black in Britain.

Policy and Research Discourse

The language of policy and research lacks ambition or motivation, being grounded in modest recognition of inequalities in society, given the challenge these pose politically and the necessary additional spend required. Most research provides evidence for the majority which may then be applied to minorities, or those with clustered disadvantage. Ambivalence and divergent political, policy, research and clinical perspectives tend to favour the advantaged, the least unwell, the most well off who are already well placed and make best use of the interventions; thus these actions widen inequalities.⁴¹

Psychiatry and Culture

Psychiatric practice and research made incredible advances in the 1960s-1990s, but since then there seems to be little innovation in terms of pharmacological or social or psychological interventions (see Chapters 2, 17). Work continues to repurpose medication, develop better and more cost-effective psychological therapies, and consider the social drivers of poor mental health. The role of race and culture has a more chequered history with psychiatry and psychology being implicated in early research and practice as being racist, culture blind, and reinforcing stereotypes. Indeed, the very power structures of society are replicated in institutions, and psychiatrists are increasingly seen as public servants who act for the government and the socially constructed public good.

Wittkower established a newsletter in 1956 called Transcultural Research in Mental Health Problems creating a new field of Transcultural Psychiatry, from McGill University Canada, since when Cultural Psychiatry (as it is more commonly called these days) has been established in several countries as a distinct approach. In the UK, the Transcultural Special Interest Group of the Royal College of Psychiatrists is the nearest to a membership society that has stood the test of time; others have come and gone, including NGOs, and charity partners, ethnicity and health units. The World Psychiatric Association has a Transcultural Section and the World Association of Cultural Psychiatry was formed in 2008. Initially Transcultural Psychiatry, as it was originally termed, was dominated by anthropological research methods and, more recently, additional qualitative and quantitative approaches are applied for the same purpose, to better understand cultural influences in the expression and presentation of mental disorders, and across distinct cultural groups, ethnic groups, and races. The latter as a focus of concern is especially common in North American discourse but has had an uneasy existence in the UK, where notions of racism and race equality remain contentious, provoking ambivalence amongst government, policy makers, commissioning bodies and research leaders.

British psychiatry did not reflect on its own contributions to racist practices and poorer outcomes for some until Julian Leff, Roland Littlewood and Maurice Lipsedge debated and contested psychiatric cultures, followed by Suman Fernando, Dinesh Bhugra, Kwame McKenzie, as well as active members of the Transcultural Special Interest Group of RCPsych (Parimala Moodley and Deenesh Khoosal). With these efforts, attention was more directly drawn to the injustice of mental health care being more coercive and less therapeutic for black and minority ethnic groups. Even this sentence, despite decades of evidence, is still disputed by some commentators whose location of problems is not in race, ethnicity or culture, but in individual risk behaviours, social status and deprivation, and psychosocial adversity including urban environments. All of these are relevant, yet if understood as individual cognitive or behavioural risk factors, rather than products of historical and social contexts, these do not explain the patterns of disparities in the incidence, experiences and outcomes from interactions with health systems. Rather more complex and intersectional and interacting causal and preventive models are required.

Conclusion

Many young black people are ambitious, want higher education, to have professional careers, or own businesses, and are prepared to work hard to achieve their goals. But like some of their parents, they face frustrating racist ‘glass ceilings’, which prevent access or promotion. Yet, encouraged by the resolve of their forerunners, they determinedly fight for their rights, and pursue their dreams. The alternative is demoralisation, depression or worse. The unequal impacts of assessment and treatment in care services compounds, and may even escalate, the detrimental impacts of pre-existing levels of inequality and historical legacies.⁴² Historical injustices are regrettably silenced in contemporary debate, just as crises are full of promises soon forgotten when the political and public gaze shifts.⁴³

Key Summary Points

• 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 inter-related to 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. Over sixty years later the situation has escalated and diversified, so that illegal drugs, gangs, and violent crime is 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 powers held in psychiatric systems are often co-opted to reflect the interests, and institutional practices and attitudes, of the state. This is most evident in detentions under the powers of the mental health act and in the forensic and criminal justice systems.

Introduction

In 2007, there were 11.4 million refugees worldwide of which the UK had just 3 per cent. This was about 300,000 people or 0.5 per cent of the UK population.²

The story in the UK is one of both welcome and rejection.³ It brings out the best and the worst of society. Refugees are traumatised by not only the experiences of their homeland and their journey but also settling in the UK.⁴ They have been disbelieved, accused of embellishing their stories to get asylum and subjected to racism.⁵

Both authors could retell gruelling accounts of torture, murder and humiliation. This is not what we want to do. We want to celebrate the resilience of refugees. We therefore dedicate this chapter to all those who came to the UK seeking protection and who have made a life in the UK against the odds.

Refugees, Psychiatrists and Mental Health Services

A refugee is defined as a person who is outside of their country of origin and who has a well-founded fear of returning there on the grounds that they may be persecuted because of race, religion, nationality, membership of a particular social group or political opinion or affiliation.⁶ Refugees are a marginalised and isolated group.⁷ We remember their humanity and that they are normal people who have had to face extraordinary circumstances. They are us.

Refugees have been recognised as entitled to international protection. Asylum seekers are waiting for their refugee status to be established legally. Such waiting causes a great deal of anxiety.⁸

The number of refugees to the UK has steadily diminished since 1960.⁹ Both before this period and in the early years covered, the UK had generally been a welcoming place in spite of the views of the hostile minority exemplified by the ‘Rivers of Blood’ speech by Enoch Powell in 1968.¹⁰

The story of refugees’ mental health during the period covered in this book was less about theoretical arguments regarding psychiatric diagnosis and more about their struggles with the Home Office, getting food on the table, having a place to live and finding acceptance and work.¹¹ All too many refugees have told us that it was neither the problems they faced back home country nor their journey that caused them the greatest difficulty but rather the challenges of surviving day-to-day in a new country facing the machinery of government which seemed to be against them.¹²

Past mental health research has been disproportionately focused on post-traumatic stress disorder (PTSD) as a diagnosis.¹³ The focus has broadened in more recent years. Refugees are now known to have a higher rate and wider range of mental health problems as well as experiencing psychosocial stress.¹⁴ Their overall risk of mental disorder is increased fivefold and may also increase with age – particularly in the case of depression and anxiety.¹⁵

Working as a clinician with refugees is more often about writing supportive letters for their housing difficulties and reports for the Home Office in the context of their immigration claims rather than about identifying and treating their mental health problems. Their story is tied up with politics and resources. They have been at the bottom rung of the society they have joined and are affected disproportionately when economies are stretched.¹⁶ This is also when racism increases. Refugee women and children are particularly marginalised and vulnerable.¹⁷

We avoid the word trauma as this tends to perpetuate the narrative of victimhood.¹⁸ We want to celebrate refugees as potential or actual contributors to the society they have joined rather than as victims. Throughout recent history, the UK has benefited overwhelmingly (economically, socially and culturally) from the contribution of refugees.¹⁹ To take one obvious example, Sigmund Freud arrived in the UK as a refugee from Austria in 1938 and lived there until his death in 1939.²⁰ Anna Freud, his daughter, was a pioneer in child mental health in what is now called the Anna Freud Centre in London. Lucian Freud, his grandson, was one of the greatest post-war British painters.

