Here we examine governmental policies that affect how people with mental health conditions are treated in society. The development of UK mental health services has been closely associated with the evolution of social policies, the increasing role of the state in the provisions for the population’s well-being, and the ‘Welfare State’. The provision of poor relief, dating from the Elizabethan Poor Law to its Victorian revision, has dominated the care of people with mental health conditions, both within and outside of institutions. Until the nineteenth century, the British state played a minimal role in the care of mental ill-health, and the 1800s witnessed a substantial growth in publicly funded asylums. These County Asylums were Poor Law institutions and remained so into the twentieth century. The UK’s modern mental health services arose from the Beveridge welfare state reforms but carried with them much of the baggage of the Victorian Poor Laws. The close relationship between the welfare state and mental health services illustrates the importance of social policy provision relating to income, employment, housing, education, health, and personal social services, to the broader provision of services for people with mental health conditions and the running of effective mental health services.

This chapter evaluates what the international and European human rights frameworks can offer, in terms of standard setting and avenues for international legal development and protection, to those irregular migrants who experience either mental health difficulties or have a psychosocial disability. The analysis in this chapter extends the normative frames of references to encompass ‘disability’, which is reconceptualised in the Convention on the Rights of Persons with Disabilities as a transformative status and a human rights argument. This chapter triangulates human rights, public health and disability-sensitive arguments to assess the relations between mental health and human rights in the context of irregular migration in human rights law and jurisprudence. While the European Court of Human Rights’ deportation cases concerning people with mental health issues tend to reflect an overall emergency-oriented and predominantly biomedical approach to mental health, several UN human rights treaty bodies set out a more holistic conceptualisation of mental health and psychosocial disability. The latter approach promotes non-discriminatory psychosocial interventions to guarantee access to community-based mental health care services and the underlying determinants of mental health for everyone regardless of migration status.

Three key drivers that introduced the new managerialism into mental health services were funding constraints, the drive to measure health care quality and the move to deinstitutionalisation. A new cadre of managers, some of which were clinicians but many of whom were not, often rode roughshod over traditional clinical administration and many psychiatrists and nurses felt ignored and undervalued. New managers pushed ahead regardless, driven by a vision that was often alien to existing service providers. New services proved to be considerably more expensive than old ones. The tribal cultures of psychiatrists, nurses, other professions and managers have always been a major influence on the way services are run, and the change towards a managerial emphasis did not assist mutual understanding. Managerialism brought a new understanding of budgets, human resources and objectives into mental health services that was largely positive but mental health services are still fashioned around systems that were established for the acute hospital sector and not readily adapted to mental health service provision.

The process of de-asylumisation into a community care–based mental health system has been a messy business, a social crusade rather than a clinically thought-out process. Concomitants like modern psychopharmacology and the effects of the Royal College of Psychiatrists’ anti-stigma campaigns have helped, but care has varied substantially in quality across the country. Community care has relied on the qualities of individual psychiatrists and Community Mental Health Team (CMHT) members, as well as local GP and/or social services support, generally not helped by the numerous government White Papers. The reversion to medium-secure mental health units and reinstitutionalisation has been a core feature, publicly unrecognised. Mental health services have coped to varying degrees despite their core asylum resource being stolen from them, and the key need now is for the elimination of the primacy of risk assessment and the maintenance of the generality of general adult psychiatry.

Chapter 6 explores US survivors’ activism in the last three decades of the twentieth century through the lens of health, illness, and medicine. Radiation illness – physical and psychosocial – continued to concern US survivors. Women were frequently primary caretakers in Asia and Asian America, spurring female survivors to consider radiation illness from both patients’ and caregivers’ perspectives. This dual challenge became a driving force for US survivors to form trans-Pacific coalitions with Japanese and Korean survivors. US survivors’ understanding of illness that placed psychosocial factors at its center drew attention from the broader Asian American community, also plagued by the lack of resources for culturally aware medical and social services. Unlike the earlier medical exams conducted on US survivors by the Atomic Bomb Casualty Commission, US survivors’ grassroots activism proved capable of producing a solution fitting their needs. One distinct accomplishment of their activism was the creation of biannual health checkups conducted in America by Japanese physicians familiar with radiation illness, funded by the Japanese government and supported by the Asian American community.

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

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

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

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