This poem, by the Irish poet and Nobel Laureate, Seamus Heaney, is as applicable to sustaining healthy communities as it is to sustaining marital harmony, which is the purpose for which it was originally written. As the scaffolding provided the foundational structure from which Heaney and his wife built the walls of their marriage, so too we can develop communities through our own collective efforts, drawing on support from health and social care practitioners of various persuasions where and when required. Once it is established, we can gain confidence from the fact that we can use what we have built together to help our communities to endure and thrive when they, too, are threatened by adversity.

As health care professionals we owe a duty of care to our patients. Our patients have a right to autonomy – to make their own decisions. If we impose treatment on them against their wishes, when they have capacity to make a decision to refuse treatment, then we may be committing the tort of battery; if we fail to treat them when they lack capacity to make treatment decisions we may be found to be negligent.

Disasters and major incidents, while uncommon in each country, occur sufficiently frequently worldwide and have such societal impacts that they make headlines on most days. Perhaps, paradoxically, emergencies are so common as to be almost ordinary, if only in purely statistical terms, if it were not for the human impact, worry and suffering that is involved. This chapter shows how disasters are integral to and, thus, present a microcosm of our worlds. Our intention is to use them, in common with each of the topics in Section 3 of this book, to explore social influences on how people, communities and societies respond to and cope with the physical and psychosocial impacts of major events. This chapter links John Drury et al.’s exploration of the contribution of social psychology to crowd science in Chapter 15 with Drury and Alfadhli’s Chapter 17, on disasters. We intend that Chapters 15, 16 and 17 provide another window on the human condition, the importance of social relationships and the powerful influences of social identity.

This book illustrates the burgeoning literature focusing on the ill effects of many forms of adversity, misfortune and disaster, whether deliberate and human-inspired or of, so-called, natural origins. There appear to be many possible ways in which humans can fare badly in response to endogenous and exogenous stress, inequity and inequality. But, by contrast with the risks and the all-too-real suffering of so many survivors, we are struck by the positive ways in which so many people appear to cope with the stress, strain and potentially deleterious impacts. Indeed, post-traumatic growth and mental health problems that are consequent on disasters do not appear to lie at the opposite extremes of a spectrum of outcome, but may co-occur.

We are moved to ask how so many people do well or reasonably well and in what ways that learning might be applied to preventing people from developing problems in the future.

Reading the first part of this book presents a striking contrast between current preoccupations in healthcare systems and the science presented here. In other words, between extant public concerns about entitlement to, funding of, and delivering healthcare in the second decade of the twenty-first century and the contents of Chapters 2, 3 and 4.

Healthcare systems and the people who fund, run and deliver them are, arguably, necessarily acutely sensitive to the socio-economic environment in which countries sit. The potential capabilities of healthcare continue to develop at increasingly rapid rates. By contrast, we live in a world in which the resources available are affected by austerity and in which the spread of affluence between the most advantaged people and the least affluent continues to grow. This is contributing to an increasing gap between potential capability and actual capacity, which appears to be expanding rapidly.

ECT remains one of the most controversial treatments in psychiatry. Although its efficacy and safety are acknowledged and have been confirmed (Chapter 1) there are still attempts (based on flawed reviews of the literature) to claim that its use cannot be scientifically justified (Read & Bentall, 2010). Media accounts of ECT tend to be highly emotive and vary from lauding ECT as life changing (Seelye, 2016) to damning it as abusive (Browne, 2000).

Public health is defined by the UK’s Faculty of Public Health as ‘The science and art of promoting and protecting health and well being, preventing ill health and prolonging life through the organised efforts of society’.

This definition locates the causes of ill health and the remedies in the realms of personal and societal agency, and not only in the remit of health practitioners. Although the latter have a role as members of society to make prevention a reality for themselves, families and communities, they play a special part in preventing further ill health for people who suffer mental illness and are seeking help for it.

Other chapters in this book attend to the relational and social fabric that enables people to flourish; it is made of good and trusting relationships, and material conditions that permit thought about purpose and meaning beyond survival.

Both the authors are clinicians who work at the Helen Bamber Foundation (HBF), a human rights charity that works with asylum seekers and refugees who have experienced extreme violations of their human rights.

Since she entered the Bergen Belsen concentration camp in May 1945, only a few weeks after its liberation, our Founder, Helen Bamber, worked continuously for nearly 70 years as a pioneer in the documentation of extreme human cruelty and in assessing the needs and providing comprehensive care for survivors of extreme cruelty. Helen’s overwhelming sense of mission and of duty were closely linked to her early experiences at Bergen Belsen, which also provided a starting point for her notion of integrated care. She spoke of bearing witness, through the detailed documentation of the mental and physical evidence of the cruelty to which her clients had been subjected, which are cornerstones of the model of integrated care.