During the period in question, considerable development took place of organisations to support refugees and asylum seekers.²¹ There has been a developing balance between specialised refugee services and mainstream (publicly funded) health and social care services. Interpreters and mediators both of language and of culture have been crucial and their role cannot be overstated.²²

Origins

Britain is an island that used to be joined to Europe by a land bridge until 10,000 years ago.²³ The first recorded arrivals were farmers from south-east Europe. There have been waves of arrivals since – the Romans in 55 bc, the Anglo-Saxons from Europe in the fifth century ad, the Vikings in ad 789, the Normans in the eleventh century.²⁴ There has been uncertainty about which of them were escaping persecution and were therefore refugees. The Huguenots – French protestants who fled French persecution in the seventeenth century – were a clear example of refugees. Since then, there have been successive waves such as a quarter of a million Irish who fled the potato famine since the1850s.²⁵ In the early twentieth century, 120,000 Jewish people arrived, fleeing from persecution (‘pogroms’) in eastern Europe and Russia.²⁶

The Second World War transformed UK policy due to the increased post-war need for labour. Volunteers were recruited from displaced camps in Europe to come to the UK. After the war, the largest refugee group were from Poland. By 1950, 85,000 people had arrived from Europe. Migrants also came from former colonial countries in the 1950s, again to meet labour shortage. There was a substantial influx of Hungarians fleeing persecution after the 1956 uprising against the communist regime.²⁷

There have been several thousand asylum seekers each year during the period covered in this book (see Table 36.1), with about half having their application granted. The influx has reflected geopolitical turmoil. Examples of this include the influx of Asians from Kenya in the 1960s and of Czech refugees after the 1968 uprising. In 1972, 30,000 Ugandan Asian refugees arrived (mainly whole families), following their expulsion by Idi Amin. Several of the new arrivals had relatives already living in the UK. They spoke English and had British passports. Their arrival was planned. They moved to places where there was more housing capacity and assimilated relatively easily. The Cypriots (mainly Greek) of 1973 and 1974 similarly came as whole families with previous UK connections. As with the Asians from Uganda, many already had family connections in the UK.²⁹

In 1974, political opponents of the Chilean and Argentinian dictatorships came to the UK. In 1979, the influx of 16,000 Vietnamese – mainly boat people from the Hong Kong camps – began. Some of the people granted protection in the UK had come as students but could not return when the situation in their country changed. These include many Iranians who were in the UK at the time of the 1983 Islamic Revolution.³⁰ In the early 2000s, many citizens of Sierra Leone left the civil war to come to the UK. About 100,000 Tamil people live in the UK – most of whom because of the prolonged Sri Lankan civil war.³¹

Many refugees came to specific areas of the UK to be within their own communities. Though this brought risks of ghettoisation, the growth of migrant communities also facilitated group support and the preservation of cultural identity. There are, for example, well-defined Vietnamese, Tamil and Somali communities in London.³²

Although the government has been keen to encourage integration,³³ there has been an ongoing tension between integration and multiculturalism.³⁴ Only a small number of refugees moved from densely populated areas such as London to less populated areas. Most of those making such moves were males in their twenties or thirties; they represent only about 10–20 per cent of refugees.³⁵

There have been services focused on particular groups – for example, Polish, Vietnamese, Irish and Somali. However, this approach has changed to one of mainstreaming all into standard NHS services regardless of origin. There are some charitable organisations that support particular communities. For example, the Vietnamese mental health project helps people from their community in accessing health care.³⁶

Reception

There are more than 190 different nationalities represented in the UK – reflective of its complex global history, including the arrival of migrants and refugees. They include many of the people who staff our NHS today. The history of refugees in the UK parallels the experience in other developed nations – a balance of official/community support and scepticism.³⁷ The tensions between embracing multiculturalism and encouraging integration are exemplified on the one hand by the development of specialised culture-specific services and on the other by encouraging incorporation into mainstream ones.³⁸ Irrespective of how the host society manages that balance, what is common in the refugee experience is the exposure to poverty and discrimination, compounding an existential loss of one’s homeland.³⁹

New arrivals’ hope for the future is linked to their application for asylum and their expectation of welcome and protection. However, simply a mention of ‘Lunar House’ in Croydon (the headquarters of ‘UK Visas and Immigration’, a division of the Home Office in the UK where most new arrivals seeking asylum attend) will provoke a marked emotional reaction in refugees. This is where they wait for hours to process their papers. It symbolises a loss of control over their lives and of hope. Many reported experiencing scepticism and a dehumanising approach. They carry a substantial baggage of fear – of not being believed and of being deported. Any inconsistency may lead to them being discredited. In consequence, they may be suspicious of state and voluntary organisations.⁴⁰

The UK is bound by two international legal instruments in its dealings with those seeking and/or granted asylum – the UN Refugee Convention of 1951 and the Protocol of 1967.⁴¹ These established basic minimum standards for refugees and asylum seekers and enshrined the right to asylum and not to be forcibly returned if such return was to result in further state-sponsored ill treatment (‘refoulement’). Additionally, the Human Rights Act 1998 provides a framework for protection of those who fall outside the Refugee Convention but whose human rights would be jeopardised by a return to their home country.

In parallel with the development of a legislative framework of protection, the history of migration and immigration in the UK is of a legal framework of increasing restrictions on entry to and domicile in the UK. The Aliens Act of 1905 and 1920 as well as successive immigration acts since 1968 have restricted the borders. From 1929 to 1939, more obstacles were put in place. Within the provisions of the 1971 Immigration Act, people can be prevented from coming to the UK based on a psychiatric diagnosis.⁴²

There are also language, cultural and informational barriers to accessing health services.⁴³ Refugees themselves often prioritise their basic needs and status before being able to address psychological issues. Health services must be aware of culture and of the intrinsic power imbalance. The agendas between refugee and health worker may be mismatched in that the mental health worker wants to focus on mental health issues while refugees may fear being disbelieved or deported and therefore try to present information in a way that might be acceptable to the health worker and perceived as ‘normal’. As a result, their accounts may appear coached and embellished, or they may appear inscrutable or ungrateful.⁴⁴

Refugees give consistent stories of their stressful experiences and the situation impeding them. Recounting stories itself can be experienced as traumatic and may be met with disbelief. There are a minority of stories that have been ‘coached’.⁴⁵ Even where this is the case (e.g. in survivors of human trafficking who have been told what to say by their traffickers and threatened with retribution to themselves or their families if they tell the truth), this does not detract from the intrinsically stressful nature of that person’s experience. It is, however, challenging for UK mental health professionals to get through these defences and to be sufficiently aware of our own prejudices and countertransference. In response to this imbalance, specific refugee and trauma-focused services were developed. There remain tensions between mainstream and specialist as well as between trauma-focused and resilience-based psychological interventions.⁴⁶

Refugee Experience

Being a refugee/migrant is intrinsically stressful.⁴⁷ There is an initial relief. This is followed by anxiety, depression, guilt, anger and fear of being returned, compounded by feelings of injustice. There is a culture shock which is increased by language difficulties.⁴⁸ The resilience of refugees is related to their experience before leaving their home country, their journey and the opportunities they have (or have not) been given to assimilate in UK. They may have what has been termed ‘survivor syndrome’, where they feel guilty about leaving behind their home country.⁴⁹ The asylum process also causes distress with protracted periods of uncertainty. Those who have pre-existing mental health issues may be more vulnerable, or problems may manifest later in life.⁵⁰ The experience of being a refugee has led people to become depressed.⁵¹ Common clinical symptoms in refugees include sleep problems, restlessness, inertia and somatisation (headaches, dyspepsia and ‘cardiac’-type symptoms).⁵²

There has been an excess focus on mental health problems rather than on social adversity. Meeting basic needs has been shown to reduce psychiatric morbidity.⁵³ Mental health problems may also be missed or misidentified as PTSD.⁵⁴ There may be an incentive to diagnose PTSD to fit with the narrative of the asylum process. This can miss other diagnoses or pathologise normal distress. For example, one study in the Somali community showed that more than a third had a mental disorder but that PTSD was present in just 14 per cent.⁵⁵ There can be cross-cultural aspects to psychosis which can lead to a barrier to treatment or inappropriate treatment. Hyperarousal, anger or silence may be misinterpreted as paranoia.

Understanding a refugee’s culture is crucial. Unaccompanied minors, single men, women and frail elderly are all particularly vulnerable.⁵⁶ Gaining employment is a key factor especially for men.⁵⁷ Being able to work is an important theme for refugees’ well-being.⁵⁸

Refugees and other migrants face obstacles in accessing health services, housing, employment, education and acceptance by the host community.⁵⁹ The longer the period of adjustment, the greater the increased risk of mental health difficulties.⁶⁰ They also feel more distressed when they hear of events back home.⁶¹

One of the authors (PH) reflects on someone he saw during this period:

Women Refugees

Women refugees are particularly vulnerable.⁶³ They have often been exposed to sexual and gender-based violence.⁶⁴ Adjustment is particularly difficult for those separated from their families and their children.⁶⁵ Traditional roles of childrearing and household chores may be affected by the refugee experience, with women disproportionately affected. Women have also been found to be less likely to be able to access services or have a social network than men.⁶⁶ Some women do not feel comfortable talking to a male health worker. They report that they would fear just being given medication for a mental health problem.⁶⁷

Among women refugees, there have been some myths that they should not and could not access primary health care and in turn all health services. It is unclear whether these arose out of suspiciousness or from a misconstrued gender belief. After sexual and gender-based violence, there can be anxiety, sexual difficulties and concerns about fertility.⁶⁸ When a woman can return to a previous role as a mother this can, however, be protective. The importance of such family reunion (often very challenging to achieve) cannot be overestimated.

Interventions

The authors have been involved in interventions in third-sector settings such as the Helen Bamber Foundation and the Vietnamese Mental Health project as well as in mainstream services. Whatever the context in which interventions are delivered, the key to good mental health is achievement of settled status and meeting basic needs. The unmet needs are the loss of one’s past and the injustice.⁶⁹

A report in 2007 describes different innovative treatments for refugees with mental health problems.⁷⁰ These were started by refugees and were locally owned, which helped with their success. They included offering refugee women work, creative therapies, horticulture, crafts and psychological therapy. Mental health services have not been viewed as a support system by the women. Instead, there have been programmes for the mental health of various groups staffed by people from that community,⁷¹ for example Somali and Vietnamese.

Employment

Programmes of employment have been a key factor in refugee integration.⁷² However, until their asylum status is settled, most asylum seekers cannot work. Finding work is difficult even after refugee status has been granted. Refugee unemployment was 36 per cent in 2002 when the general UK rate was approximately 5 per cent.⁷³ Many remain unemployed long-term in the UK even when they are technically able to work.⁷⁴ The refugee integration and employment service was established in 2008 to help with this.⁷⁵

The Example of Vietnamese Refugees

The Vietnamese diaspora to the UK began in the 1960s in different waves, including the boat people of the 1970s from Hong Kong camps. The Vietnamese struggled with a different culture and language. The stigma of mental illness was strong and symptoms were often concealed within the family. The old suffered from a loss of their role in their family and community.⁷⁶ Young men did better, and women did better if they could resume a domestic role at home. The most common psychiatric disorders in this group were schizophrenia or depression,⁷⁷ with the rate of schizophrenia 1.3 per cent higher than back in Vietnam. In the UK, the Vietnamese mental health project was set up to bridge the cultural gap, tackle stigma and work with families. Services included drop-in centres, advocacy and support in accessing mainstream services. The project provided a gateway from specialised to mainstream services.

The Life and Work of Helen Bamber

Helen Bamber (1925–2014),⁷⁸ with whom one of the authors of this chapter (CK) had the privilege of working closely with towards the end of her long and distinguished life, had a career in human rights, working mainly but not exclusively with asylum seekers and refugees, which spanned the whole of the period covered in this book. This brief summary of her career, and the ethical principles that underpinned her work, draws both on published material and on CK’s unpublished interviews with her.

In 1945, as a member of the British Jewish Relief Unit, Bamber entered the liberated concentration camp at Bergen-Belsen.⁸⁰ In 1961, Bamber joined Amnesty International and, in 1974, she helped establish the Medical Group within Amnesty. In this role, she was instrumental in persuading the British Medical Association to establish a Working Party on Torture. During the 1970s and 1980s, she helped develop a framework for documenting torture and inhuman or degrading treatment and was active in campaigning against torture internationally. The groups on whom she focused included the ‘disappeared’ in Chile, victims of the political abuse of psychiatry in the Soviet Union and people ‘interrogated’ by the authorities during the Troubles in Northern Ireland.

Bamber also worked therapeutically with individual victims of such torture and ill treatment. In 1985, she founded the Medical Foundation for the Care of Victims of Torture (now Freedom from Torture). In 2005, she set up the Helen Bamber Foundation to work with survivors of a broader range of extreme human cruelty such as human trafficking, domestic violence and ill treatment because of gender or sexual orientation as well as with survivors of torture.

The conventional wisdom identifies Bamber’s experiences of working in the newly liberated Bergen-Belsen concentration camp in 1945 as the main driver of her future work. However, as she explained to CK, her journey into human rights started even earlier, as a Jewish child in London in the 1930s, witnessing fascist mobs and hearing Hitler’s radio broadcasts.

This is not to deny the importance of what Bamber witnessed in Bergen-Belsen. As she told CK,

Bamber often spoke of the necessity of ‘bearing witness’ to the crimes of humanity and of distinguishing between bystanders and active witnesses. In her own words,

Another of Bamber’s guiding principles was that survival itself was not enough – what was needed was what she called ‘creative survival’. She encouraged the survivors she worked with to take part in cultural and skill-building group activities that helped them develop identities beyond that of ‘survivor’ while also helping them to trust and respect each other and themselves.

Bamber remained angry and energised by that anger throughout her working life but she was also a consummate diplomat. She understood that dialogue was necessary even with people and systems with whom she remained angry – and that anger and sympathy could coexist. As she told CK,

Conclusion

Refugees have been coming to the UK for generations. The waves of refugee influx during the time period addressed in this volume reflected geopolitical turmoil during the time in question. The experience of the refugee has been intrinsically stressful with increased mental health problems. Refugees suffer from an increased rate of mental illness. This is particularly evident in women.⁸³ It may take much longer to get a clear health history from a refugee. Clinicians need to be aware of culture and the refugee agenda, and follow-up may be more difficult. Refugees’ access to mental health services has also been problematic. Mainstreaming was the main approach but some specialist services enhanced access during this time. Some specialist services also developed within the voluntary sector – such as Freedom from Torture and the Helen Bamber Foundation.

Key Summary Points

• 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.⁸⁴ This 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,⁸⁵ combating discrimination and fostering inclusiveness. Resolving asylum uncertainty has been central to a reduction in mental health distress.

• 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.

Introduction

Religion, spirituality and psychiatry share many ideals, including the importance of a holistic understanding of mental well-being,¹ yet in the past have clashed. This chapter explores the journey from mutual suspicion to the recognition of their positive intersection with a focus on Britain during the period 1960–2010.

Historical Context

The divisions between religion, spirituality and medicine date back to the Enlightenment period during the seventeenth and eighteenth centuries.² During this time, scientific communities began to develop empirical methods of explanation for behaviours and mind. While other medical fields diverged quickly, mental health continued to be closely linked with religion and spirituality until psychiatry was established as a medical discipline in the mid-nineteenth century.

From the late nineteenth century onwards, Freudian psychoanalysis understood religious belief as a form of psychopathology, attributable to the conflict between instinctual drive and intrapsychic representations of social and moral expectations: the ego and superego.³ Freud asserted that religious belief in a monotheistic God was the result of a transference phenomenon which stemmed from childhood and that belief in God was similar to an exaggerated admiration of a father by his son in early childhood. In his book Totem and Taboo, he went on to say that the roots of religion arose from the need to resolve guilt through reconciliation; this need for redemption was projected onto a heavenly father.⁴

The evolution of behaviourism in the early twentieth century helped to create a gap between religion and psychology, too. Behaviourists postulated that all behaviour could be traced to physiological sources such as limbs, muscles and glands.⁵ This allowed for the development of empirical studies, seeking to put psychology on par with other natural sciences, and simultaneously dismissed the importance of internal motivations.⁶ Where there were once commonalities in practice, there now existed an ever-widening chasm fuelled by discord and distrust.

By the mid-twentieth century, the influence of biological psychiatry was increasing.⁷ The medicalisation of mental health gradually undermined the importance of the clergy, who hitherto had been primarily responsible for the care of emotional and spiritual problems in the church community.⁸ Additionally, many churchgoers perceived the rise of psychiatry/psychology as a direct ‘anti-Christian’ threat to biblical explanations of the human experience.⁹ This disconnect may have contributed to the idea that patients’ religious beliefs and spiritual concerns had no place within the realm of psychiatry and were often seen as detrimental to their psychological health. Standard psychiatric textbooks of the 1960s, such as Mayer-Gross, Slater and Roth’s Clinical Psychiatry, perpetuated the idea that religious belief could be associated with neurotic behaviours and stated that religion was practised by ‘the hesitant, the guilt-ridden, the excessively timid, those lacking clear convictions with which to face life’.¹⁰

Towards the end of the twentieth century, attitudes surrounding the involvement of religion and spirituality in psychiatry in the UK began to change, at least in part, in response to the transatlantic influence. This new outlook sparked an increase in research attempting to integrate religion and spirituality into the diagnosis and treatment of psychiatric problems. A seminal paper by Allport and Ross published in 1967, titled ‘Personal Religious Orientation and Prejudice’, highlighted the importance of considering not whether an individual is religious or not but of how important the role of that religion is in their life.¹¹ According to the authors, whereas ‘intrinsic’ religiosity provides a major motivation in life, ‘extrinsic’ religiosity is driven by other concerns, such as social esteem. Intrinsic religiosity, in contrast to extrinsic religiosity, has subsequently been shown in many studies to be good for mental health.