This chapter pulls together key matters in this book. Its title is a quote from a line given to one of the characters in Hamlet by Shakespeare. That sentence perfectly outlines the intention of Section 5 of this book and the function of this final chapter in which I endeavour to align theory, research and the practical impacts of the topics covered by this book with the circumstances in which we find health services as we near the close of the second decade of the twenty-first century. But, first, I return to Chapter 1, to recapture some of those circumstances. Then, I look at the matters on which I think we should focus in order to sustain healthcare services and incorporate the social agenda identified in this book.

Attachment theory has become a central concept in our understanding of resilience in children and young people (Fonagy et al., 1994). However, attachment theory is a relatively narrow concept, focused on the relationship between a child and his or her principal caregivers and the child’s need to seek comfort when distressed (Waters et al., 2005). Furthermore, attachment theory concerns itself with individual person’s relationships, while recognising that children can have multiple attachment relationships. However, we know that children grow up in complex systems (Bronfenbrenner, 1979) and there is a growing recognition that children and young people’s sense of belonging (to individuals, groups and organisations) is a key component of resilience (Hart et al., 2008). Thus, the concept of belonging encapsulates children’s relationships with their immediate families or carers, their friends and their friends’ families, their schools, social activities (Scouts, football clubs, youth clubs) and wider social experiences, such as religious organisations or cultural groups.

Electroconvulsive therapy (ECT) possesses several key therapeutic actions, having antidepressant, anti-manic and antipsychotic effects. The adverse effects of ECT, particularly loss of autobiographical memories, are also of great clinical importance. Whether the same ‘mechanism’ underpins all these properties is unknown. Most information about the mechanistic effects of ECT has been obtained in relation to the treatment of depression and the current review will focus on this area.

This chapter builds on previous chapters, on crowds (Chapter 15) and emergencies and disasters (Chapter 16), to show the relationship between the two. It describes a programme of research that has examined the extent to which shared social identity determines collective behaviour in emergencies and disasters.

We recognise that engagement and action by the public is necessary when communities and agencies in them plan for emergencies. The increased threat of major incidents, disasters and terrorist attacks means that professional responders will not always be in place in time or in sufficient number to help (Cole et al., 2011; see Chapter 16).

The social identity approach is relevant here because it explains the conditions under which crowds and groups of people can operate as psychological communities that support their members in times of danger and stress. This chapter also describes how social identity principles have been applied to understanding informal psychosocial support among some refugees of war.

The evidence base for the use of ECT in children and adolescents aged under 18 years (hereafter referred to as ‘paediatric ECT’) consists of individual case reports, case series and retrospective chart reviews, but no Randomised Controlled Trials (RCTs). This limited evidence base alongside concerns about the effects of ECT on the developing brain may help explain the infrequent use of ECT by child and adolescent psychiatrists. This chapter provides a summary of the issues and considerations pertaining to use of paediatric ECT within the British Isles (United Kingdom and Republic of Ireland). Although legal aspects relating to ECT are covered in Chapter 28, some reference specific to paediatric use is made here.

ECT is used more often in the elderly than in younger adults and most often for depression which, in the elderly, is common and is associated with significant morbidity and mortality (Whiteford, et al., 2010). The high rates of treatment resistance (Whiteford, et al., 2010), the relative absence of evidence based guidelines and the risks associated with biological treatments, particularly in view of the high rates of physical co-morbidity, suggest that the decision to use ECT should be considered often, but carefully, and that its application should be thoughtful.

Social relationships affect health. Of that we are certain. People who are more strongly connected live longer (e.g. Holt-Lunstad et al., 2010), are in better health (e.g. Boden-Albala et al., 2005) and experience better wellbeing (e.g. Helliwell & Putnam, 2004). None of us is immune to these effects although, clearly, poverty, inequality and age, among other factors, contribute to, and exacerbate the consequences of, social disconnection.

What is more remarkable, in the context of the evidence-base showing the profound impact of these effects, is the relatively limited investment in efforts to build and preserve the social capital of vulnerable communities, on health grounds. Recognising the potential benefits that social resources bring and the mechanisms through which they can emerge is important, but not enough. What is needed is a coherent approach to embed these resources in communities to ensure that the products of social connectedness can be sustained in the longer term.

The tradition of taking family and social histories and integrating these aspects into formulations and recommendations is a time-honoured health practice. The role of ethnic cultural understandings of family and community pertinent to this process is less clear. Alongside this, the extent to which contemporary practice keeps up with culturally responsive research, investigating concepts of family and community, is variable. This chapter covers how relevant research and practice-based evidence might inform health practitioners to better engage with concepts of family and community through an ethnic cultural lens. The topic is vast and this chapter presents a pragmatic review of the salient literature together with a tailored critique of key issues that impact on practitioners and policymakers alike.