Both versions of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III and DSM-III-R) published in the 1980s were criticised for their inclusion of negative religious references and the implication that participation in religious activity was deviant from normal mental health.¹² The introduction of a new V code (V62.89) in DSM-IV in 1994 titled ‘Religious or Spiritual Problems’ went a long way to reversing this negative portrayal. The category addressed scenarios where people may seek clinical advice following mental health distress due to religious or spiritual problems, such as ‘loss or questioning of faith’, without the need to see this as pathological.¹³ For the first time, it was widely recognised that individuals could have spiritual problems that were independent of mental disorders.

In 2001, Harold Koenig and his colleagues published the first edition of an encyclopaedic review of the scientific literature on religion and health (followed in 2012 by a second edition).¹⁴ Increasingly, the scientific literature, largely emanating from the United States and Europe, was providing an evidence base to support the contention that spirituality and religion were important variables to be considered in the promotion of mental well-being and in understanding the causation and treatment of mental disorders.

Religion and Spirituality in Britain, 1960–2010

In Britain, the church was responding to the rising social and cultural liberalism of the 1960s. Liberal Christianity was growing in popularity while conservative Christianity was becoming sometimes associated with intolerance, despite (or perhaps reflecting) Allport and Ross’s conclusions that intrinsic religiosity was associated with less prejudice.¹⁵

In his book The Religious Crisis of the 1960s, Hugh McLeod argued that secularisation in Britain created a rift within the church in the early 1960s whereby conservative Christianity was marginalised by a more liberal tradition.¹⁶ He posited that the loss of the social significance of religious beliefs, practices and institutions paved the way for reform within the church to better reflect the changing socio-political climate. He designated 1967 as the ‘turning point’ by which the Christian church succumbed to the tidal wave of secularism.¹⁷ Church attendance declined and a growing number of individuals began to designate themselves as being spiritual but not religious (SBNR) or having no religion at all.¹⁸ However, the secularisation hypothesis has been widely questioned. The sociologist Grace Davie, for example, has argued that secularisation does not necessarily correspond with a decline in religion in Britain but rather an evolution through which more people are choosing to keep their religious beliefs private, in effect ‘believing without belonging’ to an institution.¹⁹ This hypothesis also has been questioned and there is evidence to suggest that many people are ‘neither believing nor belonging’.²⁰

In this context, at least in some quarters, discourse on religion has given way to an emphasis on spirituality. Although there is currently no universal definition of spirituality, in Britain ‘spirituality’ has often been understood as a more inclusive term, applicable to individuals of all faiths and none, focusing more on individual practices and beliefs rather that institutional affiliations.²¹ In their book The Spiritual Revolution: Why Religion Is Giving Way to Spirituality, Heelas and Woodhead acknowledge that, while practice of traditional Christianity is declining and (they say) will continue to do so for decades to come, spirituality as a stand-alone concept has not yet overtaken traditional religion.²² They propose instead that the decline in Christian religiosity can be attributed to an increase in ‘holistic activity’ in middle-aged women and a shift in British culture to favour subjective governance of life, where external obligations and objective societal roles defined by religious authorities are less important than individual experience.²³

The decrease in religious affiliation to Christianity has also been associated with a decline in the transmittance of religiosity through generations.²⁴ Children and young people with religious parents are reportedly only 45 per cent likely to adopt their parents’ religious affiliations. In contrast, children brought up by non-religious parents have a 95 per cent chance of being and staying non-religious themselves.²⁵

Modernisation, industrialisation and globalisation have led to the increase of religious pluralism in Britain since 1960. Immigration has introduced new groups to the religious landscape. The growing number of religious communities has meant that the dominance of Christianity has begun to decrease. Religious pluralism is a controversial subject and was highly contested in the late twentieth century. Some scholars such as Steve Bruce have argued that pluralism weakened overall religious faith as it allowed for the element of choice, eventually leading to lower levels of religious participation.²⁶ Linda Woodhead has suggested that increasing pluralism must eventually result in a breakdown of boundaries between religious and secular groups, resulting in de-differentiation.²⁷ Others believe that pluralism is the result of the natural order of religious society where no religions are repressed, which is thought to generate higher levels of religious participation than religious monopolies.²⁸ Empirically, the beginning of the twenty-first century in Britain has seen a continued rise in pluralism accompanied by a sustained decline in Christian religious practice.

Changing Attitudes to Spirituality and Religion within Psychiatry, 1960–2010

From the 1960s through to the early 1990s, attitudes to spirituality within psychiatry began to shift. Many psychiatrists and psychologists, such as Albert Ellis, were openly dismissive of religion and spirituality through to the 1980s, maintaining that religious beliefs conferred no benefits to an individual’s mental state despite being a large part of many people’s lives.²⁹ In a paper he wrote detailing his experience as a psychiatrist in the late twentieth century, Andrew Sims remarked that in the 1960s ‘there was no sense that there could be collaboration between psychiatrists and religious leaders in the care of patients’.³⁰

By the late 1980s, however, attitudes had begun to shift to a more tolerant view of the place of spirituality and religion in psychiatry.³¹ Since that decade, several groups affiliated with both religion and psychiatry have begun to form. The Christian Medical Fellowship held its first breakfast meeting at a national conference of the Royal College of Psychiatrists (RCPsych) in 1986, helping to alleviate some of the stigma surrounding psychiatric practice and Christian faith. One of the early meetings of the Philosophy in Psychiatry Special Interest Group (formed in 1988) was centred on the topic of religion and psychiatry. In 1991, the patron of the RCPsych, HRH The Prince of Wales, gave a speech highlighting the importance of acknowledging the impact of religion and spirituality on patients’ well-being.³² By 1998, the message of HRH’s speech had been echoed a number of times at prominent meetings attended by psychiatrists and religious leaders such as the Archbishop of Canterbury.³³ The relation between religiosity and mental illness became a quickly expanding field of study and it became clear that religion and spirituality could no longer be ignored.

By the early twenty-first century, it was generally accepted that spirituality and religion provide meaningful frameworks for living and community support systems that help individuals to cope with the stresses of daily life and mental illness. In that respect, engaging in religious and spiritual belief could positively contribute to a person’s mental health and improve their outcomes following psychiatric treatment.³⁴ There have, however, been concerns surrounding the inclusion of spirituality in psychiatric practice as – it is alleged – it may lead to an erosion of professional boundaries between the doctor and their patient.³⁵

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 1999.³⁶ SPSIG is concerned with the spiritual and religious affairs of both psychiatrists and their patients and aims to promote an integrative approach to mental health care by stimulating discussion within the College on matters relating to spirituality and religion and proposing revisions to the psychiatric curriculum to better reflect the advances of psychiatric and religious research.³⁷ In 2009, an edited volume, Spirituality and Psychiatry, conceived within the SPSIG, was published by RCPsych Press, providing the first critical attempt by a group of British psychiatrists and mental health professionals to address the implications of spirituality/religion for clinical practice.³⁸

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 debate, which concluded with the passing of a motion to ‘welcome the recognition within mental health services of the significance of spirituality for assessment and treatment, and encourage parishes to ensure that the support and care of people with mental health problems, their carers and NHS staff is a key priority for the Church’s ministry’.³⁹ There was clearly an implicit reference here to the way in which spirituality was increasingly being seen – at the RCPsych and elsewhere – as an important part of mental health care. The work of the RCPsych SPSIG was explicitly referred to in the Continuing Issues in Mental Health report discussed by the Synod in 2008.⁴⁰

In the last few decades, policies have been established within various national psychiatric associations that recognise the contributions of religion and spirituality to an individual’s mental health. In the UK, the SPSIG first drafted a position statement making recommendations on practice in relation to spirituality and religion in psychiatry in October 2005.⁴¹ After a series of revisions, the recommendations were approved by the RCPsych as its position statement in 2011 (later revised in 2013). In 2015, the Executive Committee of the World Psychiatric Association also agreed a position statement on spirituality and religion in psychiatry which owed much to the RCPsych’s position statement.⁴² The impact of these policies upon clinical practice has yet to be evidenced, but a number of other national psychiatric associations have gone on to provide their own policies and guidance in relation to spirituality/religion.⁴³

The Mental Health Foundation carried out a comprehensive review of the literature on the impact of spirituality on mental health in 2006.⁴⁴ They concluded it justified ‘cautious optimism’ about the relationship between spirituality and religion in the promotion and maintenance of good psychological health, with possible mechanisms being: locus of control and coping styles; the formation and supportive nature of social networks; promotion of healthy lifestyle choices; and, even, positive effects of the built environment.⁴⁵

Religious Perspectives on Mental Health, 1960–2010

Conservative religious perspectives on mental health have followed a similar trajectory to that of psychiatric perspectives on religion. Early suspicion and alienation meant that religious groups were reluctant to accept the involvement of psychiatrists in treating mental health issues within their community. The anti-psychiatry movement of the 1960s and 1970s probably further contributed to negative Christian perspectives on psychiatry, too.⁴⁶ Some Christians considered mental illness a result of spiritual failings such as lack of faith, which could only be treated with pastoral counselling (see also Chapter 20).⁴⁷ This attitude weakened over the last few decades of the twentieth century but nevertheless persisted through to the early twenty-first century.

While psychiatry was coming to terms with the positive role that a religious support system could play in mental illness recovery, a study conducted in the United States by Mathew Stanford, published in 2007, found that many mentally ill individuals experienced negative interactions within their church communities when they sought counsel. Stanford found that, in a group of 293 Christian participants (mostly from the United States), 30 per cent reported feeling abandoned or dismissed by the church or told to ignore advice and medical prescriptions given by psychiatrists.⁴⁸ While we are not aware of similar research in the UK at this time, we imagine that in at least some churches here findings would have been very similar.

Increasing Influence of Service Users

In 1997, the Mental Health Foundation conducted the first nationwide service user–led survey. The study found that more than half of the service users and survivors associated positively their religious and spiritual beliefs with their mental health. People reported that their beliefs offered them comfort, a sense of purpose and guidance.⁴⁹ This research helped to realise the benefits of religion and spirituality to psychiatric treatments.

The Somerset Spirituality Project, also supported by the Mental Health Foundation, interviewed mental health service users in Somerset between late 2000 and early 2001 and found that they valued highly their religious experiences and considered them to be positive influences on their mental health. The Somerset Spirituality Project highlighted the importance of service users/survivors feeling supported in their spirituality within mental health services. Results from the project have been used in psychiatric training to inspire empathy and understanding towards those who are spiritually inclined (see also Chapter 13).⁵¹

Spiritual Crisis Network

The steadily increasing number of people who identified as SBNR in the late twentieth and early twenty-first centuries led to the establishment of support groups such as the Spiritual Crisis Network (SCN) in 2008. The SCN provide resources and counselling to individuals who have had spiritual experiences but may not be able to get the help they need or do not feel comfortable approaching a religious leader or a psychiatrist. Despite a lack of academic studies relating to spiritual crises, the SCN has developed a strategy to aid people in spiritual distress involving positive appraisals and construction of narrative frameworks.⁵²

Scientific and Medical Network

The Scientific and Medical Network (SMN) is an international charity founded in 1973 which is dedicated to ‘exploring and expanding the frontiers of science, medicine and spirituality’. It has a strong presence in the UK, with ten local groups. Since its conception, the SMN has encouraged scientists and medical professionals to incorporate spiritual and philosophical elements into their work, with a focus on enhancing understanding around parapsychological phenomena and how they influence the human experience and impact on mental health.⁵³

Developments in Other Professions

At the same time as the developing acknowledgement of the importance of religion and spirituality to psychiatry, there have been similar developments within other mental health professions. In nursing, the Patient’s Charter, introduced by the Department of Health in 1991, emphasised ‘respect for privacy, dignity and religious and cultural beliefs’.⁵⁴ Greasley and colleagues, in a paper on spiritual care in mental health nursing published in 2001, defined spiritual care in mental health nursing as relating to ‘the acknowledgement of a person’s sense of meaning and purpose to life which may, or may not be expressed through religious beliefs or practices’.⁵⁵ They expressed, as does Sartori in a more recent paper,⁵⁶ the view that, despite an acknowledgement that spirituality is important in the care of patients, it is still an area in which few nurses feel that they meet their patients’ needs.

Other professions have had similar concerns. Occupational therapists (OTs) take a holistic approach to practice in which they consider the role of the body, mind and spirit in illness.⁵⁷ Prior to the 1990s, they did not generally address spiritual issues with patients although, when surveyed, the results showed that they did recognise the importance of spirituality in health and rehabilitation.⁵⁸ In a follow-up study conducted in 2002, OTs reported an increase in spiritual discussions with their patients, indicative of an advancing acceptance of the role of religion and spirituality in health care.⁵⁹ Despite this, in a 2004 paper, ‘Spirituality in occupational therapy, theory in practice?’,⁶⁰ Belcham expressed concern that some OTs continued to neglect this area in their practice, for example in assessments.

Coyle and Lochner, in an article in the 2011 issue of The Psychologist,⁶¹ summarised the areas where the interactions between religion and spirituality and therapeutic practice are important to clinical and other applied psychologists: the process of assessment; responses to religious or other spiritual material which may be problematic; and in the areas of training and supervision. In the latter area, as recently as 2016, Jafari found that attention to religion and spirituality in clinical and counselling psychology training programmes was still being neglected.⁶²

Spirituality and Psychiatry in Other Faiths

The 2001 census conducted by the British government revealed that Britain is ethnically, culturally and religiously diverse, especially in larger cities such as Manchester, Glasgow and Birmingham. In London, for example, 8.5 per cent of inhabitants identified as Muslim, 4.1 per cent as Hindu, 2.1 per cent as Jewish and 0.8 per cent as Buddhist.⁶³ This section focuses on those of Islamic faith, as its adherents make up the second largest religious group in Britain.

Over the last few decades, there has been some concern that British Muslims with mental illnesses may be avoiding mainstream mental health services,⁶⁴ thus missing out on early intervention and this could be associated with poorer outcomes. Research suggests that this avoidance may be related to their religious beliefs, as many were reported to attribute their adverse experiences to supernatural causes such as ‘Jinn possession’ and/or ‘being cursed by the evil eye of envy’.⁶⁵

Explanatory models of mental illness strongly influence coping strategies and help-seeking behaviours, too. Bhui and colleagues conducted in-depth interviews in the UK with 116 people from 6 ethnic groups to ascertain how they cope with mental distress. The results showed that religious coping was most commonly practised by Bangladeshi Muslims and Afro-Caribbean Christians.⁶⁶

In an effort to combat the overt distrust of mental health services within the Muslim religious community, faith leaders (Imams) have joined chaplaincy services in NHS Trusts from the early 2000s.⁶⁷ They have worked closely with other religious leaders and healers to provide ad hoc advice and pastoral support on faith related matters and mental health. The actual provision, however, of contemporary mental health services in the UK is not faith-sensitive insofar as it does not incorporate religious principles and modalities in treatment. A more holistic approach is needed that integrates spirituality/religiosity with ‘conventional’ psychiatry. We believe that such a model would help to break down the barriers for Muslims (and others) who urgently need mental health support.

Conclusion

Religion, spirituality and psychiatry have had a complicated relationship over the years. Early mutual mistrust meant that, despite their congruent goals, there was a marked reluctance to associate them with each other. Over the decades, against a backdrop of rapid socio-political and cultural change, religion and psychiatry in Britain began to intertwine. Many psychiatrists began to see religion as a facilitator for good mental health practice and as a community-based support system which would help to improve patient outcomes. While battling the rise of secularism and the loss of social significance through religious pluralism, the Christian church has gradually adjusted its relationship with psychiatry. Other faith groups have similarly had to come to terms with a secular provision of mental health services which has often not been understanding of the spiritual and religious concerns of patients.

Key Summary Points

• Religion, spirituality and psychiatry share many ideals, such as the importance of a holistic understanding of mental well-being,⁶⁸ 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 a number of 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, which concluded with the passing of a motion to ‘welcome the recognition within mental health services of the significance of spirituality for assessment and treatment, and encourage parishes to ensure that the support and care of people with mental health problems, their carers and NHS staff is a key priority for the church’s ministry’.

• A more holistic approach to the treatment of mental health difficulties is needed that integrates spirituality/religiosity with ‘conventional’ psychiatry. We believe that such a model would help to break down the barriers to mental health services for people of strong faith and spiritual orientation who urgently need them.

Introduction

While the fifty years from 1960 did not produce a conflict on the scale of the two world wars, the UK adopted an increasingly interventionist foreign policy that drew British forces into campaigns beyond Europe. Counter-insurgency operations in Northern Ireland served as an enduring backdrop, involving 300,000 UK service personnel and resulting in 1,441 deaths between 1969 and 2006.¹ However, until the breakup of the Soviet Union in December 1991, the primary role of the British armed forces remained within NATO, protecting Western Europe from the Eastern Bloc. These long-term commitments were eclipsed when international destabilisation led to the breakup of Yugoslavia and UN peacekeeping roles followed in Bosnia, Kosovo and Macedonia. Yet, by 1997, after a decade of Conservative cuts, the defence budget as a percentage of GDP had shrunk to its lowest level in the twentieth century.² In July 1998, a strategic defence review conducted by New Labour identified growing risks: terrorism in particular but also drugs, ethnic and population pressures and scarce resources.³ The government sought to create a tri-service force able to operate regularly beyond Europe on a joint and multinational basis. Designed to raise Britain’s international influence, it required the military ‘to punch above its weight’.⁴ Deployments to Sierra Leone, Afghanistan and Iraq followed, stretching the resources of the UK armed forces to the limit. The physical and psychological casualties that were sustained created a popular support for the individual soldier but eventually eroded public support for the interventionist policy.

The Falklands War

Despite the physical challenges of the terrain and the extended supply chain, the Falklands War of spring 1982 appeared to produce little post-traumatic illness, reported as 2 per cent of all wounded.⁵ Of the 9,000 ground troops deployed, 150 (1.7 per cent) were killed in action. Although sixteen psychiatric cases were evacuated to SS Uganda, the hospital ship, only four were diagnosed with ‘battleshock’, the term then used for acute stress reaction.⁶ The lengthy sea voyages to and from the South Atlantic were thought to have provided time to prepare mentally for combat and to readjust to peacetime soldiering or a return to civilian life.⁷ Research conducted after the war identified functional somatic presentations that elevated the rate of psychiatric casualties to 8 per cent.⁸ This was significantly below the 20 per cent commonly recorded for major battles in the Second World War and was explained by the short duration of the war and the fact that British troops were highly trained regulars.⁹

Yet subsequent studies raised the possibility that the 8 per cent of all wounded did not capture the full impact of the traumatic experience.¹⁰ In 1987, Jones and Lovett reported three delayed cases of post-traumatic stress disorder (PTSD) from members of the task force.¹¹ Five years after the conflict, O’Brien and Hughes compared a group of sixty-four infantry soldiers who had served in the Falklands with matched controls who had equivalent training but had remained in the UK during the conflict.¹² On the basis of self-report questionnaires, it was found that fourteen (22 per cent) met the criteria for PTSD and a further eighteen (28 per cent) had a range of these symptoms. PTSD scores were not associated with age, rank or length of service but were higher for those who had lost comrades through wounding or death or who had killed the enemy or assisted in the management of casualties. They were also likely to have experienced emotional difficulties on returning home from the war. In 1993, a study of Falklands’ veterans found a 60 per cent rate of PTSD from fifty-three respondents who had completed a postal questionnaire. However, this was not a representative sample, as the investigators had sought volunteers using a networking model.¹³ While the operational success of the Falklands War was unquestioned, it increasingly appeared that the cost in terms of psychiatric casualties was hidden. In 2002, this notion received support from an article published in the Daily Mail claiming that 264 Falklands veterans had committed suicide, more than the 237 killed in the conflict.¹⁴ Research published by Defence Analytical Services and Advice in 2013 showed that 95 veterans had taken their own lives, which represented 7 per cent of the 1,335 who had then died since serving in the Falklands campaign.¹⁵ A lasting effect of the war was a change to the policy for commemoration of casualties. Following pressure from relatives, the Ministry of Defence (MoD) agreed that bodies could be repatriated to the UK for burial,¹⁶ a ritual that was to influence public opinion once campaigns in Iraq and Afghanistan proved costly.

Forward Psychiatry

Forward psychiatry, the classic method of managing breakdown on the battlefield developed during the First World War, was not employed in the Falklands. The two Navy psychiatrists with the task force remained on hospital ships throughout the campaign, so that a key element, return to unit, was prohibited under the terms of the Geneva Convention.¹⁷ Known by the acronym PIE (proximity to the battlefield, immediacy of delivery and expectation of recovery), the procedure had been widely used in the Second World War and Korea when it returned around 30 per cent of those treated to duty.¹⁸ However, the counter-insurgency operations in Malaya, which engaged British troops from June 1948 to July 1960, offered no obvious application for an intervention that required defined battle lines. As army psychiatrists with first-hand knowledge of forward psychiatry retired, training in its use ceased during the 1960s. The end of National Service saw the number of soldiers in the army fall from 430,000 in the mid-1950s (of whom just over half were conscripts)¹⁹ to 157,000 by 1965.²⁰ It was assumed that volunteers who had joined to the armed forces as a career would be less vulnerable to breakdown.

Forward psychiatry was reintroduced in the early 1980s in response to the threat of a massed Soviet assault from the East.²¹ Warsaw Pact forces had developed a tactic of concentrated bombardment to induce severe dissociation in front-line troops. Large numbers of ‘battleshock’ cases were predicted, requiring rapid treatment.²² The surprise attack on the Israeli Defense Force in the Yom Kippur War was identified as a model for an invasion of Europe, and Israeli clinicians were invited to the UK to brief their British counterparts.²³ Mobile field psychiatric teams (FPTs) were formed at brigade level and attached to field ambulances, comprising two doctors and four mental health nurses, and incorporated within battlefield training. To overcome stigma and present the policy in terms that fighting units would recognise, Brigadier Peter Abraham published on ‘battleshock’ and briefed British troops stationed in Germany.²⁴

Northern Ireland

Running from 1969 to 2006, counter-insurgency operations in Northern Ireland served as an enduring commitment and saw more than 300,000 UK service personnel deployed with 1,441 deaths.²⁵ The decade from 1971 to 1980, which saw the worst of the violence, raised the strength of troops in the province to 20,000. It was a period during which 330 regular soldiers and 107 members of the Ulster Defence Regiment were killed and many more injured. Nevertheless, combat stress reactions remained at a low level and were managed by community psychiatric nurses (1 per 5,000 soldiers) supported by regular clinical sessions from uniformed psychiatrists. Not until the 1980s was a full-time, army psychiatrist deployed to Northern Ireland.²⁶ However, a study in 2015 of veterans treated for PTSD at the inpatient facility of the mental health charity Combat Stress showed that 55 per cent had served in Northern Ireland compared with the Falklands (16 per cent), Iraq (33 per cent) and Afghanistan (17 per cent).²⁷ The preponderance was probably a consequence of the numbers deployed rather than a heightened incidence of traumatic events during the Troubles.

UK Recognition of PTSD

Although the American Psychiatric Association (APA) recognised PTSD in 1980, the association with Vietnam veterans delayed its acceptance in Britain. The 1986 edition of the Oxford Textbook of Psychiatry, for example, referred only to a ‘post-traumatic syndrome’ which related to ‘chronic neuroses after head injury’.²⁸ Until the 1990s, little was published on PTSD affecting UK armed forces or civilians exposed to terrorism. However, in the late 1980s, Morgan O’Connell, a Navy psychiatrist, saw an increasing number of Falklands’ veterans with chronic psychological symptoms and explored the usefulness of PTSD as a diagnosis and route to treatment. On 21 December 1988, the detonation of a terrorist bomb on board Pan Am Flight 103 from London to New York introduced Royal Air Force clinicians to the new disorder.²⁹ The aircraft crashed at Lockerbie, killing 259 passengers and crew, together with 11 local residents. Four RAF mountain rescue teams were sent to the site to look for possible survivors but found only the dead and body parts.³⁰ Gordon Turnbull, a RAF neuropsychiatrist, employed critical incident stress debriefing (CISD) to treat the teams who had not expected to encounter such devastation.³¹ CISD was adopted by the military as a way of dealing with the acute effects of trauma and subsequently proposed as a way of reducing the incidence of PTSD.³² RAF psychiatrists developed a twelve-day structured, inpatient course of group psychotherapy and day case follow-up sessions, in which psychological debriefing was the main therapeutic technique.³³

Gulf War

In contrast to the Falklands, where the size of the battlegroup was determined by available sea transport, the Gulf War in 1990–1 saw a force of 53,400 sent to Kuwait.³⁴ With such numbers and the possibility of an extended land campaign, forward psychiatry had an obvious role. Two FPTs worked in conjunction with a Battleshock Recovery Unit.³⁵ However, a short campaign with only forty-eight deaths resulted in few psychological casualties. The most challenging health effect emerged after the conflict and was given the popular term Gulf War syndrome. Veterans in the UK and the United States succumbed to a range of common, medically unexplained symptoms that impaired their daily function. Intense media and public interest followed in part because the mystery illness was hypothesised as having a toxic cause, whether from chemical weapons, vaccinations, organophosphates, depleted uranium munitions or oil well fires. Although a major research programme failed to find a unique disease,³⁶ similarities were identified with post-combat syndromes from earlier wars.³⁷ Such was the dominance of Gulf War syndrome that no studies were conducted into rates of PTSD suffered by UK service personnel and veterans until the new millennium.³⁸ An investigation of troops deployed on peacekeeping duties between 1991 and 2000 found a PTSD prevalence rate of 3.6 per cent,³⁹ while a study carried out from 2001 to 2002 of a representative sample of UK armed forces found a probable PTSD prevalence of only 2.5 per cent.⁴⁰ These percentages were equivalent to those for the UK population as a whole (males between the ages of sixteen and sixty-four having a rate of 3.6 per cent)⁴¹ and appeared to show a military with robust mental health. In retrospect, it is surprising that the first studies of PTSD in the UK military were conducted more than twenty years after the disorder had been recognised in DSM-III. This omission was to prove costly to the MoD because it created an opportunity for a legal case brought by veterans who had served in Northern Ireland, the Falklands, the Gulf and Bosnia for negligence in the detection and treatment of PTSD. With little or no published data on rates and outcomes, they were granted legal aid to test the validity of their claim for compensation in the Royal Courts of Justice.

Peacekeeping in Bosnia

In October 1992, British troops were deployed to Bosnia as part of the UN peacekeeping operation and remained there for more than a decade. Although casualties were low, many encountered the results of atrocities or found themselves constrained by rules of engagement when presented with ethnic conflicts. A self-report study of 4,250 UK troops deployed to Bosnia between 1991 and 1997 found that they were at greater risk of heavy drinking than those who had served in the Gulf War or those who had been serving at the time but not deployed to either theatre.⁴² In part explained by their younger age, it was also attributed to exposure to dangerous, provoking or humiliating experiences with limited opportunities to express the resulting anger and frustration.

Class Action for PTSD

Amid much publicity, the class action brought by 2,000 UK veterans against the MoD came to court on 4 March 2002. With so much evidence to consider, it was not until May 2003 that Mr Justice Owen delivered his judgement. The landmark case, probably the most important public inquiry into the treatment of post-traumatic illness since the Southborough committee of inquiry into shell shock, explored six key areas: the state of knowledge, screening for vulnerability, treatment, forward psychiatry, detection together with military culture and stigma.⁴³ Although the MoD was not found negligent, the judge identified a need to monitor developments in screening, detection and treatment. The MoD was reminded of the need to incorporate new knowledge into training, policy and practice.⁴⁴ Compared with the United States and Israel, the UK armed forces had limited research capacity in military psychiatry, a function both of size and of institutional culture. Following the case, the MoD funded a major research programme at the Institute of Psychiatry and the King’s Centre for Military Health Research (KCMHR) was set up in 2004, subsuming the Gulf War Illnesses Unit that had opened in 1996.

Treatment

The validation of cognitive behavioural therapy (CBT) for PTSD was the significant innovation in treatment during the period. However, the randomised controlled trials conducted in the early 1990s were of victims of sexual assault.⁴⁵ With large numbers of Vietnam veterans diagnosed with PTSD, US clinicians researched new treatments during the 1980s,⁴⁶ though the first UK study of trauma-focused CBT for service personnel was not published until 1995.⁴⁷ While it was subsequently shown that cognitive processing therapy and prolonged exposure therapy for PTSD in military and veteran populations achieved meaningful symptom reduction, 60 per cent to 72 per cent of subjects continued to meet the criteria for PTSD after treatment. Further, non-response and drop-out rates were high, suggesting a need for better ways of engaging with veterans.⁴⁸

Afghanistan and Iraq

The campaigns in Afghanistan and Iraq did not produce a syndrome characterised by medically unexplained symptoms akin to that associated with the Gulf War. As a result, the main research focus was on PTSD and latterly on rates of common mental disorders and alcohol abuse. Between March 2003 and May 2011, 120,000 UK service personnel were deployed to Iraq, of whom 179 were killed. Operations overlapped with the campaign to defeat the Taliban in Afghanistan and this too proved a lengthy and challenging commitment, ending in December 2014 with 453 lives lost. A series of cohort studies published by KCMHR revealed that the incidence of probable PTSD was lower than that recorded for US forces. The British rates were 4 per cent overall and 7 per cent for front-line units,⁴⁹ whereas studies of US troops found 13 per cent.⁵⁰ Longer tours of duty undertaken by American forces together with shorter periods between deployments, service personnel of younger age and a higher proportion of reservists were cited as the causes.⁵¹ In July 1993, the MoD had set up the Medical Assessment Programme (MAP) to investigate the symptoms of any veteran who had served in the Gulf War. Data were gathered on the physical and mental health of self-referring, ex-service personnel. Two studies by Lee and colleagues based on 3,000 and 3,233 veterans, respectively, found no unique illness or unusual disease trends.⁵² Subsequent conflicts saw the MAP’s role extended to include veterans of Bosnia, Iraq and Afghanistan. A study of 150 attendees with mental health problems, who believed these were caused by their operational service, was conducted Ian Palmer, a military psychiatrist.⁵³ Only 15 per cent of the diagnoses were of PTSD, though 89 per cent of these cases were comorbid with depression (48 per cent) or alcohol abuse (40 per cent).

Women in the UK Armed Forces

Until 1992, women who joined the armed forces had to serve in female-only units. With their abolition, women were integrated in all branches apart from those engaged in close combat. These changes corresponded with a progressive rise in the proportion of women in the UK armed forces. In 1990, women represented 6 per cent of regular forces, rising to 8 per cent by 2000 but had only achieved 11 per cent by April 2019 and are lower in the army than in the air force or navy.⁵⁴ Not until December 2014 did the Women in Close Combat Review recommend ending the ban on women in the infantry and armoured corps. However, greater integration may have increased the risk of military sexual trauma (MST). Across the world, women in the armed forces report elevated rates of mental illness compared with their male counterparts.⁵⁵ In part, this may reflect a greater willingness to disclose psychological illness but also the experience of a higher incidence of sexual assaults.⁵⁶ To date, the MoD has not sanctioned independent study of MST on the grounds it is at a low level.⁵⁷ In 2018, according to official statistics, service police conducted 153 investigations and 21 defendants were found guilty; the victims were mainly female (82.1 per cent) and the perpetrators overwhelmingly male.⁵⁸ Yet the suggestion remains that cases are under-reported.

Conclusion

Public support for the individual soldier and media focus on the welfare of veterans raised the profile of military psychiatry during the 2000s. At the end of the decade, a new edition of the Armed Forces Covenant was informed by a review of mental health services conducted by Dr Andrew Murrison MP.⁵⁹ Under the revised Covenant, veterans were granted priority access to NHS care for conditions associated with their service, subject to clinical need. The challenge of transition to civilian life was recognised and support in the form of ‘training, education and appropriate healthcare referral’ was recommended.⁶⁰ However, in the years that were to follow, other clinical priorities arose as a result of continuing campaigns in Afghanistan and Iraq, notably mild traumatic brain injury and, when it was demonstrated that validated treatments for PTSD were less effective for military populations, a growing interest in moral injury. Hence, the psychological challenges of conflict continue to evolve and demand solutions.

Key Summary Points

• Because of the focus on Gulf War syndrome, the UK military were slow to investigate rates of PTSD in service and veteran populations.

• The 1998 Strategic Defence Review that led Britain into an interventionist foreign policy drew the armed forces into a series of campaigns that stretched their resources and created additional psychological stressors.

• Military psychiatry tends to advance during periods of conflict because of the attention given to psychological casualties. Although the number of health care professionals fell over the period 1960–2010 in step with reductions in the strength of the armed forces, research capacity grew driven by greater public scrutiny and the development of formal links with the King’s Centre for Military Health Research.

• The 2002 Class Action at the Royal Courts of Justice into negligence in the detection and treatment of PTSD prompted the Ministry of Defence (MoD) to devote greater expenditure on research and the treatment of post-traumatic illnesses.

• The integration of progressively increasing numbers of women into the UK armed forces may have led to an elevated risk of military sexual trauma (MST).

Referring to work by his friend and close collaborator the early twentieth-century cultural critic Walter Benjamin, the musicologist, sociologist and philosopher Theodor W. Adorno wrote that it ‘settled at the cross-roads of magic and positivism. That place is bewitched.’² The same might be said about contemporary psychiatry. This is an observation not a reprimand, not least because of the need to maintain hope even in the face of seemingly hopeless clinical situations where the stakes are remarkably high indeed. Arguably, this is where psychiatry should be with its laudable commitment to science confronting the indeterminacy of human action. The fact that the membership of the Spirituality Special Interest Group (SIG) of the Royal College of Psychiatrists (RCPsych) is only third to that of the Philosophy and Transcultural SIG, signals the same challenge. Perhaps ‘bewitched’ is too strong a word but sometimes it feels right given the heated controversies that often surround mental health.

Psychiatry and Redemption

Messianic fantasies are usually tempered with age, but one would expect to find their spark in youth. At the beginning of our half-century 1960–2010 both society and psychiatry were young. They were young in the sense that baby boomers tilted demography towards youth; the demand for rigorous application of the scientific method in psychiatry was also young; and the loud clamour for deinstitutionalisation and community care had just began.

Throughout psychiatry, grand solutions have been conceived, ideologies trumpeted, policies formed and laws enacted. Some key examples are asylums as therapeutic institutions; the magic bullets of biological psychiatry; deinstitutionalisation and care in the community; and normalisation and recovery. Each has made positive contributions yet, by their own assessments, their efforts have been only partially redeemed. The big psychiatric hospitals have mostly closed but that now is ‘better’ is expressed with various degrees of uncertainty, if at all, by contributors to this volume. It could and should have been better.

‘Culture Is the Subject’s Nature’

Since the ‘decade of the brain’, enormous strides have been made in neuroscience.³ It has illuminated the exquisite complexity and plasticity of our neurobiology but this enlightenment has not been translated into advances in treatments to the same extent as in other medical specialties. The RCPsych secured funds from the Wellcome Trust and the Gatsby Foundation in 2018 to create a Neuroscience Board. Its purpose is to focus ‘on the exciting advances in basic and clinical neuroscience, so that trainees are better equipped to provide mental health care in the future’. This is necessary and welcome. Psychiatrists together with psychologists are the custodians of the clinical understanding and application of neuroscience in mental health and illness, though not exclusively so.

Paradoxically, while illuminating the nature of the psychophysiological mechanisms that mediate them, neuroscience has foregrounded the importance of psychological and social processes in mental health and illness.⁴ Unless this is taken fully on board, twenty-first-century neuroscience in psychiatry risks remaining therapeutically elusive, as it has been since the 1990s, the ‘decade of the brain’. In 2015, Thomas Insel reached a bleak verdict on his thirteen-year term as director of the US National Institute of Mental Health where he invested $20 billion into research on biological psychiatry: ‘I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness.’⁵ This may or may not change. If it does change, the question is by how much and how soon?

Affect, not the brain, is the primary object of the clinical medical expertise of psychiatrists.⁶ Our contributors show unambiguously that social changes have had an overwhelmingly greater impact on psychiatry and mental health services than biomedical research. We consider it likely that social changes will continue to outpace neuroscience advances in terms of the impact on the prevalence of disorders and clinical practice. As this book goes to print, the world has experienced a global pandemic from Covid-19, with enormous and uncertain long-term social effects, though we would argue that, with the enhanced role of IT and telemedicine, we have already moved further away from community and towards meta-community psychiatry and mental health.⁷ Consequently, we concur with those advocating enhanced training in the social sciences and greater integration with public health for psychiatrists.⁸

The importance of the history of psychiatry in psychiatric training has also recently been advocated.⁹ There is a strong case for the RCPsych to establish a Social Sciences and History of Psychiatry Board to perform a similar function to the Neuroscience Board in updating and safeguarding the curriculum for the future. This should include leading representatives from these other disciplines as well as Mad Studies. The aim would be to provide robust foundations and the ability to keep up with evolving literature for our professionals, in a manner analogous to neuroscience. Similarly, we need a continually developing responsiveness to service users and carers. Most psychiatrists cannot be at the cutting edge of basic research in either the social sciences or the neurosciences. Yet they should be able to keep up with major developments in the literature and translate in a mature and timely fashion what is relevant into their practice.

The importance of public mental health is increasingly understood.¹⁰ The profession will do well to engage more actively in the public sphere and be expected, trained and funded to do so. Moves in this direction should go beyond epidemiology and health services management to engage deeply with social theory and subjectivity.¹¹ This requires engaging with anthropology too, with its outstanding record of ‘thick description’ of peoples and cultures and fine conceptual analysis and investigation of personal meaning, including in severe mental illness.¹² This has implications for medical schools and psychiatric training schemes in terms of the qualities they seek in their recruits.

The Mental Health Workforce

When it comes to NHS policy, we suggest building further on the remarkable changes in mental health nursing. As a profession, it is naturally poised to maintain the right balance in making the ‘biopsychosocial’ model a tangible reality, especially for those with more severe impairments and disabilities. It has no need to privilege ‘bio’ or ‘psycho’ or ‘social’. Skills in the whole range should be supported, continuous professional development strengthened and clinical quality actively facilitated and judiciously assured. The proposal does not intend the marginalisation of other mental health professions such as psychiatry and psychology. On the contrary, we believe it will help them fulfil their mission in terms of cultivating their special strengths. Pluralist understanding and multidisciplinary services are essential. None of the professions will succeed, however, unless there is full service-user and carer engagement, adequate provision of resources and effective recruitment and retention strategies. At present, these lag unacceptably behind.

Industrial therapy (and work) aside, the shadowy presence, even absence, of action-oriented therapies in this volume reflects a significant historical gap in mental health services development. Occupational therapy is the most obvious but others such as art, drama, dance and the like are also relevant. Such neglect flies in the face of our increasing understanding of central nervous system (CNS) plasticity and the importance of meaningful personal enterprise and practical action in both health and disease.

Conclusion

Foes and friends and even practitioners sometimes caricature psychiatry as a towering monolith. However, psychiatry is what psychiatrists do; patients, carers and colleagues experience; and the broader community understands, expects and funds. We believe that Mind State and Society: Social History of Psychiatry and Mental Health in Britain 1960–2010 demonstrates that what Wittgenstein wrote about language applies to some extent to psychiatry too: ‘[it] can be seen as an ancient city: a maze of little streets and squares, of old and new houses, and of houses with additions from various periods; and this surrounded by a multitude of new boroughs with straight regular streets and uniform houses.’¹³ In our city (polis), some find a home, others refuge and care, and still others experience neglect, oppression or abuse. In writing its history, chapter authors have also contributed to psychiatry’s philosophy: ontology and ethics; resources for humility, professionalism and citizenship (politics